-> 
 
 
 
 
 
 'V' 
 
 5 
 
 ■ o v 
 
 
 
 
 o- 
 
 L-fc' - 
 
 
 r ■ ^ 
 
 $> v. 
 
 
 
 ^ V* 
 
 
 
 *> 
 
 '* > 
 
 
 
 
 * V 
 
 
 '% ¥ 
 
 : 
 
 .A 
 
 
 
 o5 "^ 
 
 
 ^, ^ 
 
 ^ 
 
 
 -/- 
 
 ^<^' 
 
 
 <H V, 
 
 
 
 ^ ^ o 
 
 4? ^ 
 
 ^^ 
 
 ^ <^ 
 
 
 
 
 W 
 
 
 ^ <v 
 
 
 
 
 
 
 *f> 
 
 
 
 V 
 
 
 
 Q> **d* 
 
,0 a 
 
 oq 
 
 :% 
 
 
 
 % a 
 
 '• C > 
 
 ^ <> 
 
 
 
 ,0 c 
 
 * 8 
 
 ^7 ^ 
 
 
 o C 
 
 
 V- 
 
 ,0 c 
 
 
 
 
 
 
 
PRACTICAL DIETETICS 
 
 WITH SPECIAL REFERENCE TO 
 DIET IN DISEASE 
 
 BY 
 
 W. GILMAN THOMPSON, M. D. 
 
 PROFESSOR OF MEDICINE IN THE CORNELL UNIVERSITY MEDICAL COLLEGE 
 
 IN NEW YORK CITY 
 
 VISITING PHYSICIAN TO THE PRESBYTERIAN AND BELLEVUE HOSPITALS 
 
 Good diet with wisdom best comforteth men " 
 
 Tusser (1520) 
 
 SECOND. EDITION, ENLARGED AND THOROUGHLY REVISED 
 
 NEW YORK 
 D. APPLE TON AND COMPANY 
 
 1902 
 
T?/T}2/(o 
 
 THE LIBRARY OF 
 CONGRESS, 
 
 Two Copies Received 
 
 MAY. 24 1902 
 
 Copyright entry 
 
 CLASS ^XXc No. 
 
 COPY B. 
 
 Copyright 1895, 1902 
 By D. APPLETON AND COMPANY 
 
 Published May, 1902 
 
PREFACE TO THE SECOND EDITION 
 
 The present edition of this work has been prepared to meet 
 the demands of an increasing interest in the practical application 
 of dietetic principles. The book has-been revised throughout, in 
 part rewritten, and over thirty .pages of new matter have been added. 
 The writer has again availed rTimself of the exceedingly valuable 
 contributions to scientific dietetics published by the United States 
 Department of Agriculture, comprising the results of food studies 
 conducted at the various experiment stations in all parts of the 
 country, and illustrating particularly the economic value of different 
 dietaries. The sections on Diet in Disease have also been enlarged 
 and, as in the previous edition, developed with special reference 
 to their practical application for the sick. 
 
 W. G. T. 
 
INTRODUCTION TO THE FIRST EDITION 
 
 The subject of the dietetic treatment of disease has not received 
 the attention in medical literature which it deserves, and it is to 
 be regretted that in the curriculum of medical colleges it is usually 
 either omitted or is disposed of in one or two brief lectures at 
 the end of a course in general therapeutics. Upon examining the 
 standard treatises upon the Theory and Practice of Medicine, as 
 well as monographs upon important diseases, such as those of the 
 circulation, nervous system, and skin, one cannot fail to be im- 
 pressed with the meagre notice given to the necessity of feeding 
 patients properly, and the subject is usually dismissed with such 
 brief and indefinite phrases as " The value of nutritious diet re- 
 quires mere mention," " A proper but restricted diet is recom- 
 mended," and favourite, if not convincing, expressions are, " The 
 patient should be carefully fed," and " General dietetic treatment 
 is of primary importance." With such vague directions the diet- 
 ing must indeed be very " general." 
 
 In many excellent works upon food and dietetics the space de- 
 voted to the practical application of dietetics to disease is compara- 
 tively insignificant, and much less emphasis is given to this matter 
 in hospitals and in the training of nurses than is demanded in the 
 interests of medical science. 
 
 A writer of wide experience in practical dietetics, Mrs. E. H. 
 Richards, says : " At present there are comparatively few persons 
 who are called upon to feed the sick to whom a glass of milk or 
 a pound of beef represent any definite amount of food materials. 
 Still fewer who can tell how much food value a glass of lemon 
 jelly or wine whey represents, and yet the adult patient is de- 
 pendent upon the attendant even more than the week-old infant 
 for the requisite nutrition." 
 
VI PREFACE 
 
 The present volume has been prepared with the view of in some 
 measure making good such deficiencies by furnishing a text-book 
 in which the practitioner of medicine may find detailed the appro- 
 priate diet for each disease which is at all influenced by right 
 feeding. 
 
 Quite as much depends upon the suitable preparation of food 
 as upon the selection and limitation of the food itself, and it has 
 therefore been thought advisable to include a general account of 
 the composition and uses of foods, and the changes which may 
 be produced in them by cooking and other processes. In this first 
 portion of the work, however, the practical application of such 
 knowledge to the feeding of the sick has been constantly empha- 
 sised rather than unnecessary scientific detail. 
 
 The reader will also find a discussion of representative hospital 
 dietaries, the official dietaries of Government institutions, and sec- 
 tions upon the proper feeding of infants and children. Numerous 
 cross references and a complete index have been added to avoid 
 undue repetition. 
 
 Bennett wrote, as long ago as 1858 : " Of all the means of cure 
 at our disposal, attention to the quantity and quality of the ingesta 
 is by far the most powerful." While fully concurring in this view, 
 that appropriate dieting is often more needed than medication, I 
 distinctly disclaim the advocacy of any special dietetic system as 
 a cure-all, as well as the specific influence of any one food in the 
 general treatment of disease. It cannot be expected that the ex- 
 perience of a single individual should cover so extensive a ground 
 as that which embraces the relative advantages of all foods, and I 
 have therefore impartially introduced the views of others, especially 
 where, as in such diseases as gout, diabetes, and obesity, opposing 
 dietetic theories are held by clinicians of extensive experience and 
 authority. Due acknowledgment of these references is made in the 
 text, but the admirable researches upon foods of our own Govern- 
 ment, found in the published reports of the Department of Agricul- 
 ture and of the Commission to the Paris Universal Exposition of 
 1889, and at the Columbian Exposition of 1893, are especially to 
 be commended. 
 
 W. Gilman Thompson. 
 
CONTENTS 
 
 Introduction 
 
 PAGE 
 
 iii 
 
 PART I 
 
 FOODS AND FOOD PREPARATIONS 
 
 Elementary composition of foods . 
 Food classification .... 
 Force production. Energy from food 
 Force-producing value of the different classes of foods 
 
 I. Water . . . . 
 
 II. Salts 
 
 III. Proteids, carbohydrates, and fats 
 Stimulating foods .... 
 Economic value of foods . 
 Nutrition ..... 
 
 Animal and vegetable foods compared 
 Vegetarianism .... 
 The classes of foods 
 
 I. Water 
 
 Uses of water in the body . 
 Purity of water . ... 
 
 Varieties of drinking water 
 
 Hard and soft water 
 
 Rain water .... 
 
 River water .... 
 
 Distilled water 
 
 Filtered water 
 
 Boiled water .... 
 Special dietetic uses of water 
 Excess of water 
 Deprivation of water. Water starvation 
 
 Thirst 
 
 Temperature of drinking water . 
 
 II. Salts 
 
 Variety of salts .... 
 Uses of salts in foods 
 Excess of salt .... 
 Deprivation of salt . . • . 
 
 Sodium salts .... 
 
 Potassium salts 
 
 Calcium salts .... 
 
 Phosphorus .... 
 
 Sulphur ..... 
 
 Iron ...... 
 
 Vegetable acids 
 
 4 
 7 
 
 18 
 18 
 19 
 19 
 23 
 24 
 29 
 29 
 35 
 37 
 37 
 38 
 38 
 39 
 39 
 39 
 40 
 40 
 40 
 41 
 4i 
 42 
 43 
 43 
 44 
 45 
 45 
 45 
 45 
 46 
 46 
 47 
 47 
 48 
 48 
 48 
 48 
 
Vlll 
 
 CONTENTS 
 
 III. Animal foods. 
 
 Milk 
 
 Exclusive milk diet 
 
 " Milk cure " ... 
 
 Chemical composition of milk 
 
 Fat 
 
 Lactose .... 
 
 Casein and albumin 
 Varieties of milk . 
 
 Cow's milk .... 
 
 Human milk 
 
 Drugs in human milk 
 Goat's milk 
 Ass's milk .... 
 
 Mare's milk 
 Milk analysis .... 
 
 Reaction, colour, taste, odour 
 Estimation of solids . 
 Estimation of fat 
 Estimation of lactose . 
 Estimation of albuminoids . 
 Milk adulteration and impurities 
 Addition of water 
 Addition of colouring matter 
 Addition of preservatives 
 Addition of thickening substances 
 Milk contamination by the cow's food 
 Contamination by the cow's condition 
 Contamination by the cow's disease germs 
 Contamination by extraneous disease germs 
 Souring and decomposition 
 Absorption of bad odours . 
 Prophylaxis against milk infection 
 Uses of milk ..... 
 
 Milk digestion .... 
 
 Normal (Rennin) 
 
 Abnormal ..... 
 
 . Adaptation of milk for the sick 
 
 Methods of altering the taste of milk 
 Methods of improving the digestibility of milk 
 Skimming ..... 
 
 Boiling ...... 
 
 Dilution with water 
 
 Dilution with alkaline and aerated waters 
 Dilution with amylaceous foods 
 Addition of alkalies, acid, and other substances 
 Methods of predigestion of milk . 
 Peptonised milk 
 Pancreatinised milk 
 Koumiss . 
 " Koumiss cure " 
 Kefir 
 
 Matzoon or zoolak . 
 Methods of sterilisation and preservation of milk 
 Sterilised milk . 
 Pasteurised milk 
 
CONTENTS 
 
 
 
 
 
 
 ix 
 
 PAGE 
 
 " Humanised milk "... .88 
 
 Modified milk. Milk laboratories 
 
 
 
 
 
 
 . 88 
 
 Milk derivatives . 
 
 
 
 
 
 
 93 
 
 Condensed milk 
 
 
 
 
 
 
 
 • 93 
 
 Cream 
 
 
 
 
 
 
 
 . 94 
 
 Butter 
 
 
 
 
 
 
 
 . 9 6 
 
 Buttermilk 
 
 
 
 
 
 
 
 • 97 
 
 Cheese 
 
 
 
 
 
 
 
 ■ 97 
 
 Whey 
 
 
 
 
 
 
 
 . 101 
 
 Eggs .... 
 
 
 
 
 
 
 
 . 101 
 
 Raw eggs. Eggnog. Egg a 
 
 lbumin 
 
 
 
 
 
 
 • 103 
 
 The cooking of eggs . 
 
 
 
 
 
 
 
 . 104 
 
 Preservation of eggs 
 
 
 
 
 
 
 
 • 105 
 
 Meats 
 
 
 
 
 
 
 
 . 106 
 
 Consumption of meat . 
 
 
 
 
 
 
 
 . 106 
 
 Composition of meats . 
 
 
 
 
 
 
 
 . 107 
 
 Raw meats . 
 
 
 
 
 
 
 
 . 108 
 
 Digestibility of meats . 
 
 
 
 
 
 
 
 . 108 
 
 Beef .... 
 
 
 
 
 
 
 
 . 109 
 
 Beef preparations for the sic' 
 
 c 
 
 
 
 
 
 
 . no 
 
 Solid meat preparations 
 
 
 
 
 
 
 
 III 
 
 Scraped meat 
 
 
 
 
 
 
 
 . Ill 
 
 Beef meal 
 
 
 
 
 
 
 
 III 
 
 Beef jelly 
 
 
 
 
 
 
 
 . Ill 
 
 Beef extracts . 
 
 
 
 
 
 
 
 112 
 
 Beef blood 
 
 
 
 
 
 
 
 112 
 
 Beef peptonoids 
 
 
 
 
 
 
 
 113 
 
 Fluid meat preparations. 
 
 
 
 
 
 
 
 
 Beef juice 
 
 
 
 
 
 
 
 114 
 
 Beef tea . 
 
 
 
 
 
 
 
 114 
 
 Bouillon 
 
 
 
 
 
 
 
 Il6 
 
 Beef broth 
 
 
 
 
 
 
 
 Il6 
 
 Beef extracts . 
 
 
 
 
 
 
 
 117 
 
 Summary 
 
 
 
 
 
 
 
 Il8 
 
 Various meats 
 
 
 
 
 
 
 
 119 
 
 Beef tongue 
 
 
 
 
 
 
 
 119 
 
 Veal 
 
 
 
 
 
 
 
 119 
 
 Mutton 
 
 
 
 
 
 
 
 119 
 
 Lamb 
 
 
 
 
 
 
 
 119 
 
 Venison 
 
 
 
 
 
 
 
 119 
 
 Pork .... 
 
 
 
 
 
 
 
 120 
 
 Ham and Bacon 
 
 
 
 
 
 
 
 120 
 
 Fowl 
 
 
 
 
 
 
 
 121 
 
 Game ..... 
 
 
 
 
 
 
 
 121 
 
 Animal viscera 
 
 
 
 
 
 
 
 121 
 
 Sweetbread 
 
 
 
 
 
 
 
 121 
 
 Tripe, liver, kidneys, brains 
 
 , blood 
 
 
 
 
 
 
 122 
 
 Isinglass, gelatin . 
 
 
 
 
 
 
 
 122 
 
 Jellies .... 
 
 
 
 
 
 
 
 123 
 
 Fish 
 
 
 
 
 
 
 
 124 
 
 Crustaceans 
 
 
 
 
 
 
 
 125 
 
 Shellfish — oysters, clams, n 
 
 lussels 
 
 
 
 
 
 
 126 
 
 Vegetable foods 
 
 
 
 
 
 
 
 127 
 
 Sugars .... 
 
 
 
 
 
 
 
 127 
 
 Sugars and the urine 
 
 
 
 
 
 
 
 128 
 
 Cane sugar, saccharose . 
 
 
 
 
 
 
 
 129 
 
X 
 
 CONTENTS 
 
 Caramel 
 
 Molasses and treacle 
 Grape sugar, glucose 
 Milk sugar, lactose 
 Mannite and levulose 
 Honey . 
 Saccharin 
 Cereals and other starchy food 
 Starchy foods in general 
 Bread making 
 
 Structure of the wheat kernel 
 
 Bran . 
 
 Gluten 
 
 Composition of bread 
 
 Bread baking 
 
 Development of carbonic-acid gas 
 
 Yeast, leaven 
 
 Baking powders 
 
 Aerated bread 
 Varieties of bread stuffs 
 
 Wheaten flour and bread 
 
 Whole-meal bread 
 
 Gluten bread 
 
 Rye bread . 
 
 Biscuits, pastry, puddings, etc. 
 Prepared farinaceous foods 
 
 Buckwheat 
 
 Rye . 
 
 Corn 
 
 Rice . 
 
 Barley 
 
 Oatmeal 
 
 Arrowroot 
 
 Tapioca, cassava 
 
 Sago 
 
 Iceland moss 
 Starchy foods for children 
 Diastase, malt extracts, etc. 
 Vegetable food 
 
 Legumes, peas, beans, lentil 
 Roots and tubers . 
 
 Potatoes 
 
 Beets 
 
 Succulent tubers 
 Green vegetables . 
 
 Cabbages, etc. 
 
 Tomatoes, etc. . 
 Fruits 
 
 Composition of fruits 
 
 Uses and properties of fruits 
 
 Fruit ripening . 
 
 Fruit poisoning 
 
 When to eat fruit 
 Fruit soups . 
 Dried fruits . 
 Digestibility of fruits 
 
CONTENTS 
 
 XI 
 
 Varieties of fruits 
 
 Lemons, limes, shaddocks 
 Oranges .... 
 Apples .... 
 Pears, peaches, etc. . 
 Bananas .... 
 Banana flour for invalids . 
 Grapes .... 
 Plums, prunes . 
 Berries, strawberries, etc. . 
 Melons .... 
 Figs and dates . 
 
 Fungi 
 
 Poisonous fungi . 
 Lichen ..... 
 
 Nuts 
 
 Fats and oils 
 
 Uses of fats .... 
 
 Digestibility of fats . 
 
 Animal fats . . . 
 
 Bone marrow .... 
 
 Vegetable fats and oils 
 
 Olive oil . 
 
 Dietetic uses of fats and oils . 
 
 Diseases in which fats are beneficial 
 
 Diseases in which fats are forbidden 
 
 Glycerin . . . 
 
 Cod-liver oil . 
 
 Chemical and physical properties 
 Dosage .... 
 
 Methods of administration . 
 Substitutes .... 
 Uses . . . . 
 
 179 
 179 
 180 
 180 
 181 
 182 
 183 
 184 
 185 
 186 
 
 187 
 188 
 188 
 189 
 190 
 190 
 192 
 192 
 194 
 
 195 
 196 
 197 
 197 
 198 
 199 
 
 199 
 199 
 199 
 199 
 200 
 201 
 203 
 203 
 
 PART II 
 
 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Stimulants and beverages 
 
 
 
 
 
 
 205 
 
 Alkaline and mineral waters, effervescing waters 
 
 
 
 
 
 207 
 
 Tannin ........ 
 
 
 
 
 
 210 
 
 Tea ....... 
 
 
 
 
 
 
 211 
 
 Physiological and therapeutic action of tea 
 
 
 
 
 
 
 212 
 
 Adulteration of tea .... 
 
 
 
 
 
 
 215 
 
 Coffee ....... 
 
 
 
 
 
 
 215 
 
 Physiological action of coffee 
 
 
 
 
 
 
 217 
 
 Adulteration of coffee 
 
 
 
 
 
 
 219 
 
 Relative value of coffee and tea 
 
 
 
 
 
 
 220 
 
 Cocoa ....... 
 
 
 
 
 
 
 221 
 
 Cacao butter 
 
 
 
 
 
 
 222 
 
 Chocolate .... 
 
 
 
 
 
 
 223 
 
 Kola . . 
 
 
 
 
 
 
 224 
 
 Alcohol ....... 
 
 
 
 
 
 
 225 
 
 General discussion of the value of alcohol 
 
 
 
 
 
 
 ■1-5 
 
 Physiological action .... 
 
 
 
 
 
 
 228 
 
Xll 
 
 
 CONTENTS 
 
 
 
 
 
 
 
 PAGE 
 
 I. As a food 228 
 
 II. As a stimulant .... 
 
 
 
 » 
 
 229 
 
 III. Action upon the muscles . 
 
 
 
 
 
 230 
 
 IV. Action upon the temperature 
 
 
 
 
 
 
 230 
 
 V. Action as a diuretic 
 
 
 
 
 
 
 231 
 
 VI. Action upon mucous membranes 
 
 
 
 
 
 
 231 
 
 VII. Action upon gastric digestion . 
 
 
 
 
 
 
 231 
 
 VIII. Alcohol absorption 
 
 
 
 
 
 
 232 
 
 IX. Alcohol elimination . i^l 
 
 
 
 
 
 
 233 
 
 X. Alcohol poisoning 
 
 
 
 
 
 
 
 233 
 
 XI. Alcohol and climate 
 
 . 
 
 
 
 
 
 
 233 
 
 Clinical uses of alcohol 
 
 
 
 
 
 
 
 234 
 
 1. As a tonic . 
 
 
 
 
 
 
 
 234 
 
 2. As a vascular and cardiac stimulant 
 
 
 
 
 
 
 235 
 
 3. Use in nervous diseases 
 
 
 
 
 
 
 236 
 
 4. Use in fevers .... 
 
 
 
 
 
 
 236 
 
 Proper time for giving alcohol . 
 
 
 
 
 
 
 237 
 
 Selection of proper alcoholic beverage 
 
 
 
 
 
 
 238 
 
 Malt liquors ...... 
 
 
 
 
 
 
 239 
 
 Beer . 
 
 
 
 
 
 
 
 
 239 
 
 Beer brewing . 
 
 
 
 
 
 
 
 
 240 
 
 Ale 
 
 
 
 
 
 
 
 
 241 
 
 Porter, stout 
 Wine 
 
 
 
 
 
 
 
 
 241 
 
 241 
 
 Composition 
 
 
 
 
 
 
 
 
 241 
 
 General properties 
 
 
 
 
 
 
 
 
 242 
 
 White wines . * 
 
 
 
 
 
 
 
 
 243 
 
 Red wines . 
 
 
 
 
 
 
 
 
 244 
 
 Varieties of wines 
 
 
 
 
 
 
 
 
 245 
 
 I. Strong dry wines 
 
 
 
 
 
 
 
 245 
 
 II. Strong sweet wines 
 
 
 
 
 
 
 
 246 
 
 III. Aromatic wines 
 
 
 
 
 
 
 
 246 
 
 IV. Acid wines 
 
 
 
 
 
 
 
 246 
 
 V. Sparkling wines 
 
 
 
 
 
 
 
 246 
 
 VI. " Perfect " wines 
 
 
 
 
 
 
 
 248 
 
 VII. Rough wines . 
 
 
 
 
 
 
 
 249 
 
 Liquors .... 
 
 
 
 
 
 
 
 250 
 
 Brandy, whisky, gin, rum 
 
 
 
 
 
 
 
 250 
 
 Therapeutic uses of liquors 
 
 
 
 
 
 
 
 251 
 
 Adulteration of liquors and 
 
 wines 
 
 
 
 
 
 
 251 
 
 Liqueurs 
 
 
 
 
 
 
 
 252 
 
 Cider .... 
 
 
 
 
 
 
 
 253 
 
 Condiments and spices . 
 
 
 
 
 
 
 
 253 
 
 Properties, uses, harmful effects . 
 
 
 
 
 
 
 253 
 
 Varieties 
 
 
 
 
 
 
 
 
 254 
 
 PART III 
 
 COOKING. — FOOD PREPARATION AND PRESERVATION. — THE QUANTITY OF FOOD 
 
 REQUIRED 
 
 Cooking . . . . . . . . . . . . . 259 
 
 Object of cooking food 259 
 
 Varieties of cooking .......... 260 
 
 1. Boiling ........... 261 
 
CONTENTS 
 
 Xlll 
 
 2. Stewing 
 
 3. Roasting 
 
 4. Grilling 
 
 5. Frying 
 
 6. Braising 
 
 7. Baking 
 
 8. Steaming 
 Soups 
 
 Cooking of fish 
 Cooking of vegetables 
 
 Food concentration. — Condensed food 
 
 Drying, desiccation, extracts 
 Diet of concentrated foods 
 Food preservation 
 
 I. Drying 
 
 II. Smoking 
 
 III. Salting 
 
 IV. Freezing 
 
 V. Refrigeration 
 
 VI. Sterilisation 
 VII Exclusion of air. — Canning 
 VIII. Antiseptic and preservative substances 
 
 Substitutes for food 
 Quantity of food required 
 Starvation and inanition 
 
 Voluntary fasting 
 
 Symptoms of starvation 
 
 Treatment after starvation 
 
 Famine 
 Improperly balanced ingredients of diet 
 
 263 
 264 
 264 
 267 
 268 
 268 
 268 
 268 
 269 
 269 
 270 
 270 
 272 
 274 
 274 
 275 
 275 
 276 
 276 
 277 
 278 
 281 
 282 
 283 
 297 
 298 
 300 
 303 
 304 
 304 
 
 PART IV 
 
 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 Age and food 
 
 Food in childhood 
 
 Food in adult life 
 
 Food in old age . 
 Individual size and food 
 Body weight and food 
 Sex and food . 
 Diet and heredity . 
 Diet and race 
 Climate and season and food 
 
 306 
 306 
 307 
 308 
 
 3ii 
 312 
 
 313 
 314 
 314 
 320 
 
 PART V 
 
 FOOD DIGESTION. — CONDITIONS WHICH ESPECIALLY AFFECT DIGESTION 
 
 Hours for meals and order of taking food 323 
 
 Appetite . .327 
 
 Abnormal cravings ...... ... 328 
 
 Variety in diet 329 
 
XIV 
 
 CONTENTS 
 
 The nervous system and digestion 
 Circulation and digestion 
 Temperature and digestion 
 Exercise and digestion . 
 Rest and sleep and digestion . 
 
 Sleep in relation to meals 
 Mental emotion and digestion 
 Food in the mouth 
 Food in the stomach 
 
 Quantity of gastric juice 
 
 Secretion of the gastric juice 
 
 Hydrochloric acid 
 
 Pepsin, albumoses, peptones 
 Peristalsis 
 
 Duration of gastric digestion of different 
 Digestion of proteids in the stomach 
 Abnormalities of gastric digestion 
 
 Hypersecretion . 
 
 Hyperacidity 
 
 Absence of hydrochloric acid 
 
 Pyrosis 
 Food in the intestine 
 
 Pancreatic juice . 
 
 Bile .... 
 
 Digestion of fats 
 
 Intestinal gases . 
 Artificial digestion . 
 
 Predigestion of starches 
 
 Predigestion of proteids 
 Food absorption 
 Elimination of food waste 
 The urine and food 
 Tobacco and food . 
 Food equivalents 
 
 foods 
 
 33i 
 332 
 333 
 336 
 337 
 338 
 340 
 340 
 34i 
 342 
 342 
 343 
 344 
 346 
 346 
 348 
 349 
 349 
 349 
 350 
 35o 
 350 
 350 
 35i 
 35i 
 352 
 352 
 353 
 354 
 358 
 359 
 360 
 360 
 361 
 
 PART VI 
 
 THE GENERAL RELATION OF FOOD TO SPECIAL DISEASES. 
 ARE CAUSED BY DIETETIC ERRORS 
 
 -DISEASES WHICH 
 
 The general relation of food to special diseases .... 
 Diseases caused by dietetic errors ....... 
 
 I. Insufficient food . . . . . . . 
 
 II. Overeating and overdrinking ...... 
 
 • III. Food in itself wholesome, but which is injurious because 
 ingredients are not properly balanced .... 
 
 IV. Food containing parasites or their embryos 
 
 Intestinal worms ......... 
 
 Trichiniasis . . . . . . . . . 
 
 V. Food containing ptomaines ....... 
 
 Poisoning by meat or game ....... 
 
 Poisoning by milk, cream, ice cream, and cheese 
 
 Poisoning by shellfish and fish 
 
 VI. Food containing other poisons than ptomaines 
 
 Grain poisoning ......... 
 
 the 
 
 363 
 365 
 366 
 366 
 
 368 
 368 
 369 
 370 
 374 
 375 
 377 
 378 
 379 
 380 
 
CONTENTS 
 
 XV 
 
 Ergotism 
 
 Lathyrism 
 
 Pellagra 
 
 VII. Food adulteration 
 Pigments 
 Salicylic acid 
 Tin and lead poisoning 
 
 VIII. Food containing micro-organisms 
 Milk infection ...... 
 
 Tubercular infection through milk and meat 
 Typhoid and cholera infection . 
 Infection through oysters 
 
 Diphtheria and scarlatina . 
 
 Foot-and-mouth disease .... 
 Food infection through flies 
 
 IX. Idiosyncrasies in regard to food . 
 
 X. Alcohol poisoning. Alcoholism . 
 Delirium tremens ..... 
 
 380 
 380 
 381 
 38i 
 383 
 384 
 384 
 385 
 385 
 386 
 
 390 
 390 
 390 
 39i 
 392 
 395 
 
 PART VII 
 
 ADMINISTRATION OF FOOD FOR THE SICK 
 
 Methods of feeding the sick 
 General rules 
 
 The appetite 
 
 Regularity in feeding 
 
 Quantity of food 
 
 Details of serving food 
 
 Feeding helpless patients 
 
 Sleep and feeding . 
 
 Cleansing the mouth 
 
 Disinfection of utensils 
 
 Feeding unconscious patients 
 Nutrient enemata 
 
 Conditions necessitating rectal feeding 
 
 Hunger and thirst during rectal feeding 
 
 Method of injection 
 
 Aids to retention 
 
 Temperature of injections 
 
 Number of injections 
 
 Care of the rectum . 
 
 Opium in enemata . 
 
 Substances available for rectal feeding 
 
 Prescriptions for food enemata 
 Food suppositories 
 Inunction foods . 
 Intravascular feeding 
 Hypodermic feeding 
 Medicines and food 
 Diet-kitchen outfit . 
 Trained purveyors of food 
 
 397 
 
 397 
 397 
 398 
 398 
 398 
 400 
 401 
 401 
 401 
 402 
 403 
 403 
 404 
 404 
 406 
 406 
 406 
 406 
 407 
 408 
 410 
 410 
 410 
 411 
 411 
 411 
 414 
 414 
 
XVI CONTENTS • 
 
 PART VIII 
 
 DIET IN DISEASE. — DIET IN INFECTIOUS DISEASES 
 
 PAGE 
 
 Diet in fever in general . . . . . . . . . 415 
 
 Pathological physiology of fever ........ 415 
 
 Dietetic treatment . 4^ 
 
 Beverages in fevers .......... 420 
 
 Alcohol as a food in fevers ......... 421 
 
 Diet in convalescence from fevers ....... 423 
 
 Typhoid fever ............ 425 
 
 Pathological physiology ......... 425 
 
 Dietetic treatment 426 
 
 Milk diet .426 
 
 Substitutes for milk diet ......... 428 
 
 Thirst 430 
 
 Alcohol ............ 431 
 
 Relation of intestinal antisepsis to diet ...... 432 
 
 Care of the mouth .......... 433 
 
 Convalescence ........... 434 
 
 Rules for feeding atypical cases . . . . . . . . 436 
 
 Typhoid fever in children ......... 437 
 
 Typhus fever ............ 437 
 
 Smallpox ............ 438 
 
 Scarlet fever ............ 438 
 
 Measles ............. 439 
 
 Mumps ............. 440 
 
 Whooping cough ........... 440 
 
 Influenza ............ 440 
 
 Diphtheria ............ 442 
 
 Intubation ............ 442 
 
 Tracheotomy ........... 444 
 
 Post-diphtheritic paralysis ......... 444 
 
 Cerebro-spinal meningitis ......... 444 
 
 Erysipelas ............ 445 
 
 Cholera ............. 446 
 
 Yellow fever 449 
 
 Pyaemia and septicaemia .......... 452 
 
 Malarial fevers . . . . . . . . . . . 453 
 
 Tetanus ............. 453 
 
 Rabies 454 
 
 Tuberculosis . . . . . . . . ... . . 454 
 
 General considerations ......... 455 
 
 Diet in mild cases .......... 460 
 
 Foods allowed in non-active cases without gastric catarrh . . 461 
 
 Diet in advanced cases ......... 462 
 
 Milk diet 463 
 
 Suralimentation ........... 464 
 
 Diet for forced feeding ......... 465 
 
 Aids to dietetic treatment . . 466 
 
 Diet " cures " for phthisis . . 4^7 
 
 DIET IN DISEASES OF THE RESPIRATORY SYSTEM 
 
 Laryngismus stridulus 467 
 
 Tubercular laryngitis .......-.- 468 
 
CONTENTS 
 
 XV11 
 
 Haemorrhage of the lungs 
 Acute capillary bronchitis 
 Chronic bronchitis . 
 Asthma ..... 
 Emphysema .... 
 Pneumonia .... 
 Broncho-pneumonia 
 
 Broncho-pneumonia in children 
 Pleurisy .... 
 
 Empyema .... 
 
 PAGE 
 468 
 469 
 470 
 470 
 
 471 
 472 
 
 474 
 
 474 
 474 
 476 
 
 DIET IN DISEASES OF THE CIRCULATORY SYSTEM AND BLOOD 
 
 Diseases of the heart 
 
 Pathological physiology 
 
 Use of fluids .... 
 
 Dietetic treatment 
 
 Cardiac valvular disease in children 
 
 Dietetic treatment of the senile heart 
 
 Angina pectoris . 
 
 Cardiac palpitation 
 Arterial sclerosis 
 Aneurism 
 
 TufneH's diet 
 Anaemia. — Chlorosis 
 Pernicious anaemia 
 
 476 
 476 
 
 477 
 477 
 478 
 479 
 482 
 482 
 482 
 J.82 
 483 
 484 
 489 
 
 DIET IN DISEASES OF THE URINARY SYSTEM 
 
 Modifications in the urine caused by food 
 Acute nephritis .... 
 
 Acute nephritis in children . 
 Albuminuria. — Functional albuminuria 
 Chronic Bright's disease 
 
 Milk diet 
 
 Pyelitis ...... 
 
 Oxaluria ..... 
 
 Calculi, renal and vesical 
 
 Lithaemia. Uric-acid diathesis. — Gravel 
 
 Gonorrhoea ...... 
 
 489 
 490 
 492 
 492 
 496 
 497 
 501 
 501 
 502 
 
 504 
 ^06 
 
 DIET IN DISEASES OF THE ALIMENTARY CANAL 
 
 Abnormal dentition 
 Catarrhal stomatitis 
 Tonsilitis and quinsy 
 Dysphagia ..... 
 Stricture and carcinoma of the cesophag 
 Feeding through a gastric fistula . 
 Foreign bodies swallowed 
 Indigestion and dyspepsia 
 
 Symptoms . 
 
 ^Etiology. Idiosyncrasies . 
 
 Examination of the stomach contents 
 
 Test meals ..... 
 
 Tests for hydrochloric acid . 
 
 Hypersecretion . 
 
 507 
 507 
 =io8 
 508 
 
 509 
 510 
 
 510 
 5ii 
 5ii 
 512 
 
 515 
 5J5 
 517 
 519 
 
XV111 
 
 CONTENTS 
 
 Tests for pepsin and rennin 
 
 Tests for motor power of stomach 
 
 Tests for absorptive power of stomach 
 Dietetic treatment of dyspepsia 
 
 Desirable foods .... 
 
 Beverages ..... 
 
 Special systems of treatment 
 
 General rules for dyspeptics 
 
 Rules for special varieties of dyspepsi 
 
 Dyspepsia in children . 
 Acute gastric catarrh 
 
 Gastric fever in children 
 Chronic gastric catarrh . 
 
 Pathological physiology 
 
 Dietetic treatment 
 
 Milk diet . 
 
 Other diet . 
 
 Convalescence 
 
 Hydrochloric acid 
 Chronic gastric catarrh in children 
 Dilatation of the stomach. — Gastrectasia 
 
 Lavage 
 
 Massage . . . 
 
 Electricity . 
 Vomiting 
 
 Pathological physiology 
 
 Dietetic treatment 
 Seasickness 
 
 Vomiting of pregnancy . 
 Ulcer of the stomach 
 Cancer of the stomach . 
 
 PAGE 
 
 519 
 520 
 
 521 
 521 
 522 
 523 
 524 
 525 
 525 
 526 
 
 527 
 529 
 530 
 531 
 531 
 532 
 533 
 534 
 535 
 536 
 536 
 538 
 54i 
 542 
 543 
 543 
 543 
 544 
 546 
 546 
 550 
 
 DIET IN DISEASES OF THE INTESTINES 
 
 Diarrhoea , . 55 2 
 
 Pathological physiology 552 
 
 Dietetic treatment .......... 553 
 
 Diarrhoea in infants and young children ....... 554 
 
 Dietetic causes ........... 554 
 
 Examination of stools ......... 555 
 
 Dietetic treatment .......... 556 
 
 Entero-colitis in infants and children. Summer diarrhoea . . . 557 
 
 Cholera infantum or acute milk infection ...... 558 
 
 Cholera morbus. Acute catarrhal enteritis in adults .... 560 
 
 Chronic enteritis in adults. Chronic intestinal catarrh. Chronic colitis . 561 
 
 Chronic intestinal indigestion in children ...... 562 
 
 Chronic gastro-intestinal catarrh. Chronic entero-colitis. Chronic diar- 
 rhoea in children .......■•• 5^3 
 
 Simple atrophy. Marasmus .......•• 564 
 
 Mucous disease. Chronic pseudo-membranous gastro-enteritis. Mem- 
 branous enteritis .......-•• 5^5 
 
 Dysentery 566 
 
 Chronic dysentery ........... 567 
 
 Acute intestinal obstruction ......... 567 
 
 Chronic constipation .......... 568 
 
 Physiology ............ 568 
 
CONTENTS 
 
 XIX 
 
 Pathological physiology 
 
 Dietetic treatment 
 
 Summary of the most useful articles o 
 
 Foods to be avoided . 
 
 Aids to dietetic treatment . 
 Constipation in infants and children 
 
 Foods recommended 
 
 Foods forbidden . 
 Hemorrhoids 
 Appendicitis . 
 
 Causation 
 
 Dietetic treatment 
 Acute peritonitis 
 Chronic peritonitis 
 
 f diet 
 
 569 
 571 
 573 
 573 
 574 
 576 
 577 
 577 
 578 
 578 
 578 
 579 
 579 
 580 
 
 DIET IN DISEASES OF THE LIVER 
 
 Diet in liver diseases in general .... 
 
 " Biliousness " 
 
 Causation ....... 
 
 Dietetic treatment . . . . . 
 
 Directions for eating .... 
 
 Acute catarrhal inflammation of the gall ducts. 
 
 rhal jaundice 
 
 Cirrhosis 
 
 Dietetic treatment of cirrhosis without ascites 
 Ascites ....... 
 
 Dietetic treatment of cirrhosis with ascites . 
 
 Fatty liver 
 
 Amyloid liver ...... 
 
 Syphilis of the liver . . 
 
 Abscess of the liver 
 
 Gallstones ....... 
 
 Pathological physiology .... 
 
 Dietetic treatment 
 
 Diet in pancreatic diseases .... 
 
 Angiocholitis. Catar 
 
 580 
 580 
 580 
 58i 
 
 583 
 
 584 
 584 
 585 
 585 
 586 
 586 
 587 
 588 
 588 
 588 
 588 
 589 
 591 
 
 DIET IN DISEASES OF THE NERVOUS SYSTEM 
 
 Neuralgia 
 
 Causation 
 
 Dietetic treatment 
 Visceral neuralgia 
 
 Gastralgia . 
 
 Enteralgia . 
 
 Hepatalgia . 
 Migraine 
 Neurasthenia 
 
 Causation 
 
 General treatment 
 
 The " rest cure " 
 
 Weir Mitchell's diet 
 
 Playfair's diet 
 
 Leyden's diet 
 
 Keating's diet 
 Insomnia and disordered sleep 
 
 591 
 59i 
 592 
 593 
 594 
 595 
 595 
 595 
 597 
 597 
 598 
 600 
 602 
 602 
 603 
 603 
 605 
 
XX 
 
 CONTENTS 
 
 Vertigo . 
 Chorea . 
 Epilepsy 
 Beri-beri 
 
 Locomotor ataxia 
 Apoplexy- 
 Acute insanity. Melancholia. 
 Forced feeding 
 
 Primary dementia. Mania 
 
 DIET IN SKIN DISEASES 
 
 Skin diseases which are caused by improper diet 
 
 General principles of dietetic treatment 
 Erythema. Urticaria 
 Acne .... 
 Eczema .... 
 
 Cases due to overeating 
 
 Typical diet for eczema 
 
 Cases due to insufficient food 
 
 Cases due to improper food 
 Eczema in nursing infants 
 Eczema in children 
 Exfoliative dermatitis 
 Rosacea 
 Psoriasis 
 Pruritus 
 Furunculosis . 
 
 DISEASES ESPECIALLY INFLUENCED BY DIET 
 
 Obesity (Polysarcia) 
 Causation 
 Dietetic treatment 
 Systems of Banting 
 
 Ebstein 
 
 Oertel 
 
 Schweninger 
 
 Schleicher 
 
 Germain See 
 
 Weir Mitchell 
 
 Yeo 
 
 Duj ardin-Beaumetz 
 Meat and hot-water treatment 
 System of Bouchard 
 System of Chambers 
 " Anti-fat " remedies 
 Diet for leanness 
 Rheumatism, acute 
 
 Chronic 
 Arthritis deformans 
 Gout 
 
 Causation 
 
 Preventive treatment 
 
 Theory of dietetic treatment 
 
 Diet for the gouty diathesis and chronic gout 
 
 Beverages 
 
CONTENTS 
 
 XXI 
 
 Diabetes mellitus . 
 Causation .... 
 Relation to gout and other disea 
 Physiological experiments . 
 The nervous system and diabetes 
 The circulation and diabetes 
 Various theories 
 Symptoms . 
 Course 
 
 Dietetic treatment 
 Foods allowed 
 Foods forbidden 
 Substitutes for bread 
 Substitutes for sugar 
 Beverages 
 Special diets 
 Skimmed milk 
 Ebstein's diet . 
 During' s diet . 
 Naunyn's diet . 
 Medicinal treatment 
 Rhachitis (rickets) . 
 Aids to dietetic treatment 
 Scurvy . 
 
 Causation 
 Hemorrhagic purpura 
 
 654 
 655 
 656 
 
 657 
 661 
 661 
 661 
 663 
 666 
 668 
 673 
 675 
 675 
 679 
 680 
 682 
 682 
 682 
 683 
 683 
 684 
 685 
 688 
 688 
 688 
 692 
 
 DIET IN MISCELLANEOUS DISEASES 
 
 Addison's disease . 
 Osteomalacia 
 Exophthalmic goitre 
 Chronic lead poisoning 
 
 Dietetic treatment 
 Dietetic complications arising from associated diseases 
 
 692 
 692 
 693 
 693 
 693 
 694 
 
 DIET FOR SURGICAL PATIENTS 
 
 Food and anaesthetics 
 
 Diet after anaesthesia 
 
 Surgical operations and injuries 
 Laparotomy. Ovariotomy . 
 Surgical inflammation. Sepsis 
 
 695 
 696 
 696 
 698 
 698 
 
 PART IX 
 
 RATIONS. — DIETARIES 
 
 Army and navy diets 
 The U. S. army rations 
 U. S. army ration in the field 
 U. S. army travel ration 
 Garrison ration for ten days 
 Foreign army rations . 
 Navy rations 
 
 700 
 700 
 702 
 702 
 705 
 707 
 710 
 
XX11 
 
 CONTENTS 
 
 Diet in prisons .... 
 
 U. S. army prison diet 
 
 New York State Reformatory diet 
 Dietetic cures 
 
 Milk cure .... 
 
 Whey cure .... 
 
 Various " cures " 
 Kneipp system 
 
 Fruit cures .... 
 
 Grape cure .... 
 
 Meat and hot-water cure 
 
 Dry cure .... 
 
 Schroth's method 
 Athletic training 
 
 Dietary of the Yale boat crew 
 
 Dietary of the Yale football team 
 Diet and occupation 
 
 Brain workers 
 
 Commercial life . 
 
 Travel 
 Diet in pregnancy 
 Diet for puerperal women 
 Selection of a wet nurse 
 Diet of a nursing mother or wet nurse 
 
 Drugs in human milk 
 Food of infants 
 
 Size of the infant stomach 
 
 Overfeeding 
 
 Methods of feeding 
 
 Feeding by the mother or wet nurse 
 
 Feeding by the bottle 
 
 Mixed feeding 
 Weaning 
 Artificial infant foods 
 
 Infant stools 
 
 Nursing bottles . 
 
 Care of infant's mouth 
 
 Weighing of infants 
 
 Premature infants 
 Food for young children 
 
 Rules for feeding young children 
 
 Dietaries for young children 
 
 Teething and food 
 
 Sleep and food . 
 Diet for school children 
 
 Hours for meals 
 Hospital dietaries . 
 
 New York Hospital . 
 
 Presbyterian Hospital 
 
 Bellevue, Gouverneur, Fordham. and 
 
 Roosevelt Hospital 
 
 Johns Hopkins Hospital 
 
 Liverpool Infirmary . 
 
 Cook County Hospital 
 
 New York Infirmary 
 
 New York State Hospital 
 
 Harl 
 
 em Hospitals 
 
CONTENTS 
 
 XX111 
 
 PAGE 
 
 Utica State Hospital for Insane 791 
 
 Dietaries of army hospitals ......... 793 
 
 United States ........... 795 
 
 British ............ 797 
 
 Prussian, French 798 
 
 APPENDIX 
 
 Receipts for invalid food and beverages suitable for fevers and conva 
 
 lescence from acute illness 
 Beverages 
 
 Demulcent and nutritive 
 
 Diuretic and refrigerant 
 Fluid beef preparations 
 
 Broths and soups 
 Solid meat preparations 
 Milk preparations 
 Egg preparations 
 Farinaceous foods 
 Gelatin preparations 
 
 799 
 799 
 799 
 800 
 801 
 803 
 804 
 806 
 807 
 809 
 8i3 
 
 LIST OF ILLUSTRATIONS 
 
 Plate I. Milk laboratory 
 
 II. Animal fats (butter and butterine) 
 III. Starch granules (wheat, barley, rye, oats, corn, and 
 rice) . . 
 
 " IV. Maize starch and wheat starch . 
 Section through wheat kernel 
 Microscopic characters of wheat . 
 
 V. Rice starch 
 
 Starch granules (marunta, potato, ginger, sago 
 peas, and beans) ..... 
 
 VII. Bean starch and pea starch . 
 
 Potato starch ...... 
 
 IX. Animal fats (beef fat and oleomargarine) 
 Comparison of daily dietaries 
 Diet sheet ....... 
 
 VI. 
 
 VIII. 
 
 Facing 88 
 
 Facing 96 
 
 Facing 133 
 
 Facing 136 
 
 . 136 
 
 . 136 
 
 Facing 155 
 
 Facing 158 
 
 Facing 162 
 
 Facing 165 
 
 Facing 192 
 
 . . 718 
 
 . 784 
 
PRACTICAL DIETETICS 
 
 PART I 
 FOODS AND FOOD PREPARATIONS 
 
 ELEMENTARY COMPOSITION OF FOODS 
 
 Of the eighty-two chemical elements, thirteen enter uniformly 
 into the composition of the body and ten more are occasionally 
 found. Of all these, several exist in very small proportion and 
 their uses are unknown, several are found more abundantly but 
 are not indispensable to life, and certain elements — namely, carbon, 
 hydrogen, oxygen, and nitrogen — are necessary ingredients of the 
 tissues of the body. These elements form compounds which, as 
 they occur in the structure of the various tissues, have the following 
 characteristics : 
 
 First, although the elements are but few in number, their molecu- 
 lar arrangement is very complex. 
 
 Second, their compounds are comparatively unstable and are 
 readily converted in the body or by chemical analysis into other 
 forms. 
 
 All food is composed of combinations of these simpler chemi- 
 cal elements which, for the most part, must be subjected to altera- 
 tion in the body itself to prepare it for assimilation by the tis- 
 sues. The nutrition of the body, therefore, involves four distinct 
 processes, viz. : 
 
 i. The secretion of digestive fluids and their action upon food in 
 the alimentary canal. 
 
 2. The absorption of the ingredients of the food when digested 
 into the blood vessels and lymphatic vessels. 
 
 3. The assimilation of the absorbed nutritious products by the 
 tissues. 
 
 4. The elimination of the waste material. 
 
 The following analysis exhibits the relative proportion of the 
 elements of which the human body is composed : 
 
2 FOODS AND FOOD PREPARATIONS 
 
 Approximate Chemical Analysis of a Man (Moss) 
 (Height, 5 feet 8 inches ; weight, 148 pounds.) 
 
 Oxygen 92.4 pounds. 
 
 Hydrogen 14.6 
 
 Carbon 31-6 
 
 Nitrogen 4-° 
 
 Phosphorus 1.4 
 
 Calcium 2.8 " 
 
 Sulphur 0.24 " 
 
 Chlorine 0.12 " 
 
 Sodium 0.12 " 
 
 Iron 0.02 " 
 
 Potassium o. 34 " 
 
 Magnesium 0.04 
 
 Silica ? 
 
 Fluorine 0.02 " 
 
 Total 148.00 pounds. 
 
 All these elements are necessarily derived from food and water 
 plus the oxygen of the air which is breathed. 
 
 The three predominating elements — oxygen, hydrogen, and car- 
 bon — are the great force producers of the body, although they 
 are tissue formers as well, and to them must be added nitrogen, 
 as serving in this double capacity, although its relation to tissue 
 formation and renewal is greater than its capacity for supplying 
 energy. 
 
 The common elements which enter into tissue formation chiefly 
 and which bear no direct relation to the main sources of the force 
 production in the body are chlorine, sulphur, phosphorus, iron, 
 sodium, potassium, calcium, and magnesium in different combina- 
 tions. Bone tissue, for example, contains about 50 per cent of 
 lime phosphate. If this substance is deficient in the food of the 
 young growing infant, the bones are poorly developed and so soft 
 that they yield to the strain of the weight of the body and become 
 bent and out of shape. This constitutes one of the principal symp- 
 toms of rickets. 
 
 Lack of iron salts in the food impoverishes the colouring matter 
 of the red blood-corpuscles on which they depend for their power of 
 carrying oxygen to the tissues, and anaemia and other disorders of 
 deficient oxidation result. 
 
 The lack of sufficient potash salts, especially potassium carbonate 
 and chloride, is a factor in producing scurvy, and the condition is 
 intensified by the use of common salt. A diet of salt meat and 
 farinaceous foods with absence of potatoes and fresh fruit and vege- 
 tables may cause it. 
 
 The lack of sodium chloride interferes with many of the functions 
 of the body immediately concerned with nutrition, such as absorp- 
 
ELEMENTARY COMPOSITION OF FOODS 3 
 
 tion (osmosis), secretion, etc., and alters the density and reactions of 
 the different body fluids. 
 
 These few illustrations suggest the diversity of roles exhibited by 
 the elements and the need for a correctly balanced diet. 
 
 In order to determine what such a diet should consist of it is ne- 
 cessary to study the value of the principal classes of foods in force 
 production and in nutrient power or tissue building, but before pro- 
 ceeding further with this discussion it will be advisable to adopt a sim- 
 ple comprehensive classification of the foods in general use by man. 
 
 The following table of analyses made by Dujardin-Beaumetz is 
 quoted by Yeo to show the proportion of nitrogen present in differ- 
 ent foods, and also the combustible carbon and hydrogen. 
 
 " The hydrogen existing in the compound in excess of what is re- 
 quired to form water with the oxygen present is calculated as carbon. 
 It is only necessary to multiply the nitrogen by 6.5 to obtain the 
 amount of dry proteids in 100 grammes of the fresh food substance : " 
 
 Beef (uncooked) 
 
 Roast beef 
 
 Calf's liver 
 
 Foie-gras. 
 
 Sheep's kidneys 
 
 Skate 
 
 Cod, salted 
 
 Herring, salted 
 
 Herring, fresh 
 
 Whiting 
 
 Mackerel 
 
 Sole 
 
 Salmon 
 
 Carp 
 
 Oysters 
 
 Lobster (uncooked) 
 
 Eggs 
 
 Milk (cow's) 
 
 Cheese (Brie) 
 
 Cheese (Gruyere) 
 
 Cheese (Roquefort) 
 
 Chocolate 
 
 Wheat (hard southern, variable average). . 
 Wheat (soft southern, variable average). . . 
 
 Flour, white (Paris) 
 
 Rye flour 
 
 Winter barley 
 
 Maize 
 
 Buckwheat 
 
 Rice 
 
 Oatmeal 
 
 Bread, white (Paris, thirty per cent water) 
 Bread, brown (soldiers' rations formerly). 
 Bread, brown (soldiers' rations at present) 
 
 Bread from flour of hard wheat 
 
 Potatoes 
 
 Beans 
 
 
 C + H. 
 
 Nitrogen. 
 
 Combustibles cal- 
 
 
 culated as carbon. 
 
 3.OO 
 
 II.OO 
 
 3-53 
 
 17.76 
 
 3-Og 
 
 15.68 
 
 2.12 
 
 65.58 
 
 2.66 
 
 12.13 
 
 3.83 
 
 12.25 
 
 5-02 
 
 16.OO 
 
 3- II 
 
 23.OO 
 
 I.83 
 
 2I.OO 
 
 2.41 
 
 9.OO 
 
 3-74 
 
 I9.26 
 
 I. 91 
 
 12.25 
 
 2.09 
 
 16.OO 
 
 3-49 
 
 I2.IO 
 
 2.13 
 
 7- -18 
 
 2-93 
 
 IO.96 
 
 I.9O 
 
 I3-50 
 
 O.66 
 
 8.00 
 
 2-93 
 
 35- 00 
 
 5.00 
 
 38.00 
 
 4.21 
 
 44.44 
 
 1.52 
 
 58.00 
 
 3.00 
 
 41.00 
 
 1. 81 
 
 39.00 
 
 1.64 
 
 38.50 
 
 1-75 
 
 41.00 
 
 1.90 
 
 40.00 
 
 1.70 
 
 44.00 
 
 2.20 
 
 42.50 
 
 1.80 
 
 41.00 
 
 i-95 
 
 44.00 
 
 1.08 
 
 29.50 
 
 1.07 
 
 28.00 
 
 1.20 
 
 30.00 
 
 2.20 
 
 31.00 
 
 o.33 
 
 11.00 
 
 4-50 
 
 42.00 
 
FOODS AND FOOD PREPARATIONS 
 
 Haricots (dry) 
 
 Lentils (dry) 
 
 Peas (dry) 
 
 Carrots 
 
 Mushrooms 
 
 Figs (fresh) 
 
 Figs (dry) 
 
 Plums 
 
 Coffee (infusion of ioo grammes). 
 Tea (infusion of ioo grammes). . . 
 
 Bacon 
 
 Butter (fresh) 
 
 Olive oil 
 
 Beer, strong 
 
 Wine 
 
 
 C + H. 
 
 Nitrogen. 
 
 Combustibles cal- 
 
 
 culated as carbon. 
 
 3-92 
 
 43.OO 
 
 3-87 
 
 43.OO 
 
 3-66 
 
 44.OO 
 
 0.31 
 
 5-50 
 
 0.60 
 
 4.52 
 
 0.41 
 
 I5-50 
 
 0.92 
 
 34.OO 
 
 o.75 
 
 28.00 
 
 1. 10 
 
 9.OO 
 
 1. 00 
 
 IO.50 
 
 1.29 
 
 71.14 
 
 0.64 
 
 83.00 
 
 Trace 
 
 98.OO 
 
 0.05 
 
 4-50 
 
 0.15 
 
 4.00 
 
 To estimate the equivalent chemical elements in the different 
 classes the following standards are adopted : 
 
 1. To obtain the amount of nitrogen in proteid foods, divide the 
 quantity of food by 6.50. 
 
 2. To obtain the carbon in fat, multiply the quantity of fat by 
 0.765. 
 
 3. To obtain the carbon in carbohydrate food, multiply by 0.444. 
 
 4. To obtain the carbon in proteid food, multiply by 0.535. 
 
 Estimates vary somewhat as to the average quantity of the ele- 
 ments carbon and nitrogen consumed per diem. In a general way it 
 may be said that the consumption of carbon is 320 grammes, and 
 that of nitrogen about 20 grammes. (See Quantity of Food, 
 page 283.) 
 
 FOOD CLASSIFICATION 
 
 Foods may be classified in various ways, according to — 
 
 1. Their physical properties. 
 
 2. Their source. 
 
 3. Their composition. 
 
 4. The role which they perform in the animal body. 
 
 Foods are classed in accordance with their general physical 
 properties : First, into solid, semisolid, and liquid foods ; secondly, 
 into fibrous, gelatinous, starchy, oleaginous, crystalline, and albu- 
 minous foods. 
 
 A subdivision sometimes used is that of the " complete " foods, 
 such as eggs or milk, which in a single article comprise all the 
 necessary ingredients and elements to support life, and " incom- 
 plete " foods, which are capable of maintaining life but a compara- 
 tively short time. 
 
 Foods may be classed as to their source primarily into animal 
 and vegetable foods. 
 
 Animal foods consist of meats, fish, shellfish, and crustaceans, 
 
FOOD CLASSIFICATION 5 
 
 eggs, milk and its products, animal fats, gelatin. The vegetable 
 foods are subdivided into cereals, vegetables proper, fruits, sugars, 
 vegetable oils. 
 
 The simplest chemical classification possible is that advocated by 
 Baron von Liebig, who was the first to suggest a really scientific 
 division of foods. He grouped all foods into two classes — 
 
 a. Nitrogenous, b. Non-nitrogenous. 
 
 Each of these classes contains food materials derived from both 
 the animal and vegetable kingdoms, although the majority of the 
 animal substances belong to the nitrogenous, and the majority of 
 vegetable substances to the non-nitrogenous group. 
 
 a. The nitrogenous group von Liebig regarded as containing 
 " plastic " elements — i. e., they are essentially " tissue builders " or 
 " flesh formers." 
 
 Nitrogenous foods are sometimes called " azotised foods " or 
 " albuminoids " — that is, substances resembling albumin. They con- 
 sist chiefly of the four elements carbon, oxygen, hydrogen, and 
 nitrogen, to which a small proportion of sulphur and phosphorus are 
 usually joined. These elements for the most part are combined as 
 some form of albumin. 
 
 Nitrogenous or proteid foods are non-crystallisable, but coagula- 
 ble, principally fluid or semisolid substances. They are fermenta- 
 ble, and under some conditions will putrefy. 
 
 The nitrogenous group comprises all forms of animal food, ex- 
 cepting fats, glycogen, and such substances as milk, sugar, and 
 honey. It includes, therefore, albumins and gelatins. Its chief rep- 
 resentatives are milk, eggs, crustaceans, fish, shellfish, flesh, and 
 fowl. It also contains such nitrogenous substances as exist in the 
 vegetable kingdom or " vegetable albuminoids." 
 
 b. The second or non-nitrogenous group von Liebig called 
 " respiratory or calorifacient foods," because their function in the 
 body is to furnish fuel or maintain animal heat. Since this original 
 classification was suggested it has been established that the non- 
 nitrogenous aliments supply energy as force, manifested through 
 muscular action, hence they are also called " force producers," in 
 distinction from the nitrogenous or proteid " tissue builders." 
 
 This is a convenient distinction to adopt, but it must not be held 
 too absolutely, for in emergencies the tissue builders are used as 
 force producers and heat producers as well. 
 
 The non-nitrogenous group contains strictly only the three ele- 
 ments carbon, hydrogen, and oxygen, although various salts are 
 mixed with both vegetable and animal foods. It includes vegetables, 
 fruits, cereals, starches, sugars, gums, fats and oils (which latter are 
 both animal and vegetable), and organic acids. Many vegetables, 
 besides some fruits, contain considerable nitrogen, but the " carbo- 
 hydrates " — i. e., starches and sugars — constitute their main bulk. 
 
6 
 
 FOODS AND FOOD PREPARATIONS 
 
 Many vegetables, and, in fact, all starch granules, contain proteid 
 material which is chiefly used in the formation of outside coverings 
 to afford protection and firmness of resistance to a softer pulp within. 
 Neither is animal food strictly nitrogenous, on account of its fat 
 and glycogen, nor is vegetable food strictly non-nitrogenous, owing 
 to its albuminoids and other forms of proteids (such as plant albumin, 
 found in the legumes, etc.), yet this classification is a very con- 
 venient and simple one which has met with general acceptance. It 
 will be used in this book whenever a further degree of subdivision 
 is not needed, but always with the understanding that it has only a 
 general and not too literal application, and, unless otherwise dis- 
 tinctly specified, " nitrogenous food " will be understood to include 
 animal food, and " non-nitrogenous food " to include vegetable food 
 of all kinds, and vice versa. 
 
 Table of Composition of Some Common Foods 
 (Hofmann.) 
 
 
 Nitrogenous 
 constituents. 
 
 Fat. 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 Total. 
 
 Fat beef 
 
 51-4 
 89.4 
 
 27-3 
 16.6 
 
 7-7 
 
 45-6 
 5-5 
 0.8 
 0.9 
 0.4 
 
 08^9 
 81.9 
 91.2 
 
 3-o 
 5-i 
 
 3.0 
 
 0.6 
 
 0.7 
 
 IOO 
 
 Lean beef 
 
 IOO 
 
 Pea flour 
 
 IOO 
 
 Wheat 
 
 IOO 
 
 Rice 
 
 IOO 
 
 
 
 Table of Composition of Common Foods 
 (Abridged from Parkes.) 
 
 Articles. 
 
 Beefsteak 
 
 Fat pork 
 
 Smoked ham 
 
 Whitefish 
 
 Poultry 
 
 White wheat in bread 
 
 Biscuit 
 
 Oatmeal 
 
 Maize 
 
 Macaroni 
 
 Arrowroot 
 
 Peas (dry) 
 
 Potatoes 
 
 Carrots 
 
 Cabbages 
 
 Butter 
 
 Egg (1-10 for shell) 
 
 Cheese 
 
 Milk (specific gravity, 1032) 
 
 Cream 
 
 Skimmed milk 
 
 Sugar 
 
 Water. 
 
 Proteids. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 74-4 
 
 20.5 
 
 3-5 
 
 
 1.6 
 
 39-0 
 
 9.8 
 
 48.9 
 
 
 2-3 
 
 27.8 
 
 24.O 
 
 36.5 
 
 
 10. 1 
 
 78.O 
 
 18. 1 
 
 2.9 
 
 
 1.0 
 
 74.O 
 
 2I.O 
 
 3-8 
 
 
 1.2 
 
 40.O 
 
 8.0 
 
 1-5 
 
 49.2 
 
 i-3 
 
 8.0 
 
 15.6 
 
 1-3 
 
 73-4 
 
 1.7 
 
 15.O 
 
 12.6 
 
 5.6 
 
 63.O 
 
 3-0 
 
 13-5 
 
 10. 
 
 6.7 
 
 64-5 
 
 i-4 
 
 I3-I 
 
 9.0 
 
 0.3 
 
 76.8 
 
 0.8 
 
 15-4 
 
 0.8 
 
 
 83-3 
 
 0.27 
 
 15-0 
 
 22.0 
 
 2.0 
 
 53-o 
 
 2.4 
 
 74-0 
 
 2.0 
 
 0. 16 
 
 21.0 
 
 1.0 
 
 85.0 
 
 1.6 
 
 O.25 
 
 8-4 
 
 1.0 
 
 91.0 
 
 1.8 
 
 5-0 
 
 5-8 
 
 0.7 
 
 6.0 
 
 0.3 
 
 9I.0 
 
 
 2-7 
 
 73-5 
 
 13-5 
 
 11. 6 
 
 .... 
 
 1.0 
 
 36.8 
 
 33-5 
 
 24-3 
 
 
 5-4 
 
 86.8 
 
 4.0 
 
 3-7 
 
 4.8 
 
 0.7 
 
 66.0 
 
 2.7 
 
 26.7 
 
 2.8 
 
 1.8 
 
 88.0 
 
 4.0 
 
 1.8 
 
 5-4 
 
 0.8 
 
 3-o 
 
 
 
 96.5 
 
 0.5 
 
FORCE PRODUCTION. ENERGY FROM FOOD J 
 
 The foregoing analyses by Hofmann and Parkes of several com- 
 mon foods illustrate the mixed character of animal and vegetable 
 foods and the difficulties of a purely chemical basis of classification. 
 
 For the purpose of the present work, it is convenient to sub- 
 divide foods by the following classification: I. Water; II. Salts; 
 III. Proteids (chiefly albumins and the allied gelatin) ; IV. Starches ; 
 V. Sugars ; VI. Fats and oils. 
 
 Protein is a comprehensive term used in food calculations to 
 signify all nitrogenous food substances, except the nitrogenous fats. 
 Proteids are nitrogenous substances of definite composition forming 
 a portion of the protein class. 
 
 Some writers class oxygen in a separate division among foods. 
 This seems unnecessary, unless a separate division is made for 
 hydrogen, and in fact for each element. The primary object of food 
 classification is to obtain a practical working basis of subdivision, 
 and the less complex this is made, the better. Further details of 
 grouping belong to the refinements of physiological or organic 
 chemistry, and are out of place in the present work. 
 
 FORCE PRODUCTION. ENERGY FROM FOOD 
 
 The two ultimate uses of all food are to supply the body with 
 materials for growth or renewal, and with energy or the capacity for 
 doing work. The energy received in a latent form, stored in the 
 various chemical combinations of foods, is liberated as kinetic or 
 active energy in two chief forms : first, as heat ; second, as motion. 
 Force is the manifestation of energy. The force developed by a 
 healthy adult man at ordinary labour averages 3,400 foot tons per 
 diem, a foot ton being the amount of force required to raise a weight 
 of one ton through the height of one foot. Of this, less than one 
 fifth is expended in motion, and more than four fifths, or 2,840 foot 
 tons, in heat, which maintains the body temperature at its normal 
 average. A man weighing one hundred and fifty pounds — or nearly 
 one thirteenth of a ton — obviously expends considerable energy in 
 merely moving his own body about from place to place, aside from 
 carrying any additional burden. 
 
 The original force developed in the various functions of animal 
 life which result in heat production and motion is in part obtained 
 from the radiant heat of the sun stored by plants in the latent form 
 of certain chemical compounds — chiefly starches and sugars — which, 
 on being consumed as food by animals, furnish energy. 
 
 A useful comparison may be made between the processes of nu- 
 trition and development of energy from food in the human body 
 and the energy derived from a steam engine and boiler. In both 
 cases the main source of energy is oxidation, and principally of car- 
 bon. In both cases the latent energy of the carbon liberated by 
 
8 FOODS AND FOOD PREPARATIONS 
 
 oxidation processes is converted into heat and motion, forms of 
 energy which bear a definite relation to one another. If a large 
 part of the original latent energy is converted into heat, less will 
 yield motion, and conversely. The proportion of these two forces 
 to each other is in the case of the most perfectly constructed en- 
 gine about one of motion to eight of heat; whereas in the human 
 body it was calculated by Helmholtz that the motion obtainable 
 from a given amount of food may stand in relation to the heat in 
 the proportion of one to five. Hence, as regards the production of 
 work through motion, the human body is a more perfectly con- 
 structed machine than the engine. Furthermore, after combustion 
 of the carbon by the fires of the boiler a certain amount of waste 
 matter or ash is produced. If this is allowed to accumulate, it 
 obstructs the draught and interferes with active oxidation. In the 
 human body, in like manner, the fuel or food consumed produces 
 ashes, such as urea and other forms of waste material, which, if not 
 removed, accumulate in the system and embarrass or retard the 
 normal oxidation processes. The body possesses the additional 
 power of modifying and distributing the fuel food which it receives 
 so as to develop its energy to the best advantage in different organs. 
 
 R. C. Carpenter, in 1898, made an exhaustive study of the energy 
 developed by a bicycle-rider named Miller. He found that the 
 energy developed by this man equalled 45 per cent of the total heat 
 of combustion calculated for his food. Professor Carpenter says : 
 " The best record of any heat engine is probably that of the Deisal 
 motor," which develops 33.7 per cent of the heat energy of its fuel, 
 and " the best record of a steam engine is that of the Nordberg 
 pumping engine at Pittsburg," which develops 2.2.7 P er cent °f 
 energy. 
 
 " With the exception of the Deisal motor the best record of 
 any oil engine per delivered horse power is about 16.5 per cent effi- 
 ciency. From this comparison it would seem that the human 
 machine is decidedly superior to any heat engine which has been 
 developed in form so as to be of any value for practical use." 
 
 Whether elementary substances are burned outside of the body 
 or oxidised within the body, the resulting products are the same. 
 There can be no loss of matter, and there can be no loss of energy. 
 The matter is simply changed in form by molecular rearrangement, 
 the energy is converted from one type into another. The following 
 simple experiment will illustrate this point : In a large covered glass 
 jar place an ounce of alcohol in a small metal vessel. Also place in 
 the jar a little lime water in a tumbler, and a thermometer. On 
 igniting the alcohol and allowing it to burn away completely, a film 
 of aqueous vapour will accumulate on the surface of the jar, and a 
 film of calcium carbonate will form on the surface of the lime water 
 produced by the union of carbonic-acid gas with the lime water. 
 
FORCE PRODUCTION. ENERGY FROM FOOD 9 
 
 The thermometer will indicate a rise in temperature of the air in the 
 jar. An ounce of alcohol consumed as food will be similarly con- 
 verted into carbonic-acid gas and water, and in this process the body 
 heat will be increased. No substance is a good food unless it fulfils 
 two conditions — viz., easy assimilation and complete combustion. 
 The proportion of any given food actually assimilated (i. e., not 
 rejected in the feces) is called its " coefficient of digestibility." 
 
 Metabolism within the body is not alone controlled by muscular 
 work, but by the nervous energy expended in its performance. For 
 example, a day labourer, like an iron founder, may be stronger and 
 do much more mechanical work than an oarsman or foot-ball player 
 in time of contest, yet he expends very little nervous energy in his 
 routine daily work, and requires less protein in his diet than the 
 athlete. In other words, severe muscular work performed for a 
 brief time under conditions of great mental excitement and nervous 
 tension demands an excess of protein, whereas continued muscular 
 effort without great fatigue or mental strain is maintained upon a 
 liberal allowance of food, which may be varied in composition if it 
 be easily digestible. 
 
 The relative importance of the different food fuels should be 
 considered. This is well summarised by Charles E. Woodruff : 
 
 " For instance, cut off the supply of oxygen, and death ensues in 
 from one to ten minutes. If water is withheld, preventing the trans- 
 portation of the fuel and oxygen to various parts of the body, death 
 follows in about two to seven days or more, according to climate, 
 exposure, and exercise. If the fuel itself is taken away, death follows 
 in from seven to forty days or more, according to the amount of 
 exposure that would abstract heat and the amount of work that 
 would use up the energy already stored up in the body. If materials 
 for the repair of tissues be excluded, death follows in a variable time, 
 dependent upon the importance of the tissue that is being starved — 
 a time varying from a week if all nitrogen is excluded, to several 
 months if the vegetable acids are excluded, or even to several years " 
 — if certain more obscure substances are withheld. 
 
 It still remains extremely difficult in the case of all foods to 
 trace their final uses in the body and determine with any approach 
 to accuracy what proportions of each furnish respectively energy, 
 repair of tissue, and heat, for there are no more complex chemical 
 processes known than those of tissue metabolism. In other words, 
 it is necessary to determine whether the actual physiological value 
 of food in the body as producing energy for muscular activity and 
 body heat corresponds with its calculated or calorimetric value, and 
 to determine standards of " fuel value." 
 
 In order to study the quantity of energy which may be derived 
 from different varieties of food, a man or an animal may be placed 
 in an apparatus known as a calorimeter. There are numerous types 
 3 
 
10 FOODS AND FOOD PREPARATIONS 
 
 of such apparatus, and Professor Atwater collected, in 1897, data 
 of 3,661 calorimeter experiments, 2,299 of which have been made 
 by various observers upon man. In the great majority of these 
 experiments the nitrogen balance was determined, and the carbon 
 balance was computed by deduction, but in a few the latter was de- 
 termined directly. The most elaborate and ingenious apparatus of 
 this sort is the " respiration calorimeter " constructed at Wesleyan 
 University by Profs. W. O. Atwater and E. B. Rosa. It con- 
 sists of a chamber seven feet long, six feet four inches high, and 
 four feet wide, in which a man may remain day and night, being sup- 
 plied with fresh air and food. The chamber is practically a many- 
 walled, air-tight box having air spaces between the walls which 
 are so constructed as to maintain a uniform temperature within and 
 prevent all external temperature changes from affecting the interior. 
 There are two inner metal walls composed respectively of copper 
 and zinc, and three outer wooden walls reinforced by thick builders' 
 paper. Between these five walls, which completely surround the 
 box, over top and bottom as well as sides, are four air spaces several 
 inches in thickness, two containing dead air and two circulating air, 
 kept in motion by electric fans and warmed or cooled according to 
 need, so as to maintain a constant temperature within. A glass* 
 window constructed with successive layers like the walls serves to 
 admit the man under observation, after which it is hermetically 
 soldered. A small air lock is used to admit food and to pass out 
 excrement for analysis. The chamber contains a folding bed, table, 
 and chair, a pair of scales, and a stationary bicycle which operates 
 a small dynamo and electric light. The heat from the light is meas- 
 ured, together with that dissipated from the man's body within the 
 chamber, and this gives a measure of muscular work converted into 
 the energy of heat. The heat is conveyed away from the chamber 
 by means of a current of cold water passing through copper pipes, 
 and is measured by electric thermometers. Circulating air is sup- 
 plied to the interior of the chamber, and samples are withdrawn for 
 analysis as it enters and leaves the chamber. In this manner is 
 measured the quantity of C0 2 and water eliminated through the 
 lungs and skin. The volume and temperature of the air is carefully 
 regulated. The subject of experimentation is put upon a measured 
 diet for four days before entering the calorimeter in order to estab- 
 lish nitrogenous equilibrium and record observations upon the food 
 excrement, amount of work performed, etc. He then enters the 
 calorimeter, where he remains four days and five nights. In the " test 
 experiments " the subject makes as little muscular exertion as pos- 
 sible, but in the " work experiments " he operates the stationary 
 bicycle for eight hours a day. The delicacy of the apparatus is 
 shown by the fact that in the thermo-electric measurement system 
 304 pairs of metallic junctions are distributed throughout the inner 
 
FORCE PRODUCTION. ENERGY FROM FOOD 
 
 I I 
 
 wall air space, and the heat generated by such slight movements as 
 turning in bed or rising from a chair at once produces a deflection of 
 the thermal galvanometer. The main value of the experiments 
 thus far conducted in this calorimeter consists in the actual demon- 
 stration that the law of the conservation of energy operates within 
 the body in precisely the same manner that it does outside. In 
 man it was found that the measured energy of the food consumed 
 by the subject within the calorimeter was within 99 per cent of the 
 calculated or theoretical energy. A margin of 1 per cent of error 
 is certainly very small in view of the difficulties of such complicated 
 experiments. It is possible that some of the energy was perma- 
 nently stored within the body, and another physiological source of 
 slight error lies in possible differences in temperature of the whole 
 body between entering and leaving the calorimeter. The other 
 important use of the respiration calorimeter is to determine the fuel 
 value of different foods, alcohol, etc., in furnishing heat and motion 
 for the body. The complete calorimeter experiment comprises : 
 (1) weighing and analysis of food, feces, and urine ; (2) determination 
 of the C0 2 and water eliminated by the patient ; (3) estimation of 
 the energy produced by the body in the form of heat, both when at 
 rest and in motion, the motion being converted into heat by means 
 of the bicycle and dynamo above described. The results obtained 
 by Professor Atwater in two of his calorimeter experiments are tabu- 
 lated by him as follows : 
 
 Comparison of Daily Income and Outgo of Protein and of Energy in the 
 Rest and Work Experiments (Nos. p and 6) 
 
 
 PROTEIN. 
 
 ENERGY. 
 
 Experiment. 
 
 Of food. 
 
 Actually 
 oxidised. 
 
 Of food. 
 
 Of 
 
 material 
 actually 
 oxidised. 
 
 Measured. 
 
 Difference 
 in per cent 
 of heat of 
 material 
 actually 
 oxidised. 
 
 Rest (No. 9) 
 
 Grammes. 
 H9-4 
 H9-4 
 
 Grammes. 
 
 115. 
 
 103. 1 
 
 Calories. 
 2,717 
 3,678 
 
 Calories. 
 2,275 
 3,830 
 
 Calories. 
 2,3lO 
 3,726 
 
 Per cent. 
 + 1.5 
 - 2.7 
 
 Work (No. 6) 
 
 Average Daily Income and Outgo of Nitrogen and Carbon in the Rest and 
 Work Experiments (Nos. g and 6), with the Estimated Gain or Loss 
 of Protein and of Fat 
 
 
 NITROGEN. 
 
 CARBON. 
 
 CALCULATED 
 GAIN OR LOSS. 
 
 Experiment. 
 
 In 
 
 food. 
 
 In 
 
 feces. 
 
 In 
 urine. 
 
 Gain 
 (+)or 
 
 loss 
 
 In 
 food. 
 
 In 
 feces. 
 
 In 
 urine. 
 
 In re- 
 spira- 
 tory 
 prod- 
 ucts. 
 
 Gain 
 
 ( + ) or 
 loss 
 
 Of pro- 
 tein. 
 
 Of fat. 
 
 Rest (No. 9).. 
 Work (No. 6). 
 
 Gms. 
 I 9 . 1 
 19. 1 
 
 Gms. 
 1.2 
 
 1-5 
 
 Gms. 
 18.4 
 16.5 
 
 Gms. 
 -O.6 
 
 + I.I 
 
 Gms. 
 261.5 
 336.7 
 
 Gms. 
 13.3 
 12.4 
 
 Gms. 
 12.6 
 12.5 
 
 Gms. 
 223.6 
 345 2 
 
 Gms. 
 + I2.0 
 -33-3 
 
 Gms. 
 -3.6 
 + 6.9 
 
 Gms. 
 
 + I8.2 
 -48.3 
 
12 FOODS AND FOOD PREPARATIONS 
 
 An ingenious device was used to differentiate the feces belonging 
 to the period of experimentation before entering the calorimeter 
 from those following ingestion of food within the apparatus. To 
 do this, just before entering the calorimeter the man is required to 
 take a few grains of lampblack with his food. This harmless sub- 
 stance colours the stool and marks the dividing line. 
 
 The unit of measurement used in calorimeter experiments is the 
 calorie, which is the amount of heat required to raise I kilogramme 
 of water from o° to i° C. ; this equals 3,100 foot pounds, or, approxi- 
 mately, it is the heat required to raise one pound of water 4 Fahren- 
 heit. Fuel value is a term denoting the total calories derivable from 
 a pound of any given food substance if it be completely combusted 
 within the body. The fuel values are calculated for a given food by 
 the factors of Rubner as follows: 4.1 calories per gramme of either 
 protein or carbohydrate, and 9.3 calories per gramme of fat. This 
 corresponds with 18.6 calories of energy for each hundredth of a 
 pound of protein or carbohydrate and 42.2 calories for the same 
 quantity of fat in any food (W. O. Atwater). Or, as stated by C. F. 
 Langworthy, the fuel value of the three chief classes of nutrients is 
 as follows : 
 
 One pound of protein yields 1,860 calories. 
 
 " " " fats " 4,220 " 
 
 " " " carbohydrates i,86o " 
 
 " In other words, when we compare the nutrients in respect to 
 their fuel values, their capacities for yielding heat and mechanical 
 power, a pound of protein of lean meat or albumin of egg is just 
 about equivalent to a pound of sugar or starch, and a little over two 
 pounds of either would be required to equal a pound of the fat of 
 meat or butter or the body fat." 
 
 The work of the average man is calculated to be about 2,000,000 
 foot pounds per diem (R. H. Thurston). This may exceptionally 
 be increased to 3,000,000 foot pounds. According to the study of 
 R. C. Carpenter of a phenomenal athlete named Miller, the latter 
 developed work amounting to over 15,000,000 foot pounds (7,500 
 foot tons) on the first day of a six-days' bicycle contest, and 5,500,000 
 foot pounds (2,750 foot tons) on the last day. 
 
 Elaborate investigations have been made with all the principal 
 classes of foods in order to estimate their nutrient, their heat-pro- 
 ducing, and their force-producing value, and many statistical tables 
 have been compiled. It should be remembered that a(l this work 
 is merely approximate, and that the liability to error in 1 the various 
 factors is considerable, but in a general way the results jare instruc- 
 tive, and they are certainly interesting and not altogether without 
 practical application. " The fuel value of a pound of protein as it is 
 ordinarily burned in the body is very nearly the same as that of a 
 
FORCE PRODUCTION. ENERGY FROM FOOD 1 3 
 
 pound of carbohydrates, but fats have a fuel value of two and one 
 quarter times that of protein and carbohydrates, or 4,220 calories 
 per pound " (A. C. True). A day labourer requires 0.28 pound of 
 protein per diem plus enough fat and carbohydrate to yield a total 
 fuel value of 3.500 calories. A professional man requires 0.22 to 
 0.25 pound of protein to yield 2,700 to 3,000 calories of energy, but 
 more than that is often consumed. Study at the Storrs experiment 
 station in Connecticut (1896) of nine families of professional men 
 showed an actual consumption of 107 grammes of protein, and a diet 
 fuel value of 3,430 calories.^ The standard for a man at light mus- 
 cular labour demands 112 grammes of protein and a fuel value of 
 3,000 calories. 
 
 The mere calculation of the nitrogen and carbon in a food does 
 not at all show its force value in the body, unless it can at the same 
 time be demonstrated that it is assimilable. Many substances appear 
 to contain abundant food energy which in reality are not economical 
 foods at all from the point of view of supplying all the needs of the 
 body ; thus beef fat is wholesome, but it contains no nitrogen for 
 tissue building, and peas contain a large proportion of flesh formers 
 as compared with heat givers. Wood pulp can be made to furnish 
 cellulose and yield much energy, but it is worse than useless in the 
 stomach of man, although some of the lower animals, like rodents, 
 can digest it and make it available for nutrition. Sugar can be 
 made from old rags in the laboratory, yet no stomach can deal with 
 such material. 
 
 Tables are now available for the calculation of the force value 
 of rations for large bodies of men under different conditions, as, for 
 example, soldiers in barracks or on the march, which are based upon 
 the principle of careful comparisons between the income and output 
 of energy of the body. That is to say, a study of the force-producing 
 value of different classes of foods, as obtained by chemical research 
 in the laboratory, is carefully compared with the amount of waste 
 matter which is eliminated by the system while a man is being fed 
 upon a measured quantity of food and kept under uniform conditions 
 as regards the amount of work performed. In this manner a check 
 is established upon the theoretical calculations of food values as com- 
 pared with their practical uses in maintaining the equilibrium of the 
 body. Obviously these experiments require great care and system, 
 and if they are to be made of intrinsic value they can only be con- 
 ducted by expert physiological chemists upon persons who are wil- 
 ling to subject themselves from periods varying from several days 
 to several weeks to conditions involving monotony of diet and 
 existence. For this reason the number of actual experiments of 
 this kind which have been made is comparatively small, and the 
 conclusions drawn from them must be accepted with considerable 
 allowance for possible error. A diet system to which a man may be 
 
H 
 
 FOODS AND FOOD PREPARATIONS 
 
 willing to submit for a few weeks is by no means always that which 
 will prove best for him through a longer period, and a too rigid ap- 
 plication of the rules established for the computation of the force 
 value of foods yields much less practical results than the experience 
 derived by those who actually control the commissary department 
 with due regard to proper economy and variation in food, but entirely 
 without resort to calculations of grammes of carbon, nitrogen, etc. 
 
 A criticism reached me from the inmates of a large girls' college, 
 where the diet was for some time experimentally regulated by an 
 expert in such matters, that " if one half the time were bestowed 
 upon properly serving and selecting the food that is given to com- 
 putation of its force-producing value, the girls would have very 
 much better appetites and digestion/' On the other hand, it is easy 
 to err if the dictates of hunger and capriciousness of appetite are 
 allowed to wholly control diet. In the lower animals the instincts 
 which these factors develop are very much safer guides than in the 
 case of man. 
 
 Nevertheless, the knowledge derived from experiments of the 
 kind under discussion is certainly useful and instructive, when allow- 
 ance is made for its relative value by taking into consideration the 
 wide range of circumstances that will modify its application which 
 occur in the organisation of different persons, in their varying 
 capacity for work, and in the condition of their external surround- 
 ings. With this word of explanation the following tables from dif- 
 ferent authors are reproduced. It will be observed that there are 
 some few discrepancies among them, but the cause has been ex- 
 plained above. 
 
 The following table of analyses, given by Major Charles E. 
 Woodruff, M. D., Surgeon, United States Army, differs in some 
 details from the preceding table by Parkes (p. 6), and adds several 
 foods with their calories : 
 
 Percentage Composition of Edible Portions of Garrison Ration 
 
 fat. 
 
 Bacon, 
 
 Beans 
 
 Pork, salt and fat. . 
 
 Sugar, ground 
 
 Sugar, brown issue. 
 
 Flour 
 
 Beef. 
 
 Potatoes 
 
 Onions 
 
 Oatmeal , 
 
 Cornmeal , 
 
 Canned apples 
 
 Dried apples 
 
 Water. 
 
 Tapioca or cornstarch, 
 
 20. 
 12.6 
 
 12. 1 
 2.0 
 3.0 
 
 12.5 
 55-o 
 78.9 
 87.6 
 
 7.6 
 15.0 
 83.2 
 25.0 
 
 2.0 
 
 Protein. 
 
 8.00 
 
 23.IO 
 
 O.90 
 
 II.OO 
 
 17.IO 
 
 2.IO 
 
 1-4 
 
 [5.IO 
 9.20 
 0.20 
 0.90 
 
 Fats. 
 
 09-5 
 2.0 
 
 82.8 
 
 1.0 
 
 27.O 
 
 O.I 
 
 0.3 
 
 7-i 
 
 3.8 
 0.4 
 1.8 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 5 
 1 
 2 
 
 2 
 
 5 
 5 
 9 
 .0 
 .6 
 .0 
 1.4 
 
 0.3 
 1.4 
 0.2 
 
 Energy, 
 calories 
 per lb. 
 
 3,o8o 
 1,615 
 3,5IO 
 1,820 
 
 i,795 
 1,644 
 1,460 
 
 375 
 225 
 1,850 
 1,645 
 315 
 1,418 
 1,820 
 
FORCE PRODUCTION. ENERGY FROM FOOD 
 
 15 
 
 Butter 
 
 Sirup 
 
 Lard 
 
 Rice 
 
 Canned corn 
 
 Canned tomatoes 
 
 Macaroni and vermicelli . 
 
 Milk, fresh 
 
 Milk, condensed 
 
 Peas 
 
 Raisins 
 
 Cheese 
 
 Prunes 
 
 Cabbage 
 
 Ham 
 
 Apricots, canned 
 
 Barley 
 
 Chocolate 
 
 Sausage 
 
 Oysters 
 
 Salmon, canned 
 
 Crabs 
 
 Crackers 
 
 Water. 
 
 10.5 
 43.7 
 
 12.0 
 
 12.4 
 81.3 
 
 96.0 
 
 13. 1 
 14. 
 
 25 
 
 12, 
 
 40 
 
 35. 
 
 30.0 
 
 92.0 
 
 41.5 
 50.0 
 
 12.0 
 41.2 
 87.1 
 63.6 
 
 Protein. 
 
 I. OO 
 
 O.60 
 
 7-4 
 2.80 
 O.80 
 9.OO 
 O.843 
 17.OO 
 26.70 
 O.4O 
 
 33 -oo 
 2.50 
 2.10 
 
 16.7 
 2.00 
 
 13.00 
 
 20.00 
 
 13.80 
 6.00 
 
 21.60 
 
 15.0 
 
 10.3 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 85.O 
 
 83*4 
 0.4 
 1.1 
 0.4 
 0.3 
 
 802 
 o 
 
 0.6 
 
 39-i 
 
 2-7 
 50.0 
 42.8 
 
 1.2 
 
 13-4 
 1.0 
 
 9.4 
 
 0.5 
 55-0 
 
 79-4 
 13.2 
 
 2-5 
 76.8 
 
 1.069 
 44.00 
 56.40 
 24.00 
 
 5 00 
 12.0 
 
 5-5 
 
 30.0 
 76.0 
 10. o 
 
 3-7 
 
 Salts. 
 
 70.5 
 
 3-o 
 2-3 
 4.0 
 0.4 
 0.6 
 
 0.3 
 0.8 
 0.164 
 3-o 
 2.9 
 0.6 
 5-o 
 0.6 
 1 
 
 7 
 .6 
 .0 
 .0 
 
 2 
 .0 
 
 4 
 
 Energy, 
 calories 
 per lb. 
 
 3.615 
 1,023 
 3,570 
 1,630 
 
 345 
 
 80 
 
 1,406 
 
 418 
 i,595 
 1,565 
 
 440 
 1,600 
 
 140 
 
 155 
 1,960 
 
 460 
 1,800 
 2,650 
 2,065 
 
 230 
 
 965 
 526 
 
 1,900 
 
 Standards for Daily Dietaries 
 
 (Compiled by Atwater.) 
 
 Weights of nutrients and calories of energy (heat units) in nutrients required in food 
 
 per day. 
 
 Children up to a year and a half. . 
 
 Children of two to six years 
 
 Children of six to fifteen years .... 
 
 Aged woman 
 
 Aged man , 
 
 Women at moderate work (Voit). , 
 Man at moderate work (Voit). ... 
 
 Man at hard work (Voit) 
 
 Man with moderate exercise (Play 
 
 fair) 
 
 Active labour (Playfair) 
 
 Hard labour (Playfair) , 
 
 Women with light exercise (At 
 
 water) , 
 
 Man with light exercise (Atwater). 
 Man at moderate work (Atwater). , 
 
 Man at hard work (Atwater) , 
 
 Man at moderate work (Moleschott) 
 Man at moderate work (Wolff).. 
 
 
 NUTRIENTS. 
 
 
 
 
 
 
 
 Potential 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Total. 
 
 energy. 
 
 Grammes. 
 
 Grammes. 
 
 Grammes. 
 
 Grms. 
 
 Calories. 
 
 28 
 
 37 
 
 75 
 
 140 
 
 767 
 
 (20-36) 
 
 (30-45) 
 
 (60-90) 
 
 
 
 55 
 
 40 
 
 200 
 
 295 
 
 I,4l8 
 
 (36-70) 
 
 (35-48) 
 
 (100-250) 
 
 
 
 75 
 
 43 
 
 325 
 
 443 
 
 2,041 
 
 (70-80) 
 
 (37-5o) 
 
 (250-400) 
 
 
 
 80 
 
 5o 
 
 260 
 
 39° 
 
 1,859 
 
 100 
 
 68 
 
 350 
 
 5i8 
 
 2,477 
 
 92 
 
 44 
 
 400 
 
 536 
 
 2426 
 
 118 
 
 56 
 
 500 
 
 674 
 
 3,o55 
 
 145 
 
 100 
 
 450 
 
 695 
 
 3,370 
 
 119 
 
 5i 
 
 53i 
 
 701 
 
 3,139 
 
 156 
 
 7i 
 
 568 
 
 795 
 
 3,629 
 
 185 
 
 7i 
 
 568 
 
 824 
 
 3.74S 
 
 80 
 
 80 
 
 300 
 
 460 
 
 2,300 
 
 100 
 
 100 
 
 360 
 
 460 
 
 2,820 
 
 125 
 
 125 
 
 450 
 
 700 
 
 3,520 
 
 150 
 
 150 
 
 500 
 
 800 
 
 4,060 
 
 130 
 
 40 
 
 550 
 
 720 
 
 3,160 
 
 120 
 
 35 
 
 540 
 
 695 
 
 3,032 
 
i6 
 
 FOODS AND FOOD PREPARATIONS 
 
 Church furnishes the following table showing the number of tons 
 which it is calculated could be raised through the height of one foot 
 bv the complete combustion of a single pound of each kind of food. 
 In the body only about a fifth of this energy would develop work, the 
 rest going into heat production : 
 
 i pound beef fat 
 
 raises 
 
 5,649 tons 
 
 1 foot high. 
 
 " oatmeal 
 
 " 
 
 2,439 " 
 
 " " 
 
 " gelatin 
 
 " 
 
 2,270 " 
 
 " " 
 
 " lean beef 
 
 " 
 
 885 " 
 
 " 
 
 " potatoes 
 
 " 
 
 618 " 
 
 " " 
 
 " milk 
 
 " 
 
 390 " 
 
 " " 
 
 " ground rice 
 
 " 
 
 2,330 " 
 
 11 ti 
 
 Landois and Stirling give the following table, which differs some- 
 what from other estimates in the relative proportion of fats and 
 starches. An adult doing a moderate amount of work takes in as 
 food per diem — 
 
 
 C. 
 
 H. 
 
 N. 
 
 O. 
 
 120 grammes albumin, containing. . . . 
 
 90 " fats, containing 
 
 330 " starches, containing. . . . 
 
 64.18 
 
 70.20 
 
 146.82 
 
 281.20 
 
 8.60 
 IO.26 
 20.33 
 
 18.88 
 
 28.34 
 
 9-54 
 162.85 
 
 
 39-19 
 
 18.88 
 
 200.73 
 
 Add 744.11 grammes O. from the air by respiration. 
 " 2,818.00 " H 2 0. 
 " 32.00 " inorganic compounds (salts). 
 
 The whole is equal to three kilogrammes and a half (seven 
 pounds), i. e., about a twentieth of the body weight, so that about 
 6 per cent of the water, about 6 per cent of the fat, about 1 per cent 
 of the albumin, and about 0.4 per cent of the salts of the body are daily 
 transformed within the organism. 
 
 An adult doing a moderate amount of work eliminates in 
 grammes : 
 
 By respiration. 
 By perspiration 
 
 By urine 
 
 By feces 
 
 Water. 
 
 C. 
 
 H. 
 
 3o 
 3-o 
 
 N. 
 
 330 
 
 660 
 
 IJOO 
 
 128 
 
 248. s 
 
 2.6 
 
 9.8 
 
 20.0 
 
 i 5 :s 
 3.0 
 
 2,8l8 
 
 2S1.2 
 
 6.3 
 
 18.8 
 
 651-15 
 
 7-2 
 
 II. I 
 
 12.0 
 
 681.45 
 
 The following table is a fair average work ration in round num- 
 bers, based on such data as those in the foregoing tables : 
 
FORCE PRODUCTION. ENERGY FROM FOOD 
 
 Estimated Work Ration, Maximum and Minimum 
 
 (Mrs. E. H. Richards.) 
 
 For one day. 
 125 
 
 no 
 
 125 
 
 90 
 45o 
 420 
 
 Proteid, grammes 
 
 Fat, grammes 
 
 Carbohydrates, grammes 
 
 Calories \ 3 ' 5 °° 
 
 I 3,ooo 
 
 About thirty grammes of salts should be added to this (Landois). 
 The bare subsistence ration is much less, as follows : 
 
 Estimated Ration to barely Sustain Life 
 
 (Mrs. E. H. Richards.) For one day. 
 
 Proteid, grammes 75 
 
 Fat, grammes 40 
 
 Carbohydrates, grammes 325 
 
 Calories 2,000 
 
 Professor Egleston's standard of nutrition is high. He places the 
 daily allowance of nutritive material at 700 grammes, divided as fol- 
 lows : Carbohydrates, 400 grammes ; fats, 150 grammes ; proteid, 150 
 grammes ; yielding in all, 3,650 calories. 
 
 The average percentage of the different food classes needed to 
 sustain a man in perfect health is thus given in the Kensington Mu- 
 seum Handbook on Food : 
 
 Percentage. 
 
 Water 81.5 
 
 Albuminoids or flesh formers 3.9 
 
 Starches and sugars 10.6 
 
 Fat 3.0 
 
 Salt (NaCl) 0.7 
 
 Phosphates, potash salts, etc 0.3 
 
 An Ideal Ration with Solid Food 
 (Mrs. E. H. Richards.) 
 
 
 AMOUNT. 
 
 PROTEID. 
 
 FATS. 
 
 CARBOHYDRATES. 
 
 
 Material. 
 
 Grms. 
 
 Oz. 
 
 Grms. 
 
 Oz. 
 
 Grms. j Oz. 
 
 Grms. 
 
 Oz. 
 
 Calories. 
 
 
 453-6 
 
 226.8 
 
 226.8 
 
 28.3 
 
 H3-4 
 
 453-6 
 
 28.3 
 
 14.17 
 
 16 
 
 8 
 8 
 1 
 
 4 
 16 
 1 
 \ 
 
 31-75 
 34-02 
 12.52 
 6.60 
 3.63 
 18.14 
 
 0. 14 
 106.80 
 
 1. 12 
 I.20 
 O.44 
 O.23 
 O.I3 
 O.64 
 
 2 . 26 . 08 
 
 257.28 
 
 9.60 
 
 4.88 
 90.72 
 27.36 
 
 389.84 
 
 9.04 
 
 0.34 
 
 0.17 
 
 3.20 
 0.96 
 
 1,206.82 
 
 Meat 
 
 Oysters 
 
 Breakfast cocoa. 
 Milk 
 
 11-34 
 2.04 
 
 7-5o 
 
 d. J.2 
 
 O.4O 
 O.O7 
 O.26 
 0. t6 
 
 243.72 
 
 70.OI 
 
 135-42 
 
 75-55 
 
 Broth 
 
 Sugar 
 
 Butter 
 
 18.I4 | O.64 
 12.27 .... 
 
 613.21 
 112. 17 
 II8.62 
 
 Total 
 
 
 
 
 
 57-97 •••• 
 
 
 2,575.52 
 
 It will be observed that the totals are somewhat less in this diet 
 than those of the table at the top of this page, which was adapted for 
 a working man, who is developing more calories. 
 
i8 
 
 FOODS AND FOOD PREPARATIONS 
 
 Table of E?iergy estimated in Foot Tons instead of Calories (Yeo) 
 Energy developed by one ounce of the following foods when oxidised in the body. 
 
 Food Stuff. 
 
 Beef (best quality), uncooked 
 
 Meat (served to soldiers), uncooked 
 
 Beef (fattened), uncooked 
 
 Meat, cooked 
 
 Corned beef (Chicago) 
 
 Salt beef 
 
 Salt pork 
 
 Fat pork 
 
 Dried bacon 
 
 Smoked ham 
 
 Whitefish 
 
 Poultry ■ 
 
 Bread 
 
 Wheat flour 
 
 Biscuit 
 
 Rice 
 
 Oatmeal 
 
 Maize 
 
 Macaroni 
 
 Millet 
 
 Arrowroot 
 
 Peas (dried) 
 
 Potatoes 
 
 Carrots 
 
 Cabbage 
 
 Butter 
 
 Eggs 
 
 Cheese 
 
 Milk (cow's) new 
 
 Cream 
 
 Skimmed milk 
 
 Sugar 
 
 Pemmican 
 
 Ale (Bass's bottled) 
 
 Stout (Guinness) 
 
 With usual per- 
 
 One ounce 
 
 centage of water. 
 
 water-free. 
 
 Foot tons. 
 
 Foot tons. 
 
 48.5 
 
 199 
 
 57-8 
 
 243 
 
 96.O 
 
 280 
 
 I02.6 
 
 240 
 
 124.O 
 
 217 
 
 52.0 
 
 138 
 
 71.6 
 
 166 
 
 202.0 
 
 336 
 
 292.3 
 
 346 
 
 179.6 
 
 267 
 
 44.3 
 
 209 
 
 50.7 
 
 204 
 
 87.5 
 
 147 
 
 I23.6 
 
 146 
 
 173-3 
 
 189 
 
 126.5 
 
 141 
 
 130.0 
 
 154 
 
 132.0 
 
 160 
 
 122.7 
 
 146 
 
 125.9 
 
 149 
 
 116. 4 
 
 138 
 
 118. 9 
 
 151 
 
 33-o 
 
 141 
 
 14-3 
 
 137 
 
 13.0 
 
 158 
 
 344-5 
 
 367 
 
 07-3 
 
 265 
 
 149.9 
 
 245 
 
 26.9 
 
 225 
 
 109.2 
 
 365 
 
 20.4 
 
 l8l 
 
 126.4 
 
 128 
 
 270.1 
 
 293 
 
 30.0 
 
 260 
 
 4i-5 
 
 360 
 
 FORCE-PRODUCING VALUE OF THE DIFFERENT 
 CLASSES OF FOODS 
 
 I. Water. — Estimated as a force producer within the body, water 
 may be said to have comparatively little value. Much of the water 
 which is either drunk or ingested in combination with foods passes 
 through the body unchanged, and is eliminated from one or more of 
 the excreting surfaces ; but some of it is undoubtedly altered or split 
 up into elements which unite with other compounds. The nature of 
 these processes is obscure, and as yet very little understood. It is 
 believed also that a certain quantity of water is produced in the body 
 by the union of oxygen and hydrogen which occurs incident to other 
 chemical change, or by the liberation of water from more complex 
 molecules. Water is entitled to rank as a food because it enters 
 
FORCE-PRODUCING VALUE OF FOODS 19 
 
 into the structural composition of all the tissues of the body, and, 
 in fact, constitutes rather more than two thirds (70 per cent) of 
 the entire body weight. Its importance is readily appreciated after 
 it has been withheld from the diet for a short time, when striking 
 physical and physiological alterations in the functions of the body 
 occur. 
 
 Yeo says that, " assuming the water-free food to be 23 ounces, 
 and a man's weight to be 150 pounds, each pound weight of the 
 body receives in twenty-four hours 0.15 ounce, or the whole body 
 receives nearly a hundredth part of its own weight. But ordinary 
 solid food contains usually between 50 and 60 per cent of water; 
 and if we add this to the water-free solids, the total daily amount 
 of so-called dry food (exclusive of liquids) is about 48 to 60 ounces. 
 But from 50 to 80 ounces of water in the liquid form is usually taken 
 in addition, and this would make the total supply of water equal 
 70 to 90 ounces, or half an ounce for each pound of body weight. ,, 
 
 II. Salts. — The salts have practically no force-producing power, 
 but they are concerned in tissue formation to some extent, especially 
 in the bones and teeth, where the lime and magnesium compounds 
 are the most stable of any in the body. Some of the compounds of 
 sulphur and phosphorus which exist in meat and bran are undoubt- 
 edly associated with the development of energy in the body, but the 
 salts are already saturated and stable, and, although their functions 
 as laboratory reagents within the body are numerous, they may be 
 left out of calculations of force-producing foods. 
 
 III. Proteids, Carbohydrates, and Fats. — It is easy to determine 
 with accuracy the force value of a pound of albumin by chemical 
 analysis, but it does not follow from this that the energy contained 
 in it will all be developed in the body at exactly the right time or 
 even within a sufficiently short period to enable the system to utilise 
 it completely. The majority of physiologists are agreed that mus- 
 cular energy is chiefly derived from non-nitrogenous foods. This 
 statement receives further confirmation in the results of an interest- 
 ing series of experiments made upon sixteen persons by Prof. Charles 
 E. Waite, of the University of Tennessee (U. S. Department of 
 Agriculture Bulletin No. 89, 1901). The experiments included rest 
 intervals followed by work periods, usually of about four hours per 
 diem. Waite found that the digestibility of the diet was uninfluenced 
 by moderate work, animal protein being more completely digested 
 than vegetable protein. He concludes as follows : 
 
 " A study of the nitrogen balance shows that in the majority of 
 cases if there was a gain during the rest period it was increased dur- 
 ing the work period, and if there was a loss it was diminished. In 
 other words, comparing the elimination of nitrogen in the urine 
 during the periods of little muscular activity and normal diet with 
 that during periods of increased activity and a diet furnishing energy 
 
20 FOODS AND FOOD PREPARATIONS 
 
 largely in excess of the heat equivalent of the measured work per- 
 formed, there seems to be a slight decrease under the latter condition. 
 This is true even when we consider the possibilities of a small loss 
 of nitrogen in the perspiration and a lag of considerable duration 
 between the breaking down of nitrogenous material within the body 
 and the excretion of nitrogen in the urine." 
 
 W. O. Atwater and H. C. Sherman state (U. S. Department of 
 Agriculture, Bulletin No. 98, 1901) that: 
 
 " Practically all of the recent experimenting with men sustains the 
 view that muscular work normally results in an increased excretion 
 of nitrogen when the work is at all severe and there is not a corre- 
 sponding increase in the fuel ingredients (fats or carbohydrates) of 
 the diet. It also implies that the increased output of nitrogen con- 
 tinues after the work stops, so that if the experiment continues but 
 one day the larger part of the increase may be found on the succeed- 
 ing day. 
 
 " Well-trained professional athletes when engaged in severe mus- 
 cular exertion metabolise relatively large amounts of protein, the 
 body tissue being drawn upon unless the protein of the food is very 
 abundant." 
 
 The daily quantity of solid food consumed by an adult male at 
 ordinary work will range between 50 and 60 ounces, and that of 
 water drunk is about the same. The requirements of severe labour, 
 if continued, exceed this range, so that as much as 75 ounces of solid 
 food may become necessary, and this should be mainly in the form 
 of albuminates and fats. Fats, compared with carbohydrates, yield 
 two and one fourth parts as much energy. The standard diet for 
 twenty-four hours for a healthy adult male at ordinary work should 
 contain, in round numbers, 20 grammes of nitrogen (contained in 
 120 grammes of proteid) and 320 grammes of carbon, a proportion 
 of 1 to 16, but, because the food is best taken in the form of a mixed 
 diet, the proportion may be stated as one part of nitrogenous or 
 animal food to three or three and one half of non-nitrogenous or 
 vegetable food. Ordinary albuminous food yields, on the average, 
 about 16 per cent of nitrogen. 
 
 Nitrogen Balance. — The nitrogen in the urine and feces may be 
 regarded as an index of the proteid food assimilated, and when these 
 two factors correspond, the body is said to be in " nitrogen equi- 
 librium," i. e., all the nitrogen actually consumed is eliminated with- 
 out storage in the body. When the body has attained its full adult 
 size, it maintains this equilibrium with but very slight variation. A 
 new diet containing either an excess or diminution of protein tem- 
 porarily disturbs this equilibrium, but it is soon readjusted. 
 
 For an adult male the average consumption of nitrogen being 20 
 grammes per diem, the ordinary allowance for daily variation does 
 not exceed 3 grammes on either side of this standard. For a man 
 
FORCE-PRODUCING VALUE OF FOODS 21 
 
 of average weight — that is, 67 kilogrammes, or 160 pounds — the 
 daily allowance of food ranges from 6 to 9 grains of carbon, and 0.25 
 to 0.36 grain of nitrogen per kilogramme of body weight. Those 
 elementary foods which approach most nearly in composition the 
 economical proportion of nitrogenous to non-nitrogenous material 
 are cow's milk and wheat flour. In the former this proportion is one 
 to three, in the latter one to four and a half. The standard ratio 
 for health of protein to the fuel ingredients — starch, sugar, and 
 fat — is 1 to 5.8. This is the ratio adopted by the Experiment Sta- 
 tions of the United States Department of Agriculture. In metabo- 
 lism experiments a time allowance must be made for the interval 
 between the ingestion of proteid food and the corresponding nitro- 
 gen increase in urine and feces. This interval is known as the 
 " nitrogen lag," and it occupies a number of hours, varying under 
 changing conditions. - 
 
 The question of the nutritive value of any fixed diet cannot be 
 solely estimated from variations in the body weight, for the loss of 
 water or of albumin may increase while fat is stored up. Neither 
 can the quantity of food eaten be relied upon for this purpose, for 
 from habit one man may eat more than another while doing the same 
 work, and may eat more than he needs. Nor is it possible to deter- 
 mine from the various excreta alone whether the body has had a 
 suitable quantity of nourishment, for they are too constantly chang- 
 ing, and " life will soon become extinct if the nutriment given be 
 measured by the metabolism of starvation " (Bauer). 
 
 A man in perfect health might easily lose weight upon the iden- 
 tical diet w r hich would enable an emaciated and feeble invalid to gain 
 flesh. In convalescence from typhoid fever, for example, one often 
 sees evidence of a daily gain in w r eight while the quantity of food is 
 still far below that necessary to support a healthy man in vigour. 
 The needs of the organism at any particular time must, therefore, be 
 taken into account as well as the strength of the digestive organs in 
 prescribing the quantity of food consumed. In making calculations 
 for the quantity of food required by large numbers of persons under 
 any conditions, somewhat more than the averages above stated 
 should be always included in order to make allowance for variations 
 in absorption and assimilation of the food by different individuals. 
 (See Quantity of Food Required, page 283.) 
 
 The carbohydrates are not as available for the repair and growth 
 of the tissues as the fats, but by their oxidation they save tissue 
 waste, and furnish both heat and muscle force. They limit the 
 formation of acetone from fat when the latter is eaten in excess 
 (Schuman-Leclercq) . 
 
 Bauer says : " The easy metabolism of the carbohydrates in the 
 body must not be regarded as depending on their great affinity for 
 oxygen ; its cause is to be sought far more in the properties of the 
 
22 FOODS AND FOOD PREPARATIONS 
 
 animal tissues. . . . The action of the carbohydrates agrees in 
 many respects with that of fat, since they are in like manner capa- 
 ble of protecting from metabolism a certain amount of the circu- 
 lating albumin and of assisting its transformation into organic 
 albumin." 
 
 But the destruction of carbohydrates in the body is very com- 
 plete, even when eaten in excess, and herein they differ from the 
 fats, " an excess of which in the food invariably produces an ac- 
 cession of fat." From these and other statements made by Bauer 
 he argues that probably the carbohydrates do not directly form fat in 
 the body, but their well-known fattening action is, when eaten with 
 albumin and fat, to spare the consumption of these latter substances, 
 which are then converted into tissue fat. 
 
 Sugar furnishes, in addition to heat, considerable muscle energy, 
 and it has been lately proved by Mosso, Vaughan Harley, and others 
 to have distinct power in relieving muscular fatigue. 
 
 Vaughan Harley found that with an exclusive diet of seventeen 
 and one half ounces of sugar dissolved in water he could perform 
 almost as much muscular work as upon a full mixed diet. The effect 
 in lessening muscle fatigue was noticeable in half an hour and reached 
 a maximum in two hours. Three or four ounces of sugar taken be- 
 fore the expected onset of fatigue postponed or entirely inhibited 
 the sensation. Schumberg recommends that the sugar be taken with 
 chocolate or in lemonade. Experiments were made by him upon 
 German soldiers which covered a period of thirty-eight days. The 
 men were given daily ten lumps of sugar (about one sixth pound), 
 and were able to withstand hunger, thirst, and fatigue much better 
 than others whose diet contained no sugar. When a muscle con- 
 tracts it is not the muscle tissue itself which is consumed, but its- 
 supply of glycogen. The candle wick is but very slowly burned 
 so long as its supply of tallow does not fail, and so the muscle is 
 spared while the carbohydrate glycogen furnishes force. When a 
 muscle is much used it increases in size, and needs more nitrogen to 
 build new substance. 
 
 The food value of sugar is thus summarised by Mary Hinman 
 Abel (U. S. Department of Agriculture, Farmers' Bulletin No. 93, 
 1899) : 
 
 " (1) When the organism is adapted to the digestion of starch, and 
 there is sufficient time for its utilisation, sugar has no advantage 
 over starch as a food for muscular work except as a preventive of 
 fatigue. 
 
 " (2) In small quantities and in not too concentrated form sugar 
 will take the place, practically speaking, weight for weight, of 
 starch as a food for muscular work, barring the difference in 
 energy and in time required to digest them, sugar having here the 
 advantage. 
 
STIMULATING FOODS 23 
 
 " (3) It furnishes the needed carbohydrate material to organisms 
 that have as yet little or no power to digest starch. Thus, milk 
 sugar is part of the natural food of the infant. 
 
 " (4) In times of great exertion or exhausting labour, the 
 rapidity with which it is assimilated gives it certain advantages over 
 starch." 
 
 The hard-working lumbermen of Canada and Maine eat a very 
 large quantity of sugar in the form of molasses. I have seen them 
 add it to tea and to almost everything they cook. Sugar has also 
 been found of much service upon polar expeditions. 
 
 Albumin burned in oxygen outside of the body is almost com- 
 pletely oxidised, but after oxidation in the body, about one third of 
 its substance is excreted, imperfectly consumed, as urea. Pfliiger 
 says : " All work of life can be performed by albumin alone, while 
 no other material in the universe can do it. The integral ingredient 
 of the living and working cell is the albumin, indeed often the only 
 organic part of it." On the other hand, the consumption of some 
 carbohydrates, such as alcohol and sugar, appears as complete within 
 the body as it may be outside of it, and the amount of energy actu- 
 ally developed is identical with that which may be theoretically 
 calculated. 
 
 The statement is sometimes made that the compounds of carbon 
 and hydrogen are slowly oxidised, and give a more continuous yield 
 of energy than nitrogenous compounds, but with less powerful indi- 
 vidual discharges. In other words, they are said to be good " main- 
 tamers of energy." There are, however, exceptions to this, such as 
 alcohol. 
 
 The proportion of nitrogenous or proteid compounds required is 
 greatest where growth is active. Many nitrogenous substances pos- 
 sess high potential and explosive energy, as illustrated by nitro- 
 glycerin and fulminating powder. Proteids are always present where 
 the phenomena of life are exhibited, and bear a direct relation to 
 their activity. 
 
 STIMULATING FOODS 
 
 In the broadest sense all food is stimulating to the functional ac- 
 tivities of the body ; but when the digestive and assimilative powers 
 are lowered, less variety and less quantity of food can be tolerated, 
 and foods that in health are never needed may become necessities ; 
 such foods, for example, are cod-liver oil and the various prepara- 
 tions of meat, such as albumoses or peptones, meat juice, etc. 
 
 Certain food substances have a distinctly stimulating action at 
 all times. The various condiments possess a local action of this 
 kind upon the alimentary organs, but not a general or systemic ac- 
 tion. The latter stimulation, manifested especially upon the nerve- 
 
24 FOODS AND FOOD PREPARATIONS 
 
 muscular apparatus, is derived from such substances as strong beef 
 extracts, coffee, tea, and alcohol, all of which at times are of great 
 service in the dietetic treatment of disease. The effect of sugar as a 
 stimulant to relieve muscular fatigue has been described in the pre- 
 vious section. 
 
 ECONOMIC VALUE OF FOOD 
 
 It is not within the scope of this work to discuss the details of 
 the economic value of food, but brief reference to one or two facts 
 will emphasise the importance of this topic. 
 
 It is estimated that the annual cost of food production in the 
 United States is at least three billion dollars, and the cost of pro- 
 duction must be doubled in estimating the price paid by the con- 
 sumer. 
 
 Naturally, many attempts have been made to tabulate the cost of 
 feeding large bodies of men employed by contract, or patients in 
 hospitals and institutions. Some of these studies have been con- 
 ducted with great care, but on a comparatively small scale, as in the 
 case of the economic diets of the French factory operatives in Mas- 
 sachusetts, the penny dinners furnished to London school children, 
 and the researches made by Mrs. Richards and Miss Talbot upon 
 pupils at the University of Chicago. Calculations upon a much 
 larger scale are available as a basis for the supply of armies and 
 navies. (See the section upon Diet for the Army and Navy.) 
 
 The economic value of food cannot be estimated exclusively 
 from its weight, and, as suggested by Williams, a pound of biscuit 
 may contain as much fuel as a pound of beefsteak, and yet the body 
 may be able to assimilate more of the beefsteak and derive more 
 energy therefrom ; and it is the chemical processes of Nature which 
 convert such substances as grass, which are not assimilable by the 
 human organism, into the flesh of the ox, which is readily digested 
 by man. 
 
 It is economical in employing large bodies of men at manual* 
 labour to feed them well, for they will do much more work propor- 
 tionately. 
 
 Carbohydrates check albuminous waste, and, like fats, yield both 
 heat and mechanical work ; hence good bread, sugar, and potatoes 
 are all economical foods for the labourer. Unlike the other classes 
 of foods, however, they do not produce brawn, and do not enter into 
 the actual structure of the tissues to any great extent, although the 
 carbohydrates may be found existing as glycogen in some of the 
 tissues, like the muscles and liver. In general, they seem to be 
 more easily metabolised than fats or proteids. Assuming 3,500 
 calories as the necessary daily standard for a labourer, one pound 
 of flour yields 0.11 pound of protein and 1,650 calories; a pound of 
 
ECONOMIC VALUE OF FOOD 
 
 25 
 
 dried beans yields 0.22 pound of protein and 1,590 calories ; but cab- 
 bage yields only 0.02 protein and 150 calories per pound, and oranges 
 0.01 protein and 160 calories. 
 
 Atwaters Table of Digestibility of Nutrients of Food Materials 
 
 In the Food Materials Below 
 
 Meat and fish 
 
 Eggs--- 
 
 Milk 
 
 Butter 
 
 Oleomargarine . . . 
 
 Wheat bread 
 
 Corn (maize) meal 
 
 Rice 
 
 Peas 
 
 Potatoes 
 
 Beets 
 
 OF THE TOTAL AMOUNTS OF PROTEIN, FATS, AND 
 
 CARBOHYDRATES THE FOLLOWING PERCENTAGES 
 
 WERE DIGESTED \ 
 
 Calculated Coefficients of Digestibility of Nutrients in Different Classes 
 
 of Foods 
 
 Standards used in calculations by the U. S. Department of Agriculture. 
 
 
 Protein. 
 
 Fats. 
 
 Carbohydrates. 
 
 Animal foods 
 
 Per cent. 
 98 
 85 
 
 80 
 
 Per cent. 
 
 97 
 90 
 
 90 
 
 Per ce&it. 
 IOO 
 
 Cereals and starches 
 
 98 
 IOO 
 
 95 
 
 Sugars 
 
 Vegetables and fruits 
 
 g 
 
 Percentage of Nutrition in Various Articles of Food (Moss) 
 
 Raw cucumbers 2 
 
 Raw melons 3 
 
 Boiled turnips \\ 
 
 Milk 7 
 
 Cabbage 7^ 
 
 Currants 10 
 
 Whipped eggs 13 
 
 Beets 14 
 
 Apples 16 
 
 Peaches 20 
 
 Boiled codfish 21 
 
 Broiled venison 22 
 
 Potatoes 22^ 
 
 Fried veal. . 24 
 
 Roast poultry 26 
 
 Raw beef. 26 
 
 Raw grapes 27 
 
 Raw prunes 29 
 
 Boiled mutton 30 
 
 Oatmeal porridge 75 
 
 Rye bread 79 
 
 Boiled beans 87 
 
 Boiled rice 88 
 
 Barley bread 88 
 
 Wheat bread 90 
 
 Baked corn bread 
 Boiled barley 
 
 Butter 
 
 Boiled peas 
 
 Raw oil 
 
26 
 
 FOODS AND FOOD PREPARATIONS 
 
 Atwaters Table for Nutrients and Potential Energy in Dietaries of 
 
 Different People 
 
 Sewing girl, London — wages 93 cents (3s. 
 
 " qd.) per week 
 
 Factory girl, Leipsic, Germany — wages 
 
 $1.21 per week 
 
 Underfed labourers, Lombardy, Italy — 
 
 diet mostly vegetable 
 
 Trappist monk in cloister, very little exer- 
 cise — vegetable diet 
 
 Miners at severe work, Germany 
 
 Brickmakers (Italians at contract work), 
 
 Munich 
 
 Brewery labourer, Munich, very severe 
 
 work, exceptional diet 
 
 German soldiers, peace footing 
 
 German soldiers, war footing 
 
 German soldiers, Franco-German War — 
 
 extraordinary ration 
 
 Other factory operatives, mechanics, etc., 
 
 Massachusetts 
 
 Glass blowers, East Cambridge 
 
 Private well-to-do family : 
 
 Food purchased 
 
 Food eaten 
 
 College students from Northern and East- 
 ern States — boarding: 
 
 Food purchased 
 
 Food eaten 
 
 Club, two dietaries of the same club : 
 
 Food purchased 
 
 Food eaten 
 
 College football team 
 
 Teamsters, marble workers, etc., with hard 
 
 work, Boston, Mass 
 
 Brickmakers, Massachusetts 
 
 United States Army ration 
 
 United States Navy ration 
 
 
 NUTRIENTS. 
 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Total. 
 
 I 
 
 1 Grins. 
 
 Grins. 
 
 Grms. 
 
 Grms. 
 
 \ " 
 
 33 
 
 316 
 
 402 
 
 52 
 
 53 
 
 30I 
 
 406 
 
 82 
 
 40 
 
 362 
 
 484 
 
 68 
 133 
 
 n 
 113 
 
 469 
 634 
 
 548 
 880 
 
 187 
 
 117 
 
 675 
 
 959 
 
 223 
 114 
 
 134 
 
 113 
 49 
 
 58 
 
 909 
 
 480 
 489 
 
 1,245 
 
 633 
 681 
 
 157 
 
 285 
 
 331 
 
 773 
 
 127 
 95 
 
 186 
 132 
 
 531 
 48 1 
 
 844 
 
 708 
 
 129 
 
 128 
 
 183 
 177 
 
 467 
 466 
 
 779 
 77i 
 
 161 
 
 138 
 
 204 
 
 184 
 
 680 
 622 
 
 1,045 
 944 
 
 115 
 104 
 
 181 
 
 163 
 136 
 292 
 
 480 
 421 
 
 557 
 
 738 
 
 661 
 
 1,030 
 
 254 
 180 
 
 120 
 
 143 
 
 363 
 365 
 161 
 184 
 
 826 
 
 1,150 
 
 454 
 
 520 
 
 i,443 
 
 1,695 
 
 735 
 
 847 
 
 Potential 
 energy of 
 nutrients. 
 
 Calories. 
 1,820 
 1,940 
 2,192 
 
 2,304 
 4,195 
 
 4,641 
 
 5,092 
 2,798 
 3,093 
 
 4,652 
 
 4,428 
 3,590 
 
 4,146 
 4,082 
 
 5,345 
 4,827 
 
 3,874 
 3,417 
 5,742 
 
 7,804 
 8,848 
 
 3,85i 
 4,998 
 
 The actual cost of elementary foods naturally varies with the 
 market, locality, season of the year, and other considerations. For- 
 tunately, however, many foods which furnish most nutriment are 
 among the cheapest and least variable in price. Breadstuff's, for 
 instance, which may easily furnish one third of the total nutrients 
 required, do not vary greatly in price, and the increase in cost of any 
 diet depends more upon the higher price of green vegetables, fruits, 
 and the better cuts of meats. Hence, when it is necessary to reduce 
 the cost of living, peas, beans, oatmeal, and flour may be economically 
 used to supply protein. Sugar, rice, pork, cornmeal, and potatoes 
 all supply fuel (energy) at small expense. If variety rather than 
 cheapness is desired, it is found in the use of green vegetables, fresh 
 fruits, butter, eggs, and the better cuts of meat. In illustration of 
 
ECONOMIC VALUE OF FOOD 
 
 27 
 
 these principles are the three following tables from nutrition in- 
 vestigations conducted by Isabel Bevier at Pittsburg, Pa. (U. S. 
 Department of Agriculture Bulletin 52, 1898): 
 
 Cost per Pound and Amounts and Fuel Value of the Digestible Nutrients 
 in 1 Pound and in 10 Cents Worth of the More Important Food 
 Materials used in a Dietary Study of a very Poor Polish Mill-worker's 
 Family in Pittsburg, Pa. 
 
 Kind of Food 
 Material. 
 
 Actual 
 
 icost per 
 
 pound. 
 
 Beef: 
 
 Stew meat 
 
 Round 
 
 Bologna sausage 
 Pork: 
 
 Ham, boiled. . . 
 
 Head-cheese.. . 
 Fish, herring, 
 
 smoked 
 
 Eggs 
 
 Butter 
 
 Milk 
 
 Flour 
 
 Oatmeal 
 
 Bread 
 
 Sugar, coffee. . . . 
 
 Beans 
 
 Potatoes 
 
 Cents. 
 
 5-o 
 " 9 
 4 
 
 NUTRIENTS AND ENERGY IN I POUND 
 
 D -. ■ t- . Carbohy- Fuel 
 
 Protein. Fat. ^^ yalue> 
 
 Pound. 
 
 O.176 
 .202 
 .176 
 
 .178 
 .183 
 
 •339 
 .126 
 .010 
 .031 
 .096 
 
 •133 
 
 .078 
 
 '.178 
 .013 
 
 Pound. 
 
 O.073 
 121 
 I 9 I 
 
 359 
 233 
 
 145 
 
 089 
 
 843 
 025 
 010 
 064 
 
 016 
 
 Pound. 
 
 O.058 
 •730 
 .669 
 •532 
 •954 
 .561 
 .130 
 
 Cat. 
 
 635 
 
 885 
 
 1,130 
 
 1,845 
 1,325 
 
 1,245 
 6lO 
 
 3,575 
 270 
 1,580 
 1,760 
 i,i35 
 i,775 
 1,442 
 265 
 
 NUTRIENTS AND ENERGY IN IO 
 CENTS' WORTH. 
 
 Protein. Fats. Carbohy- Fuel 
 drates. value. 
 
 Pound. 
 O.15 
 
 14 
 20 
 
 *9 
 
 27 
 
 25 
 06 
 
 33 
 09 
 
 03 
 13 
 
 03 
 
 Founds. 
 
 Pound. '• Cal. 
 
 0.35 ; 1,270 
 
 23 995 
 
 19 1,205 
 
 982 
 
 1,555 
 
 2,105 
 430 
 
 1,400 
 970 
 4,385 
 3,520 
 3,340 
 3,010 
 
 2,495 
 2,420 
 
 Cost per Pound and Amounts and Fuel Value of the Digestible Nutrients 
 in 1 Pound and in 10 Cents Worth of the More Important Food 
 Materials used in a Dietary Study of a Lawyer s Family in Good 
 Circumstances 
 
 Kind of Food 
 Material. 
 
 Beef: 
 
 Ribs 
 
 Round 
 
 Shoulder clod. . 
 
 Veal, chops 
 
 Lamb, roast.. . . . 
 
 Eggs 
 
 Butter 
 
 Milk 
 
 Wheat flour 
 
 Rolled oats 
 
 Bread, baker's. . . 
 Sugar, granulated 
 Beans, dried. . . . 
 
 Potatoes 
 
 Oranges 
 
 Actual 
 cost per 
 pound. 
 
 Cents. 
 I5.0 
 I5.0 
 
 11. 5 
 18.0 
 
 15-0 
 
 13-3 
 28.0 
 
 3-9 
 2.4 
 2 
 
 NUTRIENTS AND ENERGY IN I POUND 
 
 Protein. Fat. <*J£T ™. 
 
 10.0 
 
 Pound. 
 
 0.I20 
 
 .196 
 
 .184 
 
 •159 
 .164 
 . 122 
 
 .029 
 . 122 
 .144 
 
 .081 
 
 ,l6l 
 ■OI3 
 .OO8 
 
 Pound. 
 O.255 
 
 047 
 IO9 
 084 
 26l 
 086 
 
 868 
 036 
 012 
 070 
 on 
 
 016 
 
 Pound. 
 
 O.046 
 
 •729 
 .702 
 
 •517 
 .966 
 
 •593 
 .120 
 
 •043 
 
 Cal. 
 1,300 
 
 565 
 80O 
 650 
 
 1,405 
 590 
 
 3,665 
 29O 
 
 1,635 
 1,870 
 I,l6o 
 
 i,795 
 1,470 
 
 245 
 
 80 
 
 NUTRIENTS AND ENERGY IN IO 
 
 cents' WORTH. 
 
 Protein. Fat. <**£»" J™ 
 
 Pound. 
 O.08 
 
 13 
 16 
 09 
 II 
 09 
 
 o- 
 
 51 
 
 23 
 
 1 6 
 
 38 
 09 
 
 Pound. 
 
 O.I7 
 .03 
 .IO 
 .05 
 •17 
 
 .c6 
 
 •3i 
 .09 
 .05 
 . n 
 .02 
 
 .04 
 
 Pounds. 
 
 Cal. 
 865 
 
 375 
 
 700 
 
 360 
 
 935 
 
 445 
 
 1,310 
 
 75o 
 
 6,805 
 
 3,oi5 
 
 2,365 
 
 3,595 
 
 3,5O0 
 
 1,645 
 
 So 
 
28 
 
 FOODS AND FOOD PREPARATIONS 
 
 Summary of Dietary Studies here reported with Averages of Studies made 
 Elsewhere. Quantities per Man per Day 
 
 
 Cost. 
 
 Protein. 
 
 Fats. 
 
 Carbohy- 
 drates. 
 
 Fuel 
 value 
 
 
 Cents. 
 21 
 13 
 9 
 22 
 20 
 16 
 
 25 
 20 
 
 Grms. 
 91 
 
 85 
 
 77 
 147 
 112 
 
 94 
 104 
 103 
 
 Grms. 
 
 145 
 
 IO4 
 
 90 
 
 173 
 144 
 
 121 
 125 
 I50 
 
 Grms. 
 38o 
 307 
 314 
 683 
 368 
 
 385 
 423 
 402 
 
 Cat. 
 3,280 
 
 2,575 
 2,440 
 5,010 
 3.305 
 3,085 
 
 3.325 
 3.465 
 
 
 Dietary of a mill workman's family 
 
 Dietary of a boiler tender's family 
 
 Dietary of a house decorator's family 
 
 Dietary of a glass blower's family 
 
 Average 14 dietaries of professional men's families 
 Average 14 dietaries of mechanics' families 
 
 The following table is from the U. S. Department of Agriculture 
 Bulletin No. 91, 1900, and summarises dietetic studies made in widely 
 different parts of the United States : 
 
 Cost, Nutrients, and Fuel Value of Food per Man per Day in Dietary 
 Studies in Urbana and Elsewhere 
 
 Cost of 
 food. 
 
 Protein. 
 
 25.O 
 
 22.3 
 
 Teacher's family, Illinois : Cents. 
 
 Food purchased 27.0 
 
 Food wasted j .... 
 
 Food eaten .... 
 
 Professional men, Connecticut, average 
 of 9 dietaries : 
 
 Food purchased 
 
 Food wasted 
 
 Food eaten 
 
 Professional man's family, Pennsylva- 
 nia : 
 
 Food purchased 
 
 Food wasted , 
 
 Food eaten 
 
 Teacher's family, Indiana : 
 
 Food purchased 
 
 Food wasted 
 
 Food eaten 
 
 Proposed standard for man with little 
 
 muscular work (Atwater) 
 
 Mechanics' boarding club, Illinois : 
 
 Food purchased 
 
 Food wasted 
 
 Food eaten 
 
 Mechanics' families, Connecticut, av- 
 erage of 9 dietaries : 
 
 Food purchased 
 
 Food wasted 
 
 Food eaten 
 
 Mechanic's family, Indiana : 
 
 Food purchased 
 
 Food wasted 
 
 Food eaten 
 
 Fats ! C f rboh y- 
 drates. 
 
 23.O 
 
 26.O 
 
 Grms. 
 124 
 
 23 
 IOI 
 
 IIO 
 
 3 
 107 
 
 98 
 
 7 
 
 9i 
 
 in 
 
 5 
 106 
 
 112 
 
 128 
 
 11 
 
 117 
 
 113 
 
 7 
 
 106 
 
 106 
 16 
 90 
 
 Fuel 
 value. 
 
 Nutritive 
 ratio. 
 
 45 
 113 
 
 4 b 
 441 
 
 136 
 
 7 
 129 
 
 442 
 
 5 
 437 
 
 155 
 10 
 
 145 
 
 396 
 
 16 
 
 380 
 
 no 
 
 8 
 
 IC2 
 
 349 
 
 9 
 
 340 
 
 171 
 
 25 
 I46 
 
 392 
 379 
 
 153 
 
 II 
 
 142 
 
 420 
 
 14 
 406 
 
 157 
 
 23 
 
 134 
 
 475 
 
 67 
 
 408 
 
 Grms. Calories. 
 
 487 3,975 
 700 
 
 3,275 
 
 3,53o 
 
 100 
 
 3.430 
 
 3,465 
 
 185 
 
 3,280 
 
 2,910 
 130 
 
 2,780 
 
 3,000 
 
 3,720 
 
 330 
 
 3,39° 
 
 3,605 
 
 185 
 
 3,42o 
 
 3,840 
 
 555 
 3,285 
 
 1 : 6.9 
 
 1 : 6. 
 
 1 : 7. 
 
 1 = 5-4 
 t: 5-5 
 
 1 : 6.1 
 
 1 : 6.9 
 
 1 : 7.9 
 
NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 29 
 
 
 Cost of 
 food. 
 
 Protein. 
 
 Fats. 
 
 Carbohy- 
 drates. 
 
 Fuel 
 value. 
 
 Nutritive 
 ratio. 
 
 Mechanic's family, Tennessee : 
 
 Cents. 
 16.O 
 
 Grms. 
 II 9 
 
 9 
 
 IIO 
 
 103 
 
 3 
 100 
 
 125 
 
 Grms. 
 224 
 
 14 
 2IO 
 
 I44 
 
 6 
 
 138 
 
 Grms. 
 
 455 
 
 43 
 
 412 
 
 43i 
 6 
 
 425 
 
 Calories. 
 
 4,435 
 
 345 
 
 4,090 
 
 3,530 
 
 95 
 
 3,435 
 
 3,5oo 
 
 
 Food wasted 
 
 
 Food eaten 
 
 
 i:8.I 
 
 Mechanic's family, New Jersey : 
 
 28.O 
 
 
 Food wasted 
 
 
 Food eaten 
 
 
 i : 7.4 
 
 i : 6.8 
 
 Proposed dietary standard for man 
 with moderate work (Atwater) 
 
 
 In a study by E. F. Ladd, made in 1900, of eleven women students 
 in North Dakota who averaged nineteen years of age, the result was 
 as follows : 
 
 Food Eaten. 
 
 COMPOSITION AND FUEL VALUE OF FOOD 
 PER DAY. 
 
 PER WOMAN 
 
 Protein. 
 
 Fats. 
 
 Carbohydrates. 
 
 Fuel value. 
 
 Animal food 
 
 Grammes. 
 31 
 
 33 
 
 Grammes. 
 
 94 
 
 5 
 
 Grammes. 
 
 5 
 
 355 
 
 Calories. 
 1,025 
 1,635 
 
 Vegetable food 
 
 
 Total food 
 
 64 
 
 99 
 
 360 
 
 2,66o 
 
 
 
 A similar study by Atwater made upon the diet of women stu- 
 dents in Connecticut shows a consumption of 84 grammes protein, 
 128 grammes fat, and 264 grammes carbohydrate, yielding 3,015 
 calories. The accepted standard for woman at light muscular work 
 calls for 90 grammes of protein and a total fuel value of 2,400 calories 
 of energy, hence both these dietaries were deficient in protein, al- 
 though the total fuel value was considerably above the standard 
 requirement. This shows that a considerable departure from normal 
 dietetic standards is not incompatible with health. 
 
 NUTRITION. ANIMAL AND VEGETABLE FOODS 
 COMPARED 
 
 The study of nutrition, or the problem of tracing the food prod- 
 ucts, after absorption from the alimentary canal, through the various 
 changes which they undergo prior to elimination in the compara- 
 tively simple forms of waste matter — namely, water, urea, and C0 2 — 
 has long baffled the science of physiological chemistry. There are, 
 however, general principles that are established both by analysis and 
 clinical observation which concern the effect upon the system of 
 these different classes of foods. 
 
 Among the lower animals the effect upon the whole system of 
 modifications in nutrition produced by special methods of feeding 
 
30 FOODS AND FOOD PREPARATIONS 
 
 are much more striking than in man, as, for example, the feeding of 
 the queen bee, and of draught horses as compared with racers. 
 
 Animal food is believed by many to make the blood rich in fibrin 
 and corpuscles, and to increase the mineral salts, especially the phos- 
 phates ; it both repairs the old and forms new tissue ; it improves the 
 condition of the muscles, which are made firmer than they are 
 through a vegetable diet, and it favours the reduction of stored-up 
 or surplus fat. Under som^ conditions it may produce a part of the 
 body fat, although most of it is derived from other sources. (See 
 Obesity.) It also increases the quantity of urates, phosphates, sul- 
 phates, and urea normally present in the urine, and tends to make the 
 fluids of the body somewhat more acid or less alkaline. 
 
 Bauer (Dietary of the Sick) says : " The functional activity and 
 resisting power of the organism seem to be essentially connected 
 with the presence of an ample supply of albumin." 
 
 Animal food requires a considerable quantity of oxygen for its 
 complete combustion, and a diet of this nature increases the demand 
 for oxygen and favours its consumption. Meat in general has a more 
 stimulating effect upon the system and is more " strengthening " 
 than vegetable food, and it gives rise to sensations of energy and 
 activity. A meal consisting of meat remains an hour or two longer 
 in the stomach than a purely vegetable meal. It seems to satisfy the 
 cravings of hunger, bulk for bulk, to a greater extent and for a 
 longer time than vegetable food, and a man can live longer upon ex- 
 clusive nitrogenous food than upon exclusive carbonaceous food. 
 Animal food occupies less space in the stomach, and is more portable 
 than vegetable food. Moreover, albuminous foods can be eaten 
 longer alone without exciting loathing, as a rule, than can fats, 
 sugars, or even some pure starches. In fact, there is a constant 
 tendency to eat too much meat, and when its effects are not counter- 
 balanced by free outdoor exercise, it produces an excess of waste 
 matter which accumulates and causes biliousness, and sometimes 
 lithiasis, gout, etc. A carbonaceous diet taxes the excretory organs 
 to a lesser degree than animal food. 
 
 Sir Henry Thompson says : " It is a vulgar error to regard meat 
 in any form as necessary to life." Nitrogenous food man must 
 have, but it need not necessarily be in the form of meat, which " to 
 many has become partially desirable only by the force of habit, and 
 because their digestive organs have thus been trained to deal with it." 
 
 This is but partially true, for the training has become so strongly 
 a matter of heredity through many centuries that those who possess 
 it are certainly in better health for a reasonable allowance of meat in 
 their dietary, and many primitive savage tribes, have always subsisted 
 largely upon meat. Errors in diet are far more common on the side 
 of excessive meat eating than the eating of too much vegetable food, 
 especially among civilised communities. In the temperate zones an 
 
NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 3 1 
 
 increase in prosperity, together with the improvements made in the 
 methods of preparing and preserving meat as well as those in breed- 
 ing cattle for market purposes, tend to increase the habit of meat 
 eating. The common estimate, in which meat should occupy one 
 fourth and vegetable food three fourths of a mixed diet, is over- 
 stepped by many persons with whom the proportion may be two or 
 three to four. 
 
 The proper association of different foods always keeps healthy 
 men in better condition than too long continuance of any selected 
 diet system. 
 
 Sir Henry Thompson, in speaking of the advantages of a well- 
 proportioned diet, says : " A' preference for the high flavours and 
 stimulating scents peculiar to the flesh of vertebrate animals mostly 
 subsides after a fair trial of milder foods when supplied in variety. 
 . . . The desire for food is keener, the satisfaction in gratifying ap- 
 petite is greater and more enjoyable on the part of the general light 
 feeder, than with the almost exclusively flesh feeder. . . . Three 
 fourths at least of the nutrient matters consumed are from the ani- 
 mal kingdom. A reversal of the proportions indicated — that is, a 
 fourth only from the latter source, with three fourths of vegetable 
 produce — would furnish greater variety for the table, tend to main- 
 tain a cleaner palate, increased zest for food, a lighter and more 
 active brain, and a better state of health for most people not en- 
 gaged in the most laborious employments of active life." 
 
 This comment is more applicable to the upper classes in England 
 than in this country, where more attention is given to the cultivation 
 and cooking of fresh vegetables and the preparation of vegetable 
 products. 
 
 Letheby wrote : " The best proportions for the common wants of 
 the animal system are about nine of fat, twenty-two of flesh-forming 
 substances, and sixty-nine of starch and sugar." An average of 
 eighty-seven practical dietary studies made by the U. S. Department 
 of Agriculture showed that the food consumed was 45 per cent of 
 animal and 55 per cent of vegetable origin. 
 
 Meats which are deficient in fat are usually eaten with added fat. 
 Thus bacon is eaten with veal, liver, and chicken, and most fish are 
 cooked with butter or oil. Similarly, butter, eggs, or cream are 
 mixed with amylaceous foods, such as rice, sago, potatoes, etc., which 
 are lacking in fat, and cheese containing fat is added to macaroni. 
 Bacon is added to beans, and pork to greens. 
 
 " Whenever one kind of food is wanting in any particular con- 
 stituent, we invariably associate it with another that contains an ex- 
 cess of it " (Letheby). 
 
 If a labouring man is allowed an ordinary meat ration he requires 
 in addition, to obtain his requisite carbon, of fat 346 grammes, and 
 of starch 596 grammes (Voit). But he would soon tire of such a 
 
32 FOODS AND FOOD PREPARATIONS 
 
 quantity of either of these two food classes alone, and he does better 
 to eat some of each. As pointed out by Voit more than thirty years 
 ago, the available vegetable nutrients are so enclosed in cellulose or 
 woody fibre as to render their absorption difficult. Vegetable food 
 eaten in excess is liable to induce intestinal fermentation, which ex- 
 cites peristalsis, and as the intestine of man is much shorter than that 
 of herbivores, this class of food does not have time for complete 
 absorption. 
 
 The carnivorous animal fed upon lean meat alone requires a daily 
 supply equal to one twentieth of his body weight, but if a little fat 
 . be added he needs much less. 
 
 Animal food is often said to be more stimulating to the passions 
 than vegetable food, and the general character of carnivorous ani- 
 mals is more savage than that of herbivorous, although the angered 
 bull is as fierce as any carnivore. It is doubtful, however, whether 
 this is attributable so much to their different diet as to many other 
 conditions which have contributed through the survival of the fittest 
 to their differentiation. Carnivorous animals are obliged to work 
 and fight for their food ; they obtain it at uncertain and infrequent 
 intervals, often when made ravenous by long periods of fasting. 
 Herbivorous animals, on the contrary, always have their food at 
 hand, obtainable with no labour other than that of eating. The 
 Polynesian warrior is more ferocious at times on a diet of plantains 
 than the Eskimo, who eats nothing but fish, meat, and fats. 
 
 Formerly nitrogenous foods were believed to furnish the chief 
 supply of energy for the body, especially in the production of mus- 
 cular force ; but the experiments of Parkes and others made some 
 thirty years ago did much to modify this theory, and it is now be- 
 lieved that the chief value of nitrogenous food stuffs lies in tissue 
 formation in distinction from force production, which is maintained 
 by the hydrocarbons. Some energy is undoubtedly derived from 
 nitrogenous material, for no molecular rearrangement or chemical 
 reaction can take place without altering the balance of energy, but 
 the force produced by combustion of proteids is insignificant in com- 
 parison with their other uses. In support of this statement, the fol- 
 lowing facts may be cited as abundantly proved : I. Severe and long- 
 continued muscular exercise does not cause the quantity of urea in 
 the urine to be materially increased. Urea represents the ashes of 
 proteid material, and increase in its quantity is due to a more active 
 oxidation of animal food, not necessarily to tissue waste. 2. Mus- 
 cular exercise, on the contrary, does result in a great increase in the 
 amount of C0 2 eliminated from the lungs, which is primarily derived 
 from the combustion of hydrocarbons. 3. Isolated muscles made to 
 contract by artificial stimulation when contained in vacuo under a 
 bell glass have been shown to produce by their activity large quanti- 
 ties of C0 2 , but no urea. 4. Prolonged muscular exercise or extra- 
 
NUTRITION. ANIMAL AND VEGETABLE FOODS COMPARED 33 
 
 ordinary exertion can be maintained upon a diet of starchy foods 
 and fat without meat ; and during the period following the exertion 
 the urea is not increased beyond a degree which is readily accounted 
 for by a slight wasting of the nitrogenous tissues of the body. 
 
 A man cannot perform more actual muscular labour upon an ex- 
 clusive diet of animal food than of starchy food. He requires abun- 
 dant animal food to replace the general wear and tear of muscular 
 tissue, but the energy for muscular contraction is not derived from 
 nitrogenous food, but from carbohydrates, the former being used 
 merely to keep the muscles in a state of healthful equilibrium. 
 He who is physically feeble and who lacks muscular power cannot 
 restore that power by an exclusive nitrogenous diet. A man fed 
 upon nitrogenous diet without vegetable food may not work as well 
 in daily labour as when given a fair proportion of the latter ; but, on 
 the other hand, he is better fitted for sudden arduous exertion than 
 are exclusive vegetable feeders. 
 
 A mixed diet is therefore the only rational one for man, and it is 
 useless to reason otherwise from analogy with the lower animals. 
 The ox is strong and performs daily labour upon a grass diet, but he 
 extracts a large proportion of nitrogen from such food which man's 
 feebler digestive organs do not enable him to do. The proportion 
 of proteid to carbohydrate is 1 to 4.7 in such food. The horse is fed 
 upon oats when it is desired to increase his spirit and activity, and 
 he derives more nitrogen from them than does man from his oatmeal. 
 The lion derives great strength from purely nitrogenous food, but 
 even when trained he is wholly unfit for the continuous exertion that 
 herbivores can endure. 
 
 The northern Eskimo, who has absolutely no starchy or saccha- 
 rine food, eats fat with his proteid diet, and is therefore enabled to 
 acquire energy to resist extreme cold and to take very long and 
 fatiguing sledge journeys ; yet he is no stronger, nor as strong, as 
 the Central African negro, who lives upon a diet of manioc and plan- 
 tains, without meat. 
 
 " Some food rich in protein will be found in the daily diet of all 
 peoples. The Mongol eats with his rice, which is largely starch, 
 small quantities of fish, fish eggs, and goose livers, but for his supply 
 of proteid material he relies on his different preparations of bean 
 cheese and on soja sauce made from the soy bean. The Mexican, 
 whose supply of meat is scanty and of a poor quality, uses the native 
 bean or frijole at almost every meal, made into a stew with vegetables 
 and perhaps shreds of sun-dried beef, well spiced with the chili or 
 red pepper " (Mary Hinman Abel). 
 
 Man is an animal of extraordinary adaptability to his environ- 
 ment, and one must be consequently guarded in making dogmatic 
 statements in regard to his diet, and such observations as the above 
 must be taken as applying only generally, for it seems possible for 
 
34 FOODS AND FOOD PREPARATIONS 
 
 either class of foods to supplement to some extent the functions of 
 the other. This fact is illustrated in disease as well as in health. 
 For example, in the earlier stages of diabetes sugar is formed from 
 farinaceous and saccharine food almost exclusively, but in the ad- 
 vanced stages, when these substances are withheld, it can undoubtedly 
 be made from proteid material. 
 
 The combinations of foods which are by analysis shown to con- 
 tain quantities of proteids, starch, and fat, have a very different effect 
 in overtaxing the digestive organs according to the particular form 
 in which their ingredients exist. 
 
 It is a popular belief that meat requires more effort for digestion 
 than starchy food, but in health this is probably not true, provided 
 both varieties of food are taken in correct proportion, for it certainly 
 would be a strain upon the digestive system to be obliged to derive 
 all the carbon needed from an exclusive meat diet, just as it over- 
 taxes the alimentary canal to obtain sufficient nitrogenous material 
 from an exclusive vegetable diet. It cannot be said didactically that 
 a piece of beef is more or less digestible than a potato, and that it 
 taxes the energies of the digestive organs to a greater extent, 
 although it is more completely assimilated and leaves less waste in 
 the intestine. The whole question devolves upon a true balance of 
 the ingredients of a mixed diet. As regards the actual complexity 
 of the digestive processes of the several classes of food, there is but 
 little difference : both starches and proteids pass through interme- 
 diate stages on the way to the formation of their completed products, 
 and fermentation cannot be said to present greater difficulty in the 
 one case than in the other. For man, certainly, Nature never in- 
 tended that all the nutrition of the body should be derived from any 
 one class of food stuff which would require the use of certain di- 
 gestive juices, and imply the disuse of others which are normally 
 present. 
 
 A diet of animal food is much less fattening than a vegetable 
 regimen or than carbohydrates with a fair proportion of fats, but a 
 stout man does not endure fatigue, or even starvation, better than 
 a lean man. On the other hand, to increase the proteid substances 
 of the body an albuminous diet with but little carbohydrate is neces- 
 sary. Men, unless greatly emaciated, have a reserve store of energy 
 in their bodies sufficient to maintain their animal heat and keep them 
 alive for from seven to nine days, and this is true whether they have 
 been meat eaters or vegetarians. Storage of fat will help them out in 
 emergencies, but if it has been overdone — i. e., if there is too much 
 fat in the tissues — they may be weakened by it and, although they 
 have the material for force production on hand, they are unable to 
 utilise it, and are worse off than if they were spare. (See Obesity 
 and Leanness.) 
 
 Bauer says : " The material effects of albumin and of fat in the 
 
VEGETARIANISM 35 
 
 system are in a certain sense opposed, for the former increases the 
 tissue waste and secondarily the oxidation, while fat induces the op- 
 posite effects." When the organism is in health albumin constitutes 
 upon the average about 10 per cent of the body weight and fat about 
 1 6 per cent, but these proportions may vary within wide limits. 
 
 Animal food is easily cooked, requiring less fuel than vegetable 
 food, and in the process develops more flavour than does vegetable 
 food. 
 
 VEGETARIANISM 
 
 In regard to an exclusive or almost exclusive vegetable diet for 
 man, the universal experience has been that while it may keep him 
 in apparent health for some time, it eventually results in a loss of 
 strength and general resisting power against disease, which becomes 
 evident after some months, if not before. 
 
 Of vegetarianism Bauer says : " The beneficial effects of vege- 
 tarianism certainly do not depend on the fact that its followers take 
 no meat, and still more no animal food, but on their giving up their 
 former bad habits." 
 
 No doubt much of the alleged benefit of vegetarianism is due to 
 the greater freedom of action of the bowels, induced by the use of 
 bran bread and other coarse articles of food. 
 
 It is impossible to subsist for any length of time on a diet which 
 does not contain a considerable quantity of nitrogen, which con- 
 stitutes so important an element in the composition of the great 
 majority of structures of the body, and, in fact, of protoplasm itself. 
 
 Attempts have from time to time been made, for economic rea- 
 sons, to furnish large bodies of labouring men, employed by con- 
 tract or otherwise, with a purely vegetable diet ; but this diet is 
 found to defeat its own ends, in that the maximum of labour can- 
 not be maintained by men who are fed exclusively on vegetable 
 food, although some carbohydrates are essential. It gradually in- 
 duces a condition of muscular weakness and languor with disincli- 
 nation for either physical or mental work. In support of this state- 
 ment Vigsford relates that for the construction of a railway from 
 Paris to Rouen, English and French workmen were employed. 
 The former did one third more work than the French, until in the 
 French diet roast beef, as in the diet of the English, was substituted 
 for bouille and soup, after which the work done by the two gangs of 
 men was equalised. 
 
 In referring to graminivorous people, like the Bengalese, Cham- 
 bers wrote : " If required to exert themselves in any unusual way 
 when food is deficient, they simply die. The reason is evident — 
 they have been living on their own tissues, and the small quantity 
 of albuminous matter in grain is a long time in building them up 
 again, so that for weeks, or even months, their muscles are in a state 
 
36 FOODS AND FOOD PREPARATIONS 
 
 of atrophy." It is found, too, that their food must be very gradu- 
 ally altered if they are to change to a mixed diet. 
 
 Animal food in some form must be regarded as absolutely essen- 
 tial for all vigorous races. When the diet of enthusiastic " vege- 
 tarians " is carefully investigated it is found that the strictly hydro- 
 carbonaceous food is supplemented by such articles as milk, eggs, 
 etc., which are used in cooking or in other ways, although the con- 
 sumption of nitrogenous food may appear very much restricted. 
 
 It is believed by Giibler and others that an exclusive vegetable 
 diet eventually develops an atheromatous condition of the arteries, 
 on account of the large proportion of mineral salts which thus enter 
 the blood, but the evidence of this is not convincing. It is also 
 claimed that a vegetable diet favours the deposition of mineral salts 
 in different parts of the body, as phosphatic stone, gravel, and the 
 tartar on the teeth, and that living upon coarse cereals alone makes 
 the skin rough, and the individual dull, heavy, and ill-tempered. 
 
 While it is quite true that some kinds of vegetables contain a large 
 proportion of nitrogenous substance, it exists in a form in which 
 it is less easily assimilated than animal proteid. In vegetable foods 
 nitrogenous materials are more or less closely mingled with starch. 
 Cellulose itself is often very tough and insoluble in the digestive 
 fluids, so that as large a proportion of protein as 17 per cent may be 
 wasted, while not over 3 per cent of the proteid of animal food re- 
 mains undigested (Yeo). This is an important illustration of the 
 fact that one must not be guided by chemical composition alone in 
 selecting the proper dietary for man, but the question should rather 
 depend upon the actual nutrient value of the food when absorbed. 
 A food in its ultimate analysis may yield the necessary chemical 
 ingredients for a nutritious diet, and yet from imperfect digestibility 
 it may prove of little service for actual nutriment. 
 
 There are many facts in Nature in addition to those already 
 discussed which indicate without doubt that man from his earliest 
 prehistoric days has been omnivorous, adapting himself to his sur- 
 roundings and eating, in his primitive condition, whatever his envi- 
 ronment afforded, with least expenditure of labour to obtain it, now 
 vegetable, now animal food. This is shown in the structure of the 
 teeth in prehistoric skulls, and in the length of the alimentary canal 
 and character of the digestive organs and secretions as at present 
 existing. 
 
 The ancient Britons are known to have subsisted largely upon 
 acorns, berries, roots, leaves, etc., but other primitive tribes ate fish, 
 shellfish, and, when they could kill it, game. 
 
 A brief glance at the dietetic habits of the more primitive tribes 
 of mankind at present living shows that no arguments can be drawn 
 from them as to the advantages of any particular class of foods. 
 
 Many savage tribes to-day live very largely upon vegetable food, 
 
WATER 37 
 
 although an exclusive vegetable diet is almost unknown among 
 them, and most of them eat meat whenever they can obtain it, or 
 they supplement their food by nitrogenous articles, such as milk, 
 eggs, fish, and insects of various kinds. Even the Chinese and 
 Japanese, who subsist principally upon simple farinaceous food, such 
 as rice, eat also eggs, fish, pork, and chicken. On the other hand, 
 there are tribes of men inhabiting very hot countries who eat con- 
 siderable quantities of meat, as, for example, the Nubian Arabs 
 and Abyssinians. Some natives along the Congo subsist solely upon 
 fruits (plantains) and insects. The Mongolian lives by his herds — 
 upon milk products and meat — bread being scarcely known to him. 
 The Australian savage is omnivorous, and, having no cereals, he 
 subsists upon berries, beans, pith, nuts, honey, larvae, ants, etc. The 
 Papuan Islanders live chiefly upon sago, fish, and fruits. The New 
 Caledonians were formerly cannibals, but are now vegetarians by 
 preference, and prefer to trade their pigs and goats with passing 
 ships rather than to eat them. 
 
 Vegetarianism in former times has had many famous advocates. 
 Shelley was a vegetarian, so was Jean Jacques Rousseau, and Gold- 
 smith also at one time. There is a vegetarian society in England 
 which has established restaurants in London, Manchester, and sev- 
 eral other localities. In London there are upward of 4,000 mem- 
 bers of this society. There is a similar organisation in this country. 
 The creed of esoteric Buddhism has induced some persons in this 
 country to adopt vegetarian habits, but few of them adhere to them 
 strictly or for long. 
 
 THE CLASSES OF FOODS-I. WATER 
 
 It is estimated that water composes about 70 per cent of the 
 entire body weight, and it is an almost universal solvent. Its im- 
 portance to the system, therefore, cannot be overrated. The elastic- 
 ity or pliability of muscles, cartilages, and tendons, and even of 
 bones, is in great part due to the water which these tissues contain. 
 As Solis-Cohen says, " the cells of the body are aquatic in their 
 habits." The amount of water required by a healthy, man in twenty- 
 four hours is, on the average, between 65 and 70 ounces, besides 
 about 20 ounces taken in as an ingredient of solid food, thus making 
 a total of 85 to 90 ounces. The elimination of this water is divided 
 as follows : 28 per cent through the skin, 20 per cent through the 
 lungs, 50 per cent through the urine, 2 per cent through other secre- 
 tions and the feces. This is, of course, a very general computation, 
 for there is constant variation in the activity of different organs. 
 
 A large proportion of the water is taken in the form of beverages 
 composed chiefly of it, and by many persons they are substituted for 
 plain water altogether. In some countries light wines, beer, and 
 
38 FOODS AND FOOD PREPARATIONS 
 
 other fermented drinks wholly replace drinking water. This may be 
 due to habit and custom, or to necessity from lack of pure natural 
 water, but in all cases the quantity of water required to maintain the 
 functions of the body in healthful activity remains the same, whether 
 it be drunk pure or in beverages, or taken with succulent fruits and 
 vegetables, or in milk, koumiss, etc. 
 
 One of the most universal dietetic failings is neglect to take 
 enough water into the system. 
 
 Uses of Water in the Body. — The uses of water in the body may 
 be summarised as follows : 
 
 1. It enters into the chemical composition of the tissues. 
 
 2. It forms the chief ingredient of all the fluids of the body and 
 maintains their proper degree of dilution. 
 
 3. By moistening various surfaces of the body, such as the mu- 
 cous and serous membranes, it prevents friction and the uncomforta- 
 ble symptoms which might result from their drying. 
 
 4. It furnishes in the blood and lymph a fluid medium by which 
 food may be taken to remote parts of the body and the waste mat- 
 ter removed, thus promoting rapid tissue changes. 
 
 5. It serves as a distributer of body heat. 
 
 6. It regulates the body temperature by the physical processes of 
 absorption and evaporation. 
 
 All protoplasmic activity in cells ceases at once if they become 
 dry. Elementary cells, such as the amoeba, cease to move, to digest, 
 or to show any form of irritability or functional activity when dry, 
 but if water be added to them their functions will be resumed, show- 
 ing that they have been suspended and not necessarily destroyed. 
 
 The taking of much water into the stomach by its mechanical 
 pressure excites peristalsis. One or two tumblerfuls of cold water 
 taken into an empty stomach in the morning on rising favour evacua- 
 tion of the bowels in this way. The water, moreover, is quickly ab- 
 sorbed and temporarily increases the fulness of the blood vessels. 
 This promotes intestinal secretion and peristalsis. The increased 
 activity of the lower bowel is explained in this way rather than by 
 the idea that the water itself reaches the colon and washes out its 
 contents. 
 
 Lukewarm water acts as an emetic if drunk in large quantity. 
 This action fails above 95 F. and below 6o° F., and is most efficient 
 at about 90 F. 
 
 Purity of Water. — Of recent years the importance of insuring 
 the purity of drinking water has become more and more appreciated, 
 and an intelligent public is now aroused to the absolute necessity of 
 protecting their supplies of drinking water from contamination with 
 sewage, decomposing animal matter, etc. So general has the interest 
 in this subject become in this country that new laws are being 
 passed constantly to protect the water supply of large cities and 
 
WATER 39 
 
 towns. The subject is not confined to water alone, but includes ice 
 as well, for many of the germs and organic impurities of water are 
 not destroyed by freezing, and impure ice added to pure water con- 
 taminates it. It has been very clearly proved that many infections 
 may be conveyed through the agency of water ; among the most 
 important of these are the germs of typhoid fever, dysentery, and 
 cholera. Possibly, also, the germs of other diseases, such as tuber- 
 culosis and diphtheria, can exceptionally be thus conveyed, should 
 they obtain access to drinking water. Water may be further ren- 
 dered unwholesome by moulds, ferments, and excess of decaying 
 vegetable matter. (For water contaminated with lead, see Lead 
 Poisoning.) Water from shallow wells and wells near drains, barn- 
 yards, cesspools, or privies is unfit for drinking. 
 
 Varieties of Drinking Water. — Water containing a moderate 
 quantity of mineral salts, 4 or 5 grains to the gallon, is not to be 
 regarded as impure, but the composition as well as the quantity of 
 these salts affect its power as a solvent in the tissues, and may exert 
 a very decided influence upon the digestive system when present in 
 the proportion of 60 or 70 grains to the gallon. The mineral waters 
 may contain much more. Water is usually unwholesome for drink- 
 ing when derived from volcanic and basaltic mountain regions, and 
 because of organic impurities it is bad in marshy regions. 
 
 Hard and Soft Water. — An excess of lime salts and of other min- 
 eral matters in water produces constipation, flatulence, indigestion, 
 and favours the formation of calcareous deposits in various parts of 
 the body. " Hard water " unites with soap and makes it less soluble, 
 so that it is difficult to cleanse the hands with it. It also roughens 
 the skin and dries the mucous membranes. By boiling, the hardness 
 of water, which is due to the presence of earthy carbonates, is dimin- 
 ished, for the carbonic acid, which aids in holding them in suspen- 
 sion, is driven off. Water is also improved for drinking by filtering 
 through a filter paper, or clean absorbent cotton on a funnel. Boil- 
 ing the water does not precipitate neutral and alkaline salts, and a 
 purgative action may still remain if they are present. Hard water 
 is made more digestible by converting it into barley or oatmeal water. 
 Water which contains sulphate of lime causes gastric distress and 
 dyspepsia, and it may form calculi. " Soft water " is simply water 
 which is free from objectionable salts. It is more wholesome than 
 hard water. Hard and soft water have well-known characteristics in 
 regard to their effect upon the cooking of food. Calcareous drink- 
 ing waters have been believed to be factors in the development of 
 goitre and cretinism, notably in Switzerland, but many cases occur 
 in which such theory is untenable. 
 
 Rain Water. — Next to clear mountain-spring water which has run 
 through gravel and been well aerated, rain water at the close of a 
 shower is the purest form of natural water, excepting where it has 
 
40 FOODS AND FOOD PREPARATIONS 
 
 fallen through a very dusty or smoky atmosphere or has run over a 
 dirty roof. The first drops of a shower carry down with them the 
 impurities of the air, including traces of ammonia and nitric acid. 
 No natural water possesses absolute chemical purity, but water col- 
 lected at the end of a hard or long shower is very pure, having been 
 distilled by previous evaporation. 
 
 River water which has run over a rocky or gravel bed, and has 
 been well aerated, is quite pure and assimilable if properly protected 
 from sources of pollution. Free oxidation makes much organic 
 matter harmless. Flowing water by oxidation and dilution becomes 
 purified to a great extent of injurious organic matter, but is not 
 necessarily deprived of living germs of contagion, such as those of 
 typhoid fever or cholera, and the question whether their number and 
 virulence is at all diminished in such water is still a matter of con- 
 troversy. 
 
 It is now so well recognised that the impurities of water which 
 are chiefly dangerous to man are of organic germ origin that in 
 examining water which is suspected of being the cause of a typhoid- 
 fever epidemic a chemical analysis of the nitrates present, unaccom- 
 panied by a proper bacteriological examination, is entirely useless. 
 
 Distilled Water. — Distilled water is absolutely pure, but it has a 
 flat or metallic taste from absence of air and salts. It is now ex- 
 tensively furnished for drinking, and is largely in use on vessels at 
 sea. Our modern naval vessels carry apparatus for its preparation. 
 Distilled water has been recommended as a solvent for calculi, but 
 it is of doubtful efficacy. It erodes lead pipes and cisterns. 
 
 Filtered Water. — Filtration as employed to render drinking water 
 more pure is a very delusive process, unless great care be taken as 
 to the construction of the filter and the rate of filtration. Extensive 
 experiments made at Providence, R. I., and Lawrence, Mass., have 
 proved that the benefit of sand infiltration of city water results only 
 when the filters are frequently cleaned. The sand layer should not 
 be less than 30 centimetres thick, nor the rate of water flow fall 
 below 100 millimetres per second. Frequent bacteriological ex- 
 amination of the water should be made. Koch has shown that it 
 is not the sand which " filters," but the layer of mud or slime which 
 is deposited upon it and which retains bacteria. Hence the reason for 
 not allowing filters to become clogged with mud in which germs 
 multiply. During the Hamburg cholera epidemic of 1892, the neigh- 
 bouring town of Altona suffered much less severely from the disease 
 than did Hamburg, for, although the Altona water supply was con- 
 taminated by Hamburg sewage, the water was thoroughly filtered. 
 A great variety of patent filters have been devised, and they have the 
 power of making water appear pure by decolourising it and remov- 
 ing the larger organic particles and grosser impurities which it may 
 contain, but it has been conclusively shown that the bed of a filter 
 
WATER 41 
 
 which has been in use for a short time furnishes a favourable soil or 
 culture medium for the development of germs, which increase very 
 rapidly until they reach such numbers that they are washed out with 
 the filtered water, rendering it much more injurious, in some in- 
 stances, than it was before. Many of these germs are doubtless 
 harmless, but if the microbes of infectious diseases once gain access 
 to such a soil they multiply and become highly dangerous. 
 
 Boiled Water. — Boiled water is antifermentative and antiseptic. 
 
 The object of boiling the water which is to be used for drinking 
 purposes, or in the preparation of food, is to free it from all organic 
 impurities, and in some cases to precipitate salts of lime. There are 
 no forms of germs, and there are no ferments which are not killed 
 by a longer or shorter exposure to the temperature of boiling water. 
 The process consists in the application of heat to water in sufficient 
 degree to expand the air which it naturally absorbs and cause it to 
 rise to the surface in bubbles of various sizes. If the water contains 
 gases of decomposition they are expelled, and the odour is most 
 foul just before the boiling point is reached ; later it passes off, show- 
 ing when the water is fit to drink. When boiled water, cooled, is 
 drunk it tastes " flat " or insipid, but it may be freshened by pour- 
 ing it through the air from one vessel to another or by shaking it 
 with air in a carafe. Water should always be boiled before being 
 drunk if there is the slightest suspicion as to its purity. The 
 population of the larger Chinese cities is exceedingly dense, and 
 the water used by the inhabitants is impregnated with all manner 
 of filth, but it is believed that the custom of the natives of drinking 
 tea infused with boiling water, or even drinking hot water, pro- 
 tects them to a great extent from the ravages of certain microbic 
 diseases. 
 
 The special dietetic uses of water will receive attention under the 
 appropriate headings of different diseases. 
 
 Water may be of service to eliminate waste in various renal dis- 
 eases, gout, lithiasis, oxaluria, renal inadequacy, fevers, and infectious 
 diseases. If imbibed too freely with meals it lessens the activity of 
 the saliva and gastric juice. Water taken near the end of the gastric 
 digestion of a meal (i. e., two or three hours after taking food) serves 
 to dilute the contents of the stomach and wash it more easily into 
 the intestine. If stomach digestion has been slow and feeble, so that 
 the whole process has been greatly prolonged, the drinking of six or 
 eight ounces of water, either hot or cold, two hours or more after 
 taking food will facilitate its digestion. Water is highly useful in 
 constipation, and it is more quickly absorbed from the stomach 
 when the tension in the gastric vessels is low. 
 
 It is imperatively needed after severe haemorrhage, or after the 
 sudden loss of it from the system from any cause, such as the evacu- 
 ations of cholera morbus, Asiatic cholera, etc. 
 5 
 
42 FOODS AND FOOD PREPARATIONS 
 
 It is to be restricted in dilatation of the stomach, the secretion of 
 weak gastric juice, and sometimes, but not always, in diabetes insipi- 
 dus, diabetes mellitus, ascites and other dropsies, anasarca, and in 
 some forms of heart disease and obesity. 
 
 The daily quantity of water ordinarily drunk varies between two 
 and a half and four pints. About one and a half pint more is taken 
 in the food, and four and a half or five pints are therefore lost 
 through the emunctories. 
 
 Foods which contain most water are milk and succulent fruits, 
 such as grapes, oranges, grape fruit, lemons, watermelons, etc., and 
 vegetables like the tomato, squash, and many others of tropical 
 origin. All vegetables contain more water than meats, and many, 
 but not all, ripe fruits contain more than vegetables. 
 
 Excess of Water. — There is a remarkable tendency on the part 
 of the blood to maintain an equilibrium as regards its own com- 
 position, volume, and density. When a large supply of water is re- 
 ceived in the alimentary canal and absorbed by the blood vessels, 
 the blood is momentarily diluted and the blood pressure slightly 
 raised, although the latter effect will depend upon the facility with 
 which the blood vessels are dilated. The blood immediately dis- 
 tributes the water thus absorbed, and the slightly increased pressure, 
 as well as the diluted character of the blood, hastens the elimination 
 of water from the various gland surfaces. The kidneys are particu- 
 larly sensitive in this respect, and when in normal condition are the 
 great regulators of the composition of the blood and, indirectly, of 
 blood pressure by means of the elimination of water. Perspiration 
 is increased. There is a tendency also for all the tissues to keep 
 abundantly supplied with water ; a large amount of aqueous vapour 
 is exhaled from the surface of the lungs, and the digestive secretions 
 are increased in volume. The blood may subsequently become 
 more dense than before, owing to the increased functional activity 
 of different organs. More nutriment is absorbed and more car- 
 bonic acid is exhaled, and urea and uric acid may be slightly 
 increased. 
 
 If very large quantities of water, or any fluids consisting chiefly of 
 water, are imbibed throughout a long period, they tend to overwork 
 the kidneys and produce various alterations in the tissues. Practi- 
 cally, however, it seldom happens, excepting in some forms of gas- 
 tric or intestinal disorder, and other instances mentioned above, that 
 too much water is taken. When drunk in such fluids as beer, or di- 
 luted liquors, the resulting disturbances of the system are attribu- 
 table rather to other ingredients. 
 
 Laymen are usually more willing to ascribe obesity to supposed 
 excessive consumption of fluids than to overeating. They often say 
 that they suppose water is " fattening." It is so only in the sense 
 that it promotes tissue change or metabolism and washes away 
 
WATER 43 
 
 waste matter, not in the sense that it is itself a storage substance, as 
 fat is. 
 
 Deprivation of Water. Water Starvation. — When water is with- 
 held from the system for a considerable length of time its absence 
 is first apparent in the secretions and excretions, and next in the 
 various tissues of the body, the last of all being those of the nervous 
 system. More than ten or twelve hours of abstention from drink- 
 ing produces uncomfortable thirst, and one or two hours of violent 
 exercise may do so at once. 
 
 Continued deprivation of water causes the blood, by virtue of its 
 self-regulating power, to withhold fluid from the kidneys and digest- 
 ive glands. The digestive secretions therefore become less fluid, 
 of more intense reaction, and greatly diminished in quantity. The 
 mucous surfaces become dry, and the dryness, owing to the passage 
 of air and the consequent evaporation, is first felt in the mouth and 
 pharynx. The diminution in the digestive secretions, as well as their 
 altered strength, interferes with or retards their normal action upon 
 the ingesta. The proper movement of the food in the stomach and 
 intestines is retarded by its greater solidity and by the increased 
 friction of the mucous walls, especially in the lower bowel. Consti- 
 pation therefore results. The absorption of fluid through the walls 
 of the alimentary canal is retarded, and nutrition suffers in conse- 
 quence. Meanwhile the blood, to maintain its normal character, re- 
 absorbs water from the lymph spaces and different tissues of the 
 body. The muscles and other structures become dry and diminish 
 in volume. Emaciation results, which quickly reaches an extraordi- 
 nary and painful degree. The mind dwells on water constantly, and 
 taste is diminished. Finally, the nervous system suffers from dry- 
 ness and various nervous symptoms ensue, so that, in addition to 
 extreme muscular weakness and prostration, there may be convul- 
 sions, delirium, and finally coma and death. 
 
 Thirst. — As far as the individual is concerned, the suffering from 
 deprivation of water is mainly confined to the sensations of thirst 
 and dryness of the mouth. Thirst is commonly, and somewhat er- 
 roneously, referred to the mouth and the pharynx. It is true that 
 the mucous membrane in these regions becomes dry when water is 
 withheld, but thirst may be also keen when these surfaces are abun- 
 dantly moist. The sensation is the result chiefly of the expression 
 through the nervous system of the need of the body tissues in gen- 
 eral for fluid, and it is referred to the mouth and throat from force 
 of habit, which associates the act of swallowing fluid, and the use of 
 certain muscles in that process, with the subsequent relief of thirst. 
 In support of the above statement is a fact that I have several times 
 witnessed in patients having a gastric fistula made in consequence of 
 oesophageal stenosis, or in patients nourished wholly through nu- 
 trient enemata, that the sensation of thirst referred bv them to the 
 
44 FOODS AND FOOD PREPARATIONS 
 
 mouth is immediately relieved by the injection of water into the 
 stomach through the fistula, or of salt and water into the rectum. 
 
 It is asserted that shipwrecked sailors in open boats have relieved 
 their thirst by immersing their bodies in salt water. A very little 
 water is possibly absorbed under these conditions through the skin. 
 Ordinarily, however, the skin is not capable of absorbing fluid of 
 any kind to a practical extent, but immersion in water prevents 
 evaporation from the surface of the body, and by saving its loss in 
 that direction lessens thirst. Sucking a slice of lemon or drinking 
 water acidulated with a few drops of lemon juice or vinegar some- 
 times allays thirst better than plain water. The same may be said 
 of barley and oatmeal waters. Lime juice and ice is another remedy. 
 Bitartrate of potassium or very weak brandy may be used for the 
 same purpose, and is sometimes more satisfying. 
 
 On one of the arctic expeditions which resulted disastrously 
 the men had no water for two months, but ate snow, having no fuel 
 to spare to melt it. 
 
 " Hot water, as hot as can be sipped, quenches thirst much better 
 than cold " (Balfour). 
 
 Glycerin and water is sometimes used to allay thirst by rinsing the 
 mouth. The glycerin, being viscid, coats the surface of the mucous 
 membrane and prevents to some extent the drying by evaporation, 
 but it is hygroscopic and tends to abstract water if used too strong, 
 and practically it is of little service. 
 
 When it is undesirable to give water by the mouth, thirst may be 
 relieved by injection of salt and water beneath the skin (see Hypo- 
 dermoclysis) or into the rectum. 
 
 Thirst may be controlled somewhat when it is desirable to re- 
 strict the fluids ingested by giving small doses of opium (Riegel). 
 It may be that part of the benefit derived from this dru^^in the 
 treatment of diabetes is due to its controlling this symptom. It is 
 taken sometimes by professional fasters, who aim to abstain from all 
 food, and from as much drink as possible. The latter is done be- 
 cause without food water tends to promote tissue waste too rapidly, 
 and loss of strength would be more rapid upon no food and an ex- 
 cess of water than upon no food with water in great moderation. 
 
 Temperature of Drinking Water. — Water is drunk at various tem- 
 peratures from that of melting ice to no or 112 F. It is some- 
 times stated that the temperature of water influences digestion, but 
 the extent to which it does so is much exaggerated. Very cold water 
 swallowed quickly in large amount is said to contract the stomach 
 wall and stimulate the heart action. Lehman says that water drunk 
 at 6o° F. causes a fall in the pulse rate and in rectal temperature, but 
 these observations lack confirmation. This subject, as well as that 
 of the local action of hot water, will be found more fully discussed 
 under the heading Temperature and Digestion. 
 
SALTS 45 
 
 Ice is often useful in the sick-room, but it should not be given to 
 young infants. Cracked ice sometimes soothes an inflamed throat, 
 and occasionally it allays nausea. It relieves thirst only temporarily, 
 and this symptom may be increased by its prolonged use. If too 
 much is swallowed it becomes lukewarm in the stomach and may be 
 vomited. 
 
 II. SALTS 
 
 Varieties of Salts. — The principal salts derived from the food 
 are as follows : 
 
 Chlorides of sodium and potassium ; carbonates of sodium, potas- 
 sium and magnesium ; sulphates of sodium, potassium and magne- 
 sium ; phosphates of sodium, potassium, magnesium, and calcium. 
 The majority of these salts are held to be unaltered by digestive pro- 
 cesses and pass into the blood or tissues without necessary chemical 
 change. The reason for this belief is the fact of the readiness with 
 which they can be obtained, unaltered by chemical analysis, from the 
 different tissues of the body and the urine. Some compounds — 
 namely, the salts of iron and salts of the organic acids — are ingested 
 in very minute quantity and their uses are but vaguely understood. 
 Other salts, such as the chlorides, carbonates, and phosphates of the 
 alkalies and alkaline earths, are taken in much larger daily amount 
 and subserve definite purposes. 
 
 Uses of Salts in Food. — The uses of the salts derived from the food 
 are summarised as follows : 
 
 I. To regulate the specific gravity of the blood and other fluids 
 of the body. 
 
 II. To regulate the chemical reaction of the blood and the various 
 secretions and excretions. 
 
 III. To preserve the tissues from disorganisation and putre- 
 faction. 
 
 IV. To control the rate of absorption by osmosis. 
 
 V. To enter into the permanent composition of certain structures, 
 especially the bones and teeth. 
 
 VI. To enable the blood to hold certain materials in solution. 
 
 VII. To serve special purposes, such, for example, as the influ- 
 ence of sodium chloride on hydrochloric-acid formation, and that of 
 lime salts in favouring coagulation of the blood. 
 
 Generally speaking, fruits and nuts contain the least quantity of 
 salts, meats rank next, after them vegetables, and pulses and cereals 
 contain most of all. 
 
 Excess of Salt. — Salts of any kind when taken in excess with 
 the food disagree with digestion in various ways. They may prove 
 locally irritant to the gastric or intestinal mucous membrane; they 
 modify the rate of absorption of digestive material, and alter the 
 intensity of reaction of the different digestive fluids. After being 
 
46 FOODS AND FOOD PREPARATIONS 
 
 absorbed in excess they may interfere with the nutritive and chem- 
 ical processes of the blood and tissues. Some persons acquire a salt- 
 eating habit and partake too freely of common salt with the food, 
 with the result of the production of more or less dyspepsia or 
 some of the symptoms above mentioned. Too much salt in the 
 food produces thirst, and may even stimulate a craving for strong 
 drink. 
 
 Lime salts and phosphates when taken in food or drinking water 
 in large quantities for several weeks or months tend to cause the 
 deposit of renal or vesical calculi. 
 
 Deprivation of Salt. — Continued deprivation of any one of the 
 common salts, so long as others are furnished in reasonable abun- 
 dance in the food, does not result seriously. If, however, all the salts 
 are reduced in quantity, of if they are entirely excluded from the 
 diet, the system very soon begins to evince signs of malnutrition. 
 This is readily accounted for by referring to the uses of salts above 
 described. Animals or men deprived of salts for a long time suffer 
 greatly from indigestion and from lack of bodily nutrition. The 
 body may not diminish in weight, but the tissues become " flabby," 
 the muscles feeble, the mind stupid and dull, the nutrition of the skin 
 is altered, it becomes dry, and there is falling out of the hair. Event- 
 ually, in animals with salt starvation death occurs in from six to eight 
 weeks from progressive bodily weakness and inanition — a condition, 
 practically, of marasmus. 
 
 Young infants who do not obtain sufficient salts of lime — i. e., if 
 fed upon proprietary " infant foods " instead of good milk — become 
 rhachitic ; their bones ossify slowly and bend into deformities. Such 
 children are sometimes given hypophosphite-of-lime biscuits to sup- 
 ply the deficiency, but they should be properly fed upon fresh milk. 
 (See Rhachitis.) 
 
 Sodium Chloride. — Sodium chloride, or common table salt, is by 
 far the most important and valuable salt, and is used in the largest 
 amount. It has long been a symbol of wisdom and hospitality in 
 the East. It forms 60 per cent of the salts of the blood, and enters 
 into the structural formation of all the tissues and secretions of the 
 body in greater or less quantity, with the single exception of the 
 enamel of the teeth. It is estimated that the quantity which may be 
 daily appropriated from the food is about fifteen grammes. Salt 
 slightly stimulates the renal secretion, which in turn leads to thirst 
 and to drinking more fluid, which promotes interchange of the juices 
 of the body. It also excites thirst more directly. 
 
 Common salt stimulates the appetite and influences beneficially 
 the gastric secretion. It not only furnishes the chlorine for hydro- 
 chloric acid, but seems to act locally in the stomach by promoting 
 this secretion as well as the conversion of pepsinogen into active 
 pepsin. Cohn and Voit have proved that the absence of salt from 
 
SALTS 47 
 
 the diet completely checks the production of hydrochloric acid in the 
 stomach. 
 
 There are some few tribes of flesh-eating men who do not add 
 salt to their food, relying for their needs upon what they derive 
 from the food itself. This supply is therefore sufficient to maintain 
 life. In fact, as a rule, man derives enough salts from the compo- 
 sition of his food to supply the tissues and juices of the body, and 
 the additional quantity which he takes as table salt is mainly of serv- 
 ice as a condiment, to give agreeable flavour to a mixed diet and to 
 sharpen the appetite. The excess of salts in general is promptly 
 eliminated in the urine. 
 
 In most men and many of the higher mammalia the craving for 
 sodium chloride is instinctive. Stanley records in his book " In 
 Darkest Africa " instances where savages are accustomed to travel 
 many hundreds of miles under great difficulties to obtain a coveted 
 supply of salt. 
 
 Herbivorous animals are even more dependent upon salt than are 
 carnivores ; cattle and sheep, for example, must be given salt in ad- 
 dition to that contained in their food to remain in good condition. 
 
 Overdoses of salt cause diarrhoea and even gastro-enteritis, and 
 excite irritation of the nerves of the throat. 
 
 Large doses of salt have been given in pleurisy with the view of 
 increasing the density of the blood and causing reabsorption of the 
 pleuritic fluid by promoting osmosis towards the vessels. This treat- 
 ment has not met with success. The popular use of salt to control 
 pulmonary haemorrhage is of no practical value. 
 
 Almost all vegetables contain less sodium chloride than does milk, 
 the food of the young growing animal, although many of them have 
 more potassium. 
 
 Sodium chloride is of great service as a preservative of foods, 
 either used as a brine in pickling, corning beef, preserving olives, etc., 
 or in solid form to dry and keep meat and fish from decomposition. 
 
 Potassium Salts. — Next in importance to sodium chloride ranks 
 potassium chloride, which is the predominant salt of the muscles, and 
 which, like sodium chloride, is a common ingredient of nearly all the 
 tissues and fluids. The acid and neutral carbonates and phosphates 
 of sodium and potassium are important in regulating the reaction 
 of the digestive secretions and the urine. 
 
 Calcium. — The salts of calcium are chiefly of value from their 
 constituting a large percentage of the composition of the bones and 
 teeth, as well as a smaller percentage of many other tissues of the 
 body. Their presence seems to be associated constantly with cell 
 growth and development. The carbonate is often found with the 
 phosphate of lime, but in less quantity. The occurrence of cretinism 
 and goitre has been in part attributed to an excess of lime salts in the 
 food, more especially the drinking water; but this theory is not to be 
 
48 FOODS AND FOOD PREPARATIONS 
 
 accepted without question. These diseases often occur indepen- 
 dently of such cause, and are by no means always prevalent in lime- 
 water areas. 
 
 Young growing animals contain a larger percentage of earthy 
 salts than do older ones. Deposits of salts of lime occur in old 
 abscesses, tubercular concretions, tartar on the teeth, atheromatous 
 blood vessels, the arcus senilis of the cornea, and as calculi. 
 
 Phosphorus.— Phosphorus is derived from phosphates in meat 
 and its contained blood which is eaten, as well as from vegetables. 
 It enters into the composition of the bones, muscles, blood, etc. 
 
 Sulphur. — Sulphur is derived from sulphates contained princi- 
 pally in fibrin, egg albumen, the casein of milk, and from such vege- 
 tables as corn, turnips, cauliflower, and asparagus. 
 
 Iron. — The iron of the body is found in the blood pigment, where 
 it amounts, all told, to a third of an ounce. It is also present in 
 minute traces in other pigments. 
 
 Its chief source is from the blood of animals which is cooked with 
 their meat. Two quarts of milk furnish about one eleventh grain of 
 iron. It is also derived from, and it may be taken with, chalybeate 
 waters. Probably most of the iron of the body is retained and used 
 again and again. The daily quantity of iron ingested with an ordi- 
 nary mixed diet is about one eighth grain. 
 
 Vegetable Acids 
 
 The common organic or vegetable acids — citric, tartaric, malic, 
 etc. — are derived from fresh vegetables and fruits, in which they exist 
 usually in combination with the bases Ca, Na, K, etc. They are 
 indispensable articles of food, for when absorbed they form carbon- 
 ates, which aid in maintaining the alkalinity of the blood. Prolonged 
 deprivation of them usually results in the condition of scurvy. 
 
 III. ANIMAL FOODS 
 
 Animal foods contain much nutritive matter in a more or less 
 concentrated form which exists in practically the same chemical 
 combination with the body itself. They leave comparatively little 
 residue, being quite thoroughly digested. They are agreeable in 
 flavour, and they hold salts, including iron, which are of special value 
 as force producers. They are, however, inferior to starches in this 
 property unless much fat be incorporated with them. 
 
 The varieties of animal foods will be described under the head- 
 ings, milk, eggs, meat, fish, gelatin, fats. 
 
 Milk 
 
 The milk of several animals, such as cows, goats, asses, mares, 
 and camels, may be used for food, but in this country very little other 
 
ANIMAL FOODS 49 
 
 than cows' milk is employed. The varieties of milk differ slightly in 
 chemical composition, odour, and taste, but they all contain the ele- 
 ments which are necessary for the maintenance of life in fairly eco- 
 nomical proportion, so that for infants they constitute a " complete " 
 food which fully meets the requirements of the growing body, and in 
 adults they will sustain life comfortably for many months. 
 
 For these reasons milk ranks among the most important of all 
 foods, and it is necessary to determine to what extent it should be in- 
 troduced into ordinary diet. A pint of milk may be said to represent 
 approximately the nutrition contained in six ounces of beef or mut- 
 ton. Although it furnishes so useful a food, milk is by no means 
 essential to a diet designed for increasing bodily strength, and it is 
 usually omitted from the menu of athletes in active training. 
 
 Milk taken alone constitutes an insufficient diet for adults in 
 health, for to obtain the requisite 18.3 grammes of nitrogen 2,905 
 grammes of milk only are needed, against 4,652 which must be taken 
 to obtain the necessary 328.9 grammes of carbon (Bauer). (See 
 Force Production, page 20.) 
 
 Adults who are able to eat any kind of food usually maintain their 
 health in better condition by abstaining from milk except as used for 
 cooking purposes, inasmuch as it makes many persons " bilious " to 
 drink it, and produces constipation, particularly when taken in excess 
 with other foods. 
 
 Sir Henry Thompson, in condemning the excessive drinking of 
 milk by persons in good health who are at the same time eating large 
 meals of meat, says : " It is altogether superfluous and mostly mis- 
 chievous as a drink for those who have reached adult age and can 
 digest solid food." There are, however, many diseases in which a 
 partial, or for a time an exclusive, milk diet is to be recommended. 
 
 Milk in considerable quantity — i. e., equal to one third or one half 
 the total amount of food consumed — is often highly desirable in such 
 diseases as tuberculosis, chronic Bright's disease, and anaemia. 
 
 Exclusive Milk Diet. — An exclusive milk diet is useful in the 
 following conditions and diseases : 
 
 1. In infancy for the first year, and sometimes for the first 
 eighteen months. 
 
 2. All acute infectious diseases of young children. 
 
 3. Typhoid fever. 
 
 4. Acute Bright's disease, and at times in chronic nephritis. 
 
 5. Acute pyelitis. 
 
 6. Chronic gastric catarrh. 
 
 7. Gastric ulcer and carcinoma. 
 
 8. Neurasthenia. 
 
 A milk diet is so easy to prescribe, so cheap, and so easily pro- 
 curable, that it is always the first resort of those who, from indiffer- 
 ence or lack of knowledge of the first principles of dietetics, are 
 
50 FOODS AND FOOD PREPARATIONS 
 
 unwilling or unable to take pains to study the peculiarities and 
 needs of the individual case. It is an easily measured food, and it 
 becomes a routine practice in hospitals — where almost always more 
 attention is awarded to medication than to diet — to order milk diet 
 for all patients who are not at the convalescent or full house table, 
 and it is doubtless safe to err in this direction, but it is by no means 
 always the best that can be done for the patients. 
 
 An exclusive milk diet in time becomes monotonous and weari- 
 some to most adults, and may produce dyspepsia, constipation, and 
 interfere with the functional activity of the liver. Aside from nausea, 
 which the continued use of milk may excite, a positive loathing for 
 the taste of it may be developed, unless the regimen is modified 
 by occasional variation. This is a matter of considerable impor- 
 tance in feeding patients suffering from typhoid fever, chronic 
 Bright's disease, chronic gastric catarrh, and other affections for 
 which milk diet is often prescribed ; for if other substances are sub- 
 stituted from time to time in small amounts, while milk is still re- 
 tained as the chief food, it may be continued as such for a much 
 longer time. On seeking the cause for the disagreement of milk, it 
 is found in the fact that it contains too large a proportion of nitro- 
 genous material as compared with the hydrocarbons, so that, in order 
 to obtain sufficient of the latter, an excess of proteid is ingested, 
 which interferes with normal digestion. 
 
 For a man in health a pure milk diet, as Ewald says, is " slow 
 starvation," although it is an excellent food for a short time. If kept 
 too long upon it, he develops a condition akin to scurvy. (See 
 Diet in Scurvy.) This, however, does not invariably follow in 
 disease, and J. K. Mitchell refers to a patient with diabetes and 
 nephritis who lived upon milk alone for seven years, and kept in 
 active business. 
 
 Infants and children tire of milk less easily than adults. Whereas 
 the adult needs twenty-three ounces of water-free food per diem to 
 maintain healthful equilibrium, he must consume nine pints of milk 
 at a specific gravity of 1.030 to supply it. The excess of albumin, 
 fat, and water which he would then obtain is wasteful for him, 
 although it is good for the young. But in illness life is comfortably 
 maintained upon a smaller quantity for a few weeks, and in typhoid 
 fever four or five pints is an ample allowance, and it is often better 
 to give less. (See Diet in Typhoid Fever.) In a case of chronic 
 Bright's disease, if the patient is not confined to bed, it may be neces- 
 sary to give six or seven pints. 
 
 In order to digest large quantities of milk it must be taken in 
 measured doses at frequent intervals. In typhoid fever, for ex- 
 ample, from three to five ounces may be given every two hours. In 
 some diseases it is best to give two ounces every hour, in others six 
 or eight ounces everv three hours. 
 
ANIMAL FOODS 5 I 
 
 Milk leaves no coarse waste residue in the intestine like the indi- 
 gestible fibre of meat or the cellulose of vegetables and fruits. Not- 
 withstanding this fact, an exclusive milk diet yields considerable bulk 
 of fecal matter, and a typhoid-fever patient living on milk alone often 
 has daily evacuations of medium size. Riibner found that in health a 
 diet of milk alone yields larger stools than either roast beef or Qgg 
 alone. Yet by weight the absorption of milk is shown to be very 
 complete, and four thousand grammes of milk ingested by the mouth, 
 when perfectly digested, yield but one hundred grammes of feces 
 (Riibner). There is a marked loss through the feces of the salts of 
 lime which have been contained in the milk. These facts explain 
 in part why milk is so constipating. 
 
 Prof. Charles E. Wait, in the course of nutrition investigations 
 of a club of students at the University of Tennessee (U. S. Depart- 
 ment of Agriculture, Bulletin No. 53, 1898), says: 
 
 " The average of ten experiments with an exclusive milk diet 
 showed 92.1 per cent of the protein and 86.3 per cent of the carbo- 
 hydrates to be digested. Five experiments made with an exclusive 
 bread diet or with bread and sugar showed 82 per cent of the protein 
 and 99 per cent of the carbohydrates to be digested. Five experi- 
 ments with a diet of bread and milk showed 97.1 per cent of the 
 protein and 98.7 per cent of the carbohydrates to be digested. In 
 other words, the protein in milk alone or in bread alone seems to 
 be much less completely digested than when the two are eaten 
 together." 
 
 " Milk Cure." — The " milk cure " has been carried out success- 
 fully by Pecholier, Weir Mitchell, Karell, and others for the treat- 
 ment of obstinate hysteria, hepatic congestion, dropsy, and various 
 anomalies of nutrition. The patient is given no food but milk, 
 which Pecholier orders every two hours in small amount, increasing 
 the quantity until three litres a day are taken. Mitchell commences 
 with doses of half an ounce to two ounces every two or three hours, 
 and increases the dosage by half an ounce until sixty ounces or 
 more are taken. If the taste of milk is disagreeable, coffee, salt, or 
 caramel is added. If thirst is complained of, natural water or Seltzer 
 water is given. After three or four weeks, rice, arrowroot, and thin 
 slices of white bread are allowed, and after five weeks raw meat or 
 one or two cutlets. The milk, meanwhile, is continued. After a 
 day or two of this treatment, hunger and thirst are not usually com- 
 plained of. At first the pulse is accelerated, but there is seldom any 
 conspicuous nervousness. The tongue is coated, the water in the 
 urine is increased, there is obstinate constipation (which must be 
 relieved by enemata or medicines), the stools are hard and ochre or 
 white in colour, and a great deal of epigastric distress and feeling of 
 emptiness are present. The arterial tension is lowered ; there may be 
 muscular prostration. There is loss of weight at first. If the treat- 
 
52 
 
 FOODS AND FOOD PREPARATIONS 
 
 ment is persevered in, at the end of a fortnight there is marked 
 improvement in the feelings and condition of the patient, and after 
 six or eight weeks the cure is usually far advanced. 
 
 Chemical Composition of Milk. — The chemical ingredients which 
 make milk valuable as a food are water, salts, fats, milk sugar or 
 lactose, and albuminous materials, chiefly casein, with some albumin. 
 Scheibe and Henkel claim to have found traces of citric acid in nor- 
 mal cow's milk. 
 
 The published analyses of milk vary slightly, chiefly in regard to 
 the quantity of fats observed. 
 
 The following analyses are placed together for comparison : 
 
 
 Wanklyn. 
 
 London Dairy. 
 
 Bell. 
 
 Leeds. 
 
 E. W. Stewart. 
 
 Fat 
 
 3.20 
 
 9-3o 
 
 4.IO 
 
 8.80 
 
 4.OI 
 
 9-3i 
 
 3-75 
 
 8.86 
 
 3.80 
 9.20 
 
 Other solids 
 
 Total solids 
 
 Water 
 
 12.50 
 
 87.50 
 
 12.90 
 87.IO 
 
 13-32 
 
 86.68 
 
 12.61 
 87-39 
 
 I3.OO 
 87.OO 
 
 
 
 100.00 
 
 IOO.OO 
 
 100 . 00 
 
 100 . 00 
 
 IOO.OO 
 
 The above London Dairy analysis is based upon the examination 
 of 120,000 samples of milk conducted by the chemist to the dairy 
 during a period of twelve years. The third analysis is by Dr. J. 
 Carter Bell, an English public analyst, and the fourth is by Prof. 
 Albert H. Leeds. 
 
 Fat and Cream. — Milk fat is mainly formed of glycerides of 
 palmitic and oleic acid (Warington), the latter constituting about 
 50 per cent (Ruppel), with five or six other fatty acids, such as 
 myristic and stearic, represented in minute quantity. 
 
 While the percentage of fat in milk, as shown by chemical anal- 
 ysis in the above tables, is about 4 per cent, that of cream itself is 
 considerably higher, but cream is not pure fat. It is simply an aggre- 
 gation of the oil globules in the top portion of the milk with a little 
 proteid and carbohydrate. Average milk contains 8 to 10 per cent 
 of cream. Alderney milk may have as high as 20 or even 30 per 
 cent. Good milk should form a layer of cream about two inches 
 and a half thick as it stands in a quart bottle. 
 
 The globules of milk fat vary in size between 0.0005 an d 0.00005 
 inch in diameter, and the smallest do not rise to the surface as cream, 
 for their albuminous coverings are proportionately heavier (Waring- 
 ton). " The fuel value of a pint of cream is not far from 1,425 calo- 
 ries, or about the same as one and one eighth pounds of bread, or 
 one and one half dozen bananas, or four and one half pounds of pota- 
 toes " (A. C. True). 
 
 The following table is from the U. S. Department of Agriculture, 
 Farmers' Bulletin No. 74, 1898: 
 
ANIMAL FOODS 
 
 53 
 
 Amounts of Nutrients in a Pound {Pint) of Milk as compared with a 
 Pound of Meat, Bread, and Other Food Products 
 
 Food Materials. 
 
 Milk (i pint). 
 
 Whole milk 
 
 Skim milk (0.3 per cent fat) 
 Buttermilk 
 
 Other food materials 
 (1 pound each). 
 
 Cheese 
 
 Butter 
 
 Beef, sirloin 
 
 Mutton, side , 
 
 Pork: 
 
 Loin 
 
 Ham 
 
 Salt, fat 
 
 Chicken 
 
 Codfish : 
 
 Fresh 
 
 Salt 
 
 Mackerel, salt 
 
 Oysters, solids 
 
 Wheat flour ,-. 
 
 Cornmeal 
 
 Oatmeal 
 
 Wheat bread 
 
 Crackers 
 
 Dried beans 
 
 Beets 
 
 Potatoes 
 
 Turnips 
 
 Apples 
 
 
 
 EDIBLE PORTION. 
 
 
 Water. 
 
 NUTRIENTS. 
 
 Protein. 
 
 Fat. 
 
 Carbo- 
 hydrates. 
 
 Mineral 
 matter. 
 
 Pound. 
 
 Pound. 
 
 Pound. 
 
 Pound. 
 
 Pound. 
 
 O.87 
 
 O.O3 
 
 O.O4 
 
 O.O5 
 
 O.OI 
 
 O.9O 
 
 O.O4 
 
 
 O.05 
 
 O.OI 
 
 O.gi 
 
 O.O3 
 
 O.OI 
 
 O.O5 
 
 O.OI 
 
 O.34 
 
 O.26 
 
 0.34 
 
 0.02 
 
 0.04 
 
 O.II 
 
 O.OI 
 
 O.85 
 
 
 0.03 
 
 0.53 
 
 O.I6 
 
 O.I7 
 
 
 O.OI 
 
 0.43 
 
 O. 13 
 
 O.24 
 
 
 O.OI 
 
 O.44 
 
 O.I4 
 
 0.25 
 
 
 O.OI 
 
 0.35 
 
 O.13 
 
 0.34 
 
 
 0.04 
 
 O.07 
 
 0.02 
 
 O.87 
 
 
 0.04 
 
 O.48 
 
 O.I5 
 
 O.OI 
 
 
 O.OI 
 
 O.58 
 
 O.II 
 
 
 
 O.OI 
 
 O.4O 
 
 0.16 
 
 
 .... 
 
 0.19 
 
 O.38 
 
 0.17 
 
 0.17 
 
 
 O.IO 
 
 O.88 
 
 0.06 
 
 0.02 
 
 O.O3 
 
 O.OI 
 
 O.I2 
 
 O.II 
 
 O.OI 
 
 0.75 
 
 O.OI 
 
 O.I3 
 
 0.09 
 
 0.02 
 
 0-75 
 
 O.OI 
 
 O.O7 
 
 0.16 
 
 0.07 
 
 O.68 
 
 0.02 
 
 0.35 
 
 O.IO 
 
 O.OI 
 
 0.53 
 
 O.OI 
 
 O.08 
 
 O.II 
 
 O.IO 
 
 O.69 
 
 0.02 
 
 O.I3 
 
 0.22 
 
 0.02 
 
 0.59 
 
 0.04 
 
 O.70 
 
 O.OI 
 
 
 O.08 
 
 O.OI 
 
 O.67 
 
 0.02 
 
 
 O.I5 
 
 O.OI 
 
 O.62 
 
 O.OI 
 
 
 O.06 
 
 O.OI 
 
 O.62 
 
 O.OI 
 
 
 O.I2 
 
 
 Fuel 
 value. 
 
 Calories. 
 
 325 
 I70 
 I6 5 
 
 1,05 
 3,605 
 1,040 
 1,275 
 
 1,340 
 
 1,655 
 
 3,715 
 
 325 
 
 205 
 
 315 
 1,050 
 
 235 
 1,645 
 1,655 
 I,86o 
 1,205 
 1,895 
 1,590 
 
 170 
 
 325 
 135 
 
 255 
 
 Solids Other than Fat. — These are as follows : 
 
 
 Wanklyn. 
 
 Leeds. 
 
 E. W. Stewart. 
 
 Ash 
 
 O.60 
 4.40 
 4-30 
 
 O.68 
 4.42 
 3.76 
 
 O.60 
 
 Lactose 
 
 4-55 
 4-05 
 
 Albuminoids 
 
 Letheby gives the percentage of lactose as 5.2, which is too high 
 for the average. 
 
 Lactose. — Lactose is an important ingredient of milk. When 
 chemically pure it is hard, transparent, white, and crystalline. It is 
 now obtainable in much purer commercial form than formerly, when 
 in addition to its diuretic effect, if given therapeutically, it often ex- 
 cited fermentation and even glycosuria. It has but a faintly sweetish 
 taste, and in its properties is allied to both sucrose and starch. Its 
 
54 FOODS AND FOOD PREPARATIONS 
 
 chief function in human milk is to supply energy for heat produc- 
 tion for the infant whose muscles are not yet active in developing 
 this force, and it constitutes about one half of the total solids of milk, 
 exclusive of fat ; but the quantity present in cow's milk varies greatly, 
 and, as a general rule, it bears an inverse ratio to the amount of fat 
 and casein present. It is less liable than cane sugar to ferment in 
 the stomach ; and alone it is not susceptible to alcoholic fermentation, 
 but in the presence of fermenting nitrogenous material it is con- 
 verted into lactic acid, making the milk sour. It is promptly ab- 
 sorbed from the alimentary canal, not remaining over an hour in the 
 stomach. 
 
 Casein and Albumin. — The principal albuminoid of milk is casein, 
 but there are a half dozen proteids which have been described, show- 
 ing different behaviour on coagulation, in polariscopic rotation, etc. 
 There is an albumin present called lactalbumin, which is coagulable 
 by heat and forms the tenacious " scum " which floats on top of 
 boiled milk. This albumin plays an important role by surrounding 
 the minute oil globules of the milk and preventing them from agglu- 
 tination — in other words, it helps maintain the fat in permanent fine 
 emulsion. It is contained in solution in whey. Traces of peptones 
 have also been found in milk. 
 
 Casein itself is non-coagulable by heat, even by boiling, but it is 
 coagulated in firm tough clots by acids, such as the hydrochloric 
 acid of the gastric juice, and by many organic acids which occur as 
 products of malfermentation in the stomach. Lactic acid is the com- 
 mon agent in forming the coagulae. Casein is also coagulated, but 
 less firmly, by the special milk-curdling ferment " rennin," which is 
 actively present in the infant stomach, and in the third stomach of 
 the calf. The casein clot formed by rennin, unlike that of lactic acid, 
 is not redissolved by neutralisation with alkalies. Casein is present 
 in milk chiefly in an alkaline form as potassium caseinate, and in 
 conjunction with calcium phosphate. 
 
 Varieties of Milk. — Cow's milk differs much in quality accord- 
 ing to the breed and condition of the animal, quality of its food, and 
 care bestowed upon feeding and hygienic surroundings. The chief 
 variation concerns the quantity of cream produced. 
 
 The milk of Alderney, Jersey, and Guernsey cows has more pro- 
 teid than that of ordinary animals, and Alderneys give more fat 
 than longhorns. Individual cows are liable to vary among them- 
 selves and from day to day in the quantity of their milk, and there- 
 fore, notwithstanding general belief, it is a disadvantage to feed an 
 infant always upon the milk of the same cow. More uniformity will, 
 on the average, be secured by feeding the mixed milk of several ani- 
 mals, the variations in the components neutralising each other. 
 
 " Strippings " is the name given to residual milk which may be 
 drawn off shortly after the ordinary milking has been completed. 
 
ANIMAL FOODS 55 
 
 Contrary to popular belief, it possesses no advantage as food over the 
 rest of the milk, and what little difference in composition exists can 
 be artificially produced. It is richer in fat but poorer in casein than 
 the milk first drawn. For infant use it should be diluted with two 
 parts of water. 
 
 Human Milk. — Human milk differs from cow's milk in several 
 important particulars. For this reason it becomes necessary when 
 infants are fed upon the latter to so modify it as to render it more 
 digestible for them. 
 
 The important differences between human milk and cow's milk 
 are that woman's milk is sweeter by one third and contains little 
 less than half as much casein. The analyses of the United States 
 Department of Agriculture give the percentage of casein in cow's 
 milk as varying between 3.43 and 3.91, whereas that of mother's milk- 
 averages 1.5, hence the importance of diluting cow's milk in the early 
 months of infant feeding. As Leeds says, the calf grows faster 
 and has to manufacture more muscle than the baby — it needs more 
 albumin for tissue building. The casein of mother's milk, moreover, 
 forms smaller coagulae both with rennet and in the stomach, which 
 are more easily dissolved. The normal reaction of human milk is 
 alkaline. Cow's milk varies from faintly alkaline to neutral, and it 
 often becomes acid, especially when the animals are not pasture-fed. 
 There is nearly one half per cent more fat, and the globules exist in a 
 finer emulsion in woman's than in cow's milk. Cow's milk appears 
 richer, whiter, and more opaque than human milk. 
 
 These differences are emphasised by the following comparative 
 analyses by Leeds of average cow's milk and human milk : 
 
 
 Sound dairy milk. 
 
 Human milk. 
 
 Reaction 
 
 Feebly acid. 
 
 1029.7 
 
 Always present. 
 
 3.75 per cent. 
 4.42 
 
 3.76 " 
 0.68 
 
 Persistently alkaline. 
 
 1031-3 
 Absent 
 
 Specific gravity 
 
 Bacteria 
 
 Fats 
 
 Lactose 
 
 4.13 per cent. 
 
 7.0 
 
 2.0 
 
 Albuminoids 
 
 Ash 
 
 0.2 " 
 
 
 
 Total solids 
 
 12.61 
 
 13-33 
 
 
 It requires more acid to precipitate the proteid from woman's 
 milk than from cow's milk. Giving a nursing woman an excess 
 of nitrogenous food does not increase the albuminoid elements of her 
 milk so much as the fats, while giving fattv or rich food in excess 
 does not increase the cream or other ingredients of her milk — it may, 
 indeed, diminish them by disordering her digestion. The nursing 
 mother's diet must therefore be plain but substantial, especially in 
 regard to animal foods. Excessive fat or proteid in the milk dis- 
 orders the infant's digestion. 
 
56 
 
 FOODS AND FOOD PREPARATIONS 
 
 The following analyses illustrate the extent of possible variation 
 in good specimens of human milk : 
 
 Eight Human Breast-milk Analyses (C. Harrington) 
 (Infants all digesting well and gaining in weight.) 
 
 
 I. 
 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 Fat 
 
 Per cent. 
 
 4-37 
 6.30 
 
 3-27 
 0.16 
 
 Per cent. 
 3.76 
 
 6-95 
 2.04 
 O. 14 
 
 12 89 
 87.II 
 
 lOO.OO 
 
 Per cent. 
 3.16 
 7.20 
 I.65 
 0.21 
 
 12.22 
 
 87.78 
 
 lOO.OO 
 
 Per cent. 
 3.82 
 5-70 
 I.08 
 0.20 
 
 Per cent. 
 2.96 
 5.78 
 1. 91 
 O.I2 
 
 Per cent. 
 2.O9 
 6.70 
 I.38 
 O.I5 
 
 Per cent. 
 2.02 
 
 6-55 
 2.12 
 
 O.I5 
 
 IO.84 
 89.16 
 
 lOO.OO 
 
 Per cent. 
 2.36 
 7.IO 
 2.20 
 O.I6 
 
 Milk sugar 
 
 Albuminoids .... 
 Mineral matter. . 
 
 Total solids . . . 
 Water 
 
 14.10 
 
 85.90 
 100.00 
 
 IO.80 
 89.20 
 
 IO.77 
 89.23 
 
 IO.32 
 89.68 
 
 lOO.OO 
 
 11.82 
 88.18 
 
 
 
 
 lOO.OO 
 
 lOO.OO 
 
 lOO.OO 
 
 For the analysis of human milk about half an ounce is required, 
 drawn from the middle nursing period, for the milk becomes pro- 
 gressively richer during nursing. 
 
 Prof. Albert H. Leeds (American Text-book of the Diseases of 
 Children, pp. 42, 43) has shown, by a table of analyses of milk from 
 eighty women of different nationalities, ages, and periods of lactation, 
 that although " the average amount of nitrogenous matters [albumi- 
 noids] is somewhat greater at beginning of lactation, the difference 
 is not very marked. . . . There is no progressive change in the 
 composition of milk during lactation, but after the function has been 
 normally established the milk remains substantially the same during 
 the entire period. . . . The child obtains more nutriment day by 
 day, but it is by spontaneously increasing the quantity according to 
 the best rule, which is that of normal appetite, and not by absorbing 
 stronger and stronger food." 
 
 Somewhat different conclusions are reported by Vanderpoel 
 Adriance and John S. Adriance, based upon analyses of the milk of 
 120 healthy mothers at the Nursery and Childs' Hospital, New York. 
 In each case the sample was obtained after allowing the infant to 
 nurse for two minutes, and periods studied were from the second 
 day to the fifteenth month of lactation. They found that of all the 
 ingredients of human milk the fat varies most, and varies throughout 
 lactation, the extremes being 7.61 and 1.31 per cent. The fat bears 
 a rough general proportion to the proteid of 3 : 1. The carbohydrate, 
 which weighs during the middle period of lactation more than all 
 the other solids together, increases throughout lactation, and ranges 
 from 5.35 to 7.95 per cent. 
 
 The proteid percentage is highest during the colostrum period, 
 when it may reach 8.60 per cent, and falls rapidly towards the end 
 of lactation. Pfeiffer found it as low as 1.52 at the seventh month, 
 but this is extreme reduction. It is increased by worry and nervous- 
 
ANIMAL FOODS 57 
 
 ness and by lack of exercise ; it is lessened by reduction of meat in 
 the dietary, and vice versa. The salts diminish from .27 per cent 
 on the second day to .14 at the fifteenth month. 
 
 The average specific gravity is given by Adriance as 1.030. It is 
 lessened by increase of fat and increased by increase of proteid. 
 
 Human colostrum differs from the later milk as follows : It con- 
 tains colostrum corpuscles which remain from seven to ten days ; it 
 has a yellow colour, which disappears with the corpuscles ; it is 
 laxative to the infant ; its fat varies greatly ; the quantity of sugar is 
 lowest and of proteid and ash highest of any period of lactation. 
 
 Drugs in Human Milk. — Many drugs are excreted through the 
 mother's milk, and it is often the case that an infant is affected by 
 suckling such milk. It is possible to act upon infants through this 
 medium, but the strength of solution in which the drug reaches them 
 is far too uncertain. An infant has been killed by nursing from a 
 mother who had taken an overdose of laudanum (Fletcher). Acids 
 given to a nursing mother may cause colic in the child. Neutral 
 salts loosen the bowels, and potassium salts act as diuretics for 
 infants when taken by the mother. Aromatic oils, and probably all 
 volatile oils, reappear in the mother's milk. The agreeable taste 
 of some of these substances causes the child to suck harder, and 
 excites thereby a reflex stimulation of the mammary glands to fur- 
 ther secretion. 
 
 Among other drugs which have been determined in the mother's 
 milk after ingestion by the stomach are : Senna, rhubarb, scammony, 
 sulphur, castor oil, ammonium salts, turpentine, copaiba, anise, dill, 
 garlic, wormwood, and jalap. Antimony passes readily into mother's 
 milk, and should be given with caution to nursing women. Potas- 
 sium iodide, corrosive sublimate, and other mercurial salts, arsenic, 
 zinc, and lead, all may be excreted in the milk at periods varying from 
 four hours to several days after their administration and continue to 
 be eliminated for a day or two after the drug has been withheld. 
 
 Vegetable acids give rise to carbon dioxide in milk. If nursing 
 mothers partake freely of fresh fruit and green vegetables their milk 
 may gripe and purge their infants. Violent exercise and violent 
 mental emotion are harmful to the milk. 
 
 Goafs milk is the least digestible and nutritious of milks, although 
 it contains the most solids. It is scarcely used at all in the United 
 States except sometimes by very poor foreigners, as it is in Switzer- 
 land and other mountainous European countries, and for some East- 
 ern tribes it is a staple variety of milk. Cheese is also made from it 
 on a large scale. It has a peculiar strong odour and taste, which are 
 disagreeable to those who are unaccustomed to it, and which are par- 
 tially expelled by boiling. They are due to a substance called hircin 
 or hircic acid. 
 
 Goat's milk contains an excess of fat, and for this reason is too 
 6 
 
58 FOODS AND FOOD PREPARATIONS 
 
 rich for infant food, and gives rise to vomiting and diarrhoea. The 
 coagulas formed by it are very tough. 
 
 Ass's milk contains the least solids of all the edible milks, except 
 mare's milk, and is poor in casein and fat. It has a fair proportion 
 of sugar, more than cow's milk but less than human milk. Ass's 
 milk is sweet and easy of digestion, although it has a tendency to 
 cause diarrhoea. 
 
 Experiments in the feeding of children direct from asses were 
 conducted in Paris in 1883 at the Hospice des Enfans Assistes. One 
 ass sufficed to nourish three infants besides her own foal. The asses 
 were kept near the ward and the infants were brought to them to 
 nurse. Syphilitic infants belonging to a class in which death had 
 been the invariable rule were thus nursed, and 70 per cent were saved. 
 The experiment does not seem to have found favour elsewhere. 
 Goats were first tried, but proved of no service for direct nursing. 
 
 Mares milk, like ass's, contains less proteid and less fat, but more 
 lactose than cow's milk. 
 
 The casein of mare's milk is intermediate in digestibility between 
 human and cow's milk. Both ass's and mare's milk are used in the 
 steppes of Russia and in Siberia for the manufacture of koumiss. 
 (See Koumiss.) 
 
 Reindeer milk contains 18 per cent of solids, and, generally speak- 
 ing, those domestic animals living farthest north have the most solids 
 in their milk. 
 
 Milk Analysis. — An accurate analysis of milk requires much 
 skill and the equipment of a well-organised laboratory, but it is often 
 important for physicians to be able to judge for themselves of the 
 quality of food so universally prescribed by them, and it is there- 
 fore deemed appropriate to describe some of the easier methods of 
 qualitative examination. The minimum standard to which milk 
 must conform, as established by the New York City Health Board, 
 is as follows : 
 
 Per cent. 
 
 Water 88 .00 
 
 Fat 3.50 
 
 Total solids 12.00 
 
 Solids not fat 8 . 50 
 
 Reaction, Colour, Taste, Odour. — Good cow's milk should be 
 almost neutral, reddening blue litmus paper but very slightly if any. 
 The normal colour is white and is due to the fat globules, but it may 
 be slightly yellow, especially if the cow has been feeding in wheat 
 fields (Hind). The taste is sweet and the odour faint and fresh. 
 Bad milk often has a bad odour, either sour or derived from absorp- 
 tion from some neighbouring material. It is sour to the taste, 
 reddens litmus paper strongly, and if held to the light in a test tube 
 or small thin glass it may have a bluish or reddish tinge and appear 
 

 ANIMAL FOODS 59 
 
 watery. It curdles in tough, stringy, or glutinous yellowish lumps 
 of large size. 
 
 Estimation of Total Solids. — To estimate the total solids of milk 
 several tests are employed. Their object is to furnish data in regard 
 to the nutrient power of the milk and to detect adulteration. 
 
 A common method used by health boards is to weigh and evap- 
 orate five cubic centimetres of milk to dryness in a small, flat-bot- 
 tomed, platinum crucible of a known weight. This process takes 
 about an hour. The residue is then dried for an hour more at ioo° 
 F. and weighed. The milk dries in two layers. The upper layer 
 consists of a thin film of fat, which is dissolved in petroleum and 
 benzine. The lower honeycombed layer is then washed and dried 
 and weighed again. The loss in weight after removing the upper 
 layer represents the amount of fat present. The soluble salts and 
 soluble proteid are then dissolved out by warm water and alcohol 
 and separated. Ignition over a Bunsen burner drives off all organic 
 matter, and leaves the ash, which is again weighed. 
 
 Another less laborious method consists in the use of an instru- 
 ment called a " lactometer," by which the specific gravity of the 
 milk is taken. 
 
 A lactometer is a glass spindle resembling a urinometer, but is 
 about fifteen centimetres long, and it easily floats in a quart measure. 
 It is graduated to measure the specific gravity from o° (the water 
 line) to 40 . Milk in which it floats at below 29 is almost surely 
 watered, or if it floats above 33 the milk is skimmed. The specific 
 gravity of the milk being taken with the lactometer, the amount of 
 dilution is readily computed by comparing it with the normal stand- 
 ard, 30 . Suppose this specific gravity to be 21 in a given case, 
 then 30:21:: 100:70. That is, the normal gravity, 30, is to the 
 gravity of the sample examined as 100 parts of normal milk are to 
 the sample, or, in other words, only 70 parts per hundred of the 
 sample are milk, and 30 parts of water have been added. To facili- 
 tate the calculation, the space between o° and 40 may be divided into 
 100 parts; each division of the second scale represents i° or 1 per 
 cent of milk. Thus, if the lactometer stands at 50 of this second 
 scale, there is only 50 per cent of milk in the sample. 
 
 There has been much dispute regarding the use of the lactom- 
 eter, on the ground that an excessive amount of cream, on account 
 of the lightness of the fat, diminishes the specific gravity of a really 
 rich milk. On the other hand, it is claimed that the diminished 
 gravity is always due to increase in the quantity of water, and that 
 milk rich in cream will also contain less water, and therefore main- 
 tain the normal standard. The matter has been tested in the courts, 
 and in New York city the lactometer test alone is always sufficient 
 to insure conviction in trials for adulteration of milk with water. 
 
 Sometimes in estimating the specific gravity acetic acid is first 
 
6o 
 
 FOODS AND FOOD PREPARATIONS 
 
 added to precipitate the casein, which is removed with the fat ; the 
 specific gravity of the whey is then taken. Hassell claims that the 
 latter is more constant that the specific gravity of milk itself. 
 
 L. Emmet Holt furnishes the following table of variations in 
 specific gravity of human milk and their causes, as determined by a 
 lactometer of his own device : 
 
 Human Milk (Holt) 
 
 Normal average 
 
 Healthy variations.. . 
 Healthy variations. . . 
 Unhealthy variations 
 
 Variations 
 
 Variations , 
 
 Variations 
 
 Variations , 
 
 Variations 
 
 Specific gravity 
 70 F. 
 
 Cream — 24 hours. 
 
 I. 031 
 
 1.028 to 1.029. 
 1.032 to 1.033. 
 Below 1.028.. . 
 
 Below 1.028.. . 
 Below 1.028.. . 
 
 Above 1.033. . 
 
 Above 1.033.. 
 Above 1.033. ■ 
 
 Proteids. 
 
 8 per cent 1.5 per cent. 
 
 9 to 12 per cent Normal (rich milk). 
 
 5 to 6 per cent Normal (fair milk). 
 
 High (above 10 per cent). Normal or slightly 
 
 below. 
 Low. 
 
 Very low (very poor 
 milk). 
 
 High Very high (very rich 
 
 milk). 
 
 Normal High. 
 
 Low Normal (or nearly 
 
 so). 
 
 Normal (5 to 10 per cent). 
 Low (below 5 per cent). . 
 
 " Milk presenting only moderate variations from the average — 
 e. g., specific gravity 1.028, cream 4 per cent, or specific gravity 
 1.033, cream 10 per cent — can usually be modified by appropriate 
 treatment. If, however, the specific gravity is from 1.018 to 1.024, 
 and cream only 2 per cent to 3 per cent, it is hopeless." (Holt.) 
 
 Estimation of the Fat. — To estimate the amount of fat or cream 
 the sample of milk is allowed to stand in a cool place for twenty- 
 four hours in a " creamometer." This is a simple glass tube twenty- 
 five millimetres wide and twenty-five centimetres deep, which is 
 graduated in hundredths from above downward. It is filled with 
 milk to the zero level. The cream rises to the top, and the per- 
 centage of volume is read off. 
 
 This method is amplified by Marchand's process, in which a simi- 
 lar graduated tube is employed, but the cream is more completely 
 separated by means of the addition of ether and a little liquor sodse. 
 Ninety-five per cent alcohol is then put into a flask with the milk, 
 and the whole is vigorously shaken, after which it is allowed to stand 
 at 130 to 140 F. In half an hour the fat forms a distinct layer at 
 the top of the graduated tube. The error by this process is said to 
 be less than 0.3 per cent. 
 
 Dilution of milk by water is determined in the New York Health 
 Board by use of a Swedish separating machine, the principle of which 
 is as follows : Glass tubes are used having a diameter of about half 
 an inch with a contracted neck graduated in percentages. A minute 
 perforation at the neck admits the entrance of water. The tubes are 
 
ANIMAL FOODS 6 1 
 
 first nearly filled with sulphuric acid and a measured quantity of 
 milk is added. The tubes are corked with rubber, placed in a pan 
 filled with water at 150 F., and rotated in a centrifugal machine at a 
 speed of 40,000 revolutions a minute. The temperature of the 
 water is then reduced to 52 F., and the percentage of fat is read 
 off from the narrow neck of the tubes. Water is found to have 
 entered through the perforation, and by its intermediate specific 
 gravity it lies between and separates the fat and sulphuric acid. The 
 process requires half an hour's time, and twenty samples may be 
 examined at once. 
 
 The richness of the milk in cream, or its dilution with water, may 
 also be measured by its opacity. Five cubic centimetres of water 
 are placed in a glass cell, called a " lactoscope " or " diaphanometer " 
 (Dome), with parallel sides, through which a candle placed at a dis- 
 tance of a metre may be seen. More milk is then added, drop by 
 drop, until the opacity of the cell contents obscures the light. This 
 method is more tedious and less accurate than the previous one. 
 Cream varies in specific gravity between 1.010 and 1.024. 
 
 A simple method of roughly determining the quantity of fat in 
 human milk is given by Nias. The milk is placed in a test tube, 
 made distinctly alkaline by a few drops of liquor potassse, boiled, 
 and left for a few hours in a warm place. The fat, floating on the 
 surface, is then estimated by graduations on the side of the test tube. 
 It is of course necessary to use test tubes of uniform calibre in 
 making comparative tests. 
 
 Estimation of Lactose. — The method of quantitative estimation of 
 milk sugar is the same as that employed for glucose in the urine. 
 The casein is first precipitated by acetic acid. The whey is filtered 
 and tested with Fehling's copper solution or with a polariscope. 
 Convenient tables are made to facilitate the calculation. 
 
 Estimation of Albuminoids. — In the method of Nias to determine 
 the albuminoids the sample of milk is placed in a graduated test 
 tube, as if to estimate the cream, and after some hours the super- 
 natant fat is drawn off by a pipette. Acetic acid is next added until 
 a strongly acid reaction develops. The milk is then boiled. All 
 the albuminoids are precipitated, and after standing overnight the 
 quantity may be read off on the side of the graduated tube. 
 
 MILK ADULTERATION AND IMPURITIES 
 
 Of recent years it has been discovered that a very large propor- 
 tion of infant mortality is traceable to the use of impure milk, and 
 that many diseases, especially diarrhceal disorders of summer, are 
 preventable when proper care is exercised to protect the milk supply. 
 The subject is rapidly claiming public attention, and suitable control- 
 ling legislation has been already adopted in most civilised countries. 
 
62 FOODS AND FOOD PREPARATIONS 
 
 The prevention of adulteration and contamination of milk is a 
 matter of vital importance from both an economic and hygienic 
 standpoint. Children, who are so largely dependent upon milk, do 
 not well tolerate its adulteration, and milk is so much used as a raw 
 food — perhaps more than any other one article of diet — that its care- 
 ful inspection in regard to contamination by disease germs or adul- 
 terants is imperative, and the constant vigilance of the health boards 
 of large cities is required to protect the public from imposition. 
 According to H. D. Chapin and G. B. Fowler, of the Milk Com- 
 mission appointed by the Medical Society of the County of New 
 York to investigate the milk supply of that city in 1900, " over 
 6,000 children under five years died in New York city from diar- 
 rhoeal diseases largely due to drinking old and contaminated 
 milk." 
 
 It is better and simpler, however, for much of the inspection to 
 be done at the dairy farms, and in many parts of this country the 
 State boards of health appreciate the importance of this matter, and 
 the sale of milk from diseased cows is prevented at first hand. When 
 a cream separator at a creamery is cleaned it is often found to con- 
 tain a residue of manure, hairs, dirt, and perhaps pus and blood from 
 inflamed udders. 
 
 The examination of milk requires the adoption of a legal standard 
 of quality. In New York city the Health Board depends chiefly 
 upon the use of the lactometer above described. (See Estimation of 
 Solids in Milk, page 59.) In States such as Massachusetts, Rhode 
 Island, and Maine a chemical analysis is required by law. The 
 normal specific gravity established is 1.030 (in New York 1.029), 
 and the normal average amount of cream is 8 per cent by volume. 
 
 The inspection of milk in all large cities and towns is made at 
 the railway stations or ferries where the cans are received. The 
 examination is under the direction of expert officers, usually mem- 
 bers of the local health board. It is impossible and unnecessary to 
 examine all the milk brought in, but the officers make frequent 
 seizures and destroy at once all milk found below the legal standard. 
 Milk sold in shops and otherwise must also be occasionally exam- 
 ined, for its dilution and adulteration is very easy and profitable to 
 the unscrupulous. Gross impurities in milk, such as dirt, hair, etc., 
 may be removed by filtration through absorbent cotton. A few 
 germs are also removed in this manner. A noted milk dealer of Ber- 
 lin, who dispenses 60,000 quarts of milk daily, forces it through 
 gravel filters from below upward, thereby removing the gross im- 
 purities. 
 
 Milk may be altered by — 
 
 1. Addition of water, pure or impure. 2. Addition of colouring 
 matter. 3. Addition of preservatives. 4. Addition of substances 
 used for thickening after dilution. 
 
ANIMAL FOODS 63 
 
 1. The commonest method of adulterating milk, and the one 
 often most difficult of detection, is by dilution with water. If the 
 water thus used is pure it does no harm other than to defraud the 
 consumer ; but if impure, as it often is when drawn from wells near 
 manure heaps, in barnyards, or country privies, it may prove fatal. 
 
 2. The normal whiteness and opacity of milk is due to its fat glob- 
 ules. If milk has been much diluted it becomes pale and bluish, and 
 both milk and cream are sometimes artificially coloured with anilines 
 or other pigments. This form of fraud is less injurious to health 
 than the others, for but very minute quantities of colouring matters 
 are employed. Annotto is the commonest dye used to impart a 
 yellow colour to milk, cream, and butter. It is prepared from the 
 seeds of a tropical American tree (Bixa orellana). It is detected by 
 allowing the milk to stand in a tall glass, when the lower stratum 
 will contain the pigment associated with the casein instead of re- 
 maining colourless, while the naturally yellower cream floats on top 
 (Hird). The cow's food may sometimes colour the milk red or pink, 
 and it may be so stained by traces of blood, in which latter case the 
 lower layers are of deeper hue than the upper. 
 
 3. Various substances are added to milk and its products — con- 
 densed milk, butter, cheese, and koumiss — to keep them from sour- 
 ing. These are usually sodium bicarbonate, borax, or boric acid. 
 Salicylic acid and formaldehyde are less often used. In small quan- 
 tities they do not affect its taste or hurt the digestion of adults, but 
 they may be injurious and even fatal to infants, and their use should 
 never be tolerated. Salicylic acid is sometimes put into beer for a 
 similar purpose, although this is prohibited by law. The presence 
 of boric acid is detected by mixing one part of milk with two parts 
 each of hydrochloric acid and saturated turmeric tincture. After 
 drying on a water bath and adding a little ammonia, a dark-blue 
 colour appears which changes to green. 
 
 4. Both milk and cream, after dilution with water, are sometimes 
 thickened again with such substances as flour, arrowroot, farina, 
 whiting, chalk, tragacanth, or carbonate of magnesia, which disguise 
 the natural blueness of the attenuated fluid. Effervescence in milk 
 produced by addition of a strong mineral acid shows the presence of 
 carbonates. Sugar is added to raise the specific gravity of diluted 
 skimmed milk. 
 
 Milk is contaminated or rendered unfit for use by — 
 1. Improper or poisonous foods eaten by the animal. 2. Poor 
 condition of the animal, due to nursing, worrying, etc. 3. Con- 
 tamination by disease germs from the cow. 4. Contamination by 
 extraneous disease germs. 5. Souring and decomposition. 6. Ab- 
 sorption of bad odours. 
 
 1. The colour of milk is affected by various substances ingested 
 by the cow ; thus madder turns it saffron, rhubarb makes it red or 
 
64 FOODS AND FOOD PREPARATIONS 
 
 yellow (Mosler), and it is coloured blue by some drugs. The colour 
 is then uniform throughout the milk, and not superficial as in the 
 case of the blue imparted by the growth of fungi, as described below. 
 If milk be made blue by addition of litmus the solution will be red- 
 dened by action of such bacilli as the lactic-acid bacillus, the bacillus 
 typhosus, and the streptococcus pyogenes. 
 
 Cows fed on brewers' swill or refuse of glucose factories, or cows 
 allowed to eat decaying autumn leaves, garlic, certain injurious 
 meadow plants, or strong-smelling plants like cabbages, turnips, 
 and onions, will give unhealthy, strong-smelling, bad-tasting, or de- 
 teriorated milk. Beets tend to make cow's milk acid. Cows should 
 not be given unclean water to drink. Offensive odours and tastes 
 imparted to milk through the cow, or by absorption from surround- 
 ing substances, are most intense while the milk is fresh ; whereas 
 if due to bacteriological influences, they only become apparent after 
 some hours, and go on increasing. H. Weller found nearly i per 
 cent of alcohol in milk from cows fed on distillery slops which con- 
 tained 6 per cent of it. 
 
 2. The milk first secreted after calving (colostrum) contains 
 more albumin than casein. It is viscid, turbid, frothy, yellow, 
 slightly acid, and coagulates on boiling. In the cow colostrum has 
 a sickly odour, and is purgative even when cooked. It remains so 
 for about a month after parturition. Colostrum corpuscles may be 
 easily detected by microscopic examination. 
 
 The bulling cow may be highly nervous during ovulation, and, as 
 a reflex consequence, her milk becomes acid. 
 
 Cows which are teased and worried by dogs or otherwise, or 
 made to exercise too much, give milk which sours easily and dis- 
 agrees with infants. Underfeeding makes the animal give inferior, 
 watery milk. 
 
 3. Cows suffering from certain diseases may transmit them 
 through their milk to man, although this method of infection is less 
 common than that through milk to which germs have had access in 
 process of handling or transportation. The principal diseases which 
 may be derived from the cow through her milk are tuberculosis and 
 diphtheria. 
 
 The Massachusetts Society for Promoting Agriculture, in a re- 
 port upon " The Infectiousness of Milk," confirms the fact that milk 
 from cows having tubercular udders is infectious to man. (This 
 statement is contradicted by Koch, who, in common with several 
 other observers, has claimed that human and bovine tuberculosis 
 are non-interchangeable.) Tubercle bacilli were also demonstrated 
 in the milk of twelve out of thirty-six cows having tuberculosis, 
 but whose udders were not affected. The inference is drawn from 
 the report that 3 per cent of the milk furnished to Boston is in- 
 fected. It is estimated that 6 per cent of all cows are tubercular. 
 
ANIMAL FOODS 65 
 
 Tubercular milk is of poorer quality, thinner, and bluer than normal 
 milk. 
 
 Cases have been reported of infection of a nursing infant through 
 a tubercular mother's milk, and calves are undoubtedly so infected 
 through cows ; but it must be remembered that the infant is much 
 exposed to infection by its mother's sputum, and may inhale dried 
 sputum from beneath her bedclothing or within the room. 
 
 However, the presence of tubercle bacilli has been indubitably 
 demonstrated at least a half dozen times in human breast milk. 
 Tabes mesenterica and tubercular meningitis in children have been 
 caused by infected milk. 
 
 The foot-and-mouth disease of cattle is transmitted to man if the 
 milk of cows so affected be drunk without boiling, which destroys 
 the germs (Bollinger). This disease is transmitted even when the 
 milk is diluted ten times or taken in coffee or tea, but adults must 
 drink a good deal of it in order to become affected. Butter and 
 cheese made from such milk also carry the infection (Schneider). 
 The foot-and-mouth disease diminishes the quantity of milk given by 
 the cow by one half, and the milk coagulates too quickly and has a 
 yellowish colostrum-like appearance. If the disease be severe the 
 milk separates into slimy coagulse and whey, and, on boiling, curdles 
 in stringy masses. In other cases the taste is acid, and on standing 
 twelve hours a yellow sediment is precipitated with a nauseous, ran- 
 cid odour. The milk becomes infected from sores upon the nipples. 
 
 4. Extraneous disease germs may find their way into milk 
 through contact with unclean hands, or from polluted water used for 
 dilution, or for washing cans and pans. 
 
 Soxhlet says that if mother's milk were sold like cow's milk after 
 as much careless handling, it would produce as much disease. 
 Calves have been known to acquire diarrhoea when fed milk from 
 unclean pails, and the animals were cured by allowing them to suck 
 the very cows that had been milked into the pails. According to 
 Sedgwick, milk may contain a million bacteria to the cubic centimetre 
 after its journey from cow to table. 
 
 Cow's milk is too often tainted with excrementitious matter from 
 the stable or cow yard. The cows lie upon foul bedding, or be- 
 spatter their udders continually in barnyard filth. Soxhlet has said 
 that in judging the quality of milk one should consider " not so much 
 what the cow fed on, as rather what kind of cow dung the milk 
 contains." 
 
 The following data from the report of a commission of disin- 
 terested physicians upon the " Walker-Gordon guaranteed milk " 
 from the dairy at Plainsboro, N. J., exhibit an ideal system of cleanli- 
 ness. Each milkman before milking is required to cleanse his hands 
 in hot water with soap and a nail-brush ; he then dons a clean white 
 linen suit from the sterilising chamber, and takes a clean towel and 
 
66 FOODS AND FOOD PREPARATIONS 
 
 milking-stool ; he is not allowed to moisten his hands with the milk 
 in milking, and he must wash his hands each time before milking 
 another cow. All cows must have given a negative tuberculin test, 
 and all are groomed twice a day before milking. Pine shavings are 
 used for bedding. The milk is drawn into pails with small openings, 
 to exclude droppings from the animal's belly. The milk is strained 
 through sterilised absorbent cotton and placed in a cooler, which 
 reduces the temperature to 40 F. within twenty minutes after leav- 
 ing the udder. It is then bottled and stored in ice water ready for 
 shipment. 
 
 Milk carelessly transported promptly absorbs germs from the air 
 or from unclean receptacles, and it is an excellent culture medium 
 for rapid growth of such germs as those of tuberculosis, scarlatina, 
 diphtheria, and typhoid fever, which may gain access to it in that 
 manner. When local epidemics of such diseases break out, there 
 should always be a thorough investigation of the sources of milk 
 supply, and a bacteriological examination of the milk itself should 
 be instituted. Many persons imagine that a chemical analysis is 
 sufficient, but this is useless for .detection of disease germs. 
 
 Severe epidemics of typhoid fever have of late years been attrib- 
 uted to infected milk by H. E. Smith, at Waterbury, Conn. ; by L. H. 
 Taylor, at Wilkesbarre, Pa. ; and by Littlejohn, who traced the origin 
 of sixty-three cases to one dairy. Fourteen cases of typhoid fever 
 occurring in East Barrington, N. H., in 1896, were traced to the 
 eating of ice-cream contaminated by a milkman who had continued 
 milking while himself suffering from the fever. No one who is 
 nursing a case of typhoid or scarlet fever or diphtheria, or who in any 
 way handles the discharges or clothing of such patients, should be 
 allowed to touch milk or milk receptacles, much less to milk a cow. 
 
 At Brewster, N. Y., Miller reported twenty-four cases of scarla- 
 tina which occurred among those who drank the milk supplied by 
 one dairyman while his daughter had scarlet fever. The disease was 
 not otherwise prevalent in the town at the time. 
 
 E. Hart reported at the Seventh International Medical Congress 
 a series of epidemics in England the origin of which he had traced 
 to milk. Of these, fifty were of typhoid fever, fourteen of scarlatina, 
 and seven of diphtheria. 
 
 The diphtheria bacillus has not thus far been proved to be trans- 
 mitted direct from the cow to man, but cows inoculated under the 
 shoulder with diphtheritic microbes exhibit the germs in the milk 
 after developing local lesions of the udders. Those epidemics of 
 diphtheria the spread of which has been attributed to milk have 
 probably been due to contamination through the handling of the 
 milk by milkers or dairymen having the disease themselves or who 
 have been in close contact with it. In this country Goodwin and 
 W. H. Stillwin have both reported such epidemics occurring in 
 
ANIMAL FOODS 6? 
 
 Michigan in 1879. W. J. Howard, Jr., studied an epidemic of 100 
 cases in 49 houses in Ashtabula, Ohio, in 1894, which he is confi- 
 dent was referable to a milk supply delivered by boys who had 
 severe angina at the time, although the bacillus diphtheria was not 
 found in their throats. The New York Health Board reported the 
 discovery of the germs in cheese made by a milkman in whose family 
 diphtheria was present. 
 
 A mould, the Oidium lactis, or penicillium, and the Bacterium cyano- 
 genum are germs which produce a blue colour in milk and sour 
 it. The mould also grows upon cream cheese. This colour appears 
 first upon the surface if the milk be not agitated, and it differs 
 from the uniform blue imparted by adulteration with water, or by 
 poisonous plants, drugs, etc. Milk thus affected is irritant, and may 
 cause febrile gastritis, stomatitis, or diarrhoea. 
 
 Milk is coloured lemon yellow by the Bacterium synxanthum 
 (Ehrenberg), and red by chromogenic fungi. 
 
 The fungi and germs themselves do not impart the colours, but 
 develop various anilines — aniline blue, fuchsin, etc. — from the casein 
 (Schroter). 
 
 " Clouty cream " is produced by germ action. 
 
 5. There are ten different varieties of bacteria which are capable 
 of inciting lactic-acid fermentation of the milk sugar (Leeds), all of 
 which cause the milk to " sour " and curdle, and some, but not all, 
 simultaneously develop carbonic acid and alcohol. A large propor- 
 tion of the bacteria of milk rises with the cream to the surface (Free- 
 man). Milk may be really decomposing although it has not yet 
 coagulated. 
 
 The first process, that of the formation of lactic acid, is a pre- 
 liminary to the normal digestion of milk, but the second is abnormal 
 and interferes with it. The sour milk curd may be redissolved by 
 neutralisation with alkalies. 
 
 The Bacillus acidi lactici may sour the milk before it is ingested, 
 or, like many germs, their action may not be apparent before swal- 
 lowing the milk, but it begins immediately thereafter in the stomach. 
 
 Good, clean, uncontaminated milk should keep fresh exposed 
 in a clean room at the ordinary temperature of 68° F. for forty-eight 
 hours without souring and coagulating. But if the air is much 
 warmer, or if the milk is tainted in any manner, it will sour in a few 
 hours. Boiled milk keeps fresh rather more than half as long again 
 as fresh milk. 
 
 6. The absorbent power of milk is strong, and it may acquire 
 a strong odour from substances kept in its vicinity. It may acquire 
 a bad flavour at the same time, or may have the odour alone. 
 
 If left in a refrigerator with stale cheese, ham, onions, decompos- 
 ing meat, etc., it soon becomes spoiled in this manner. Milk easily 
 absorbs the odour of tobacco, camphor, or of turpentine from fresh 
 
68 FOODS AND FOOD PREPARATIONS 
 
 paint, and, in fact, the odour of almost any volatile substance. It 
 should never be left exposed in the sick-chamber or in a bathroom, 
 or near a waste pipe. 
 
 PROPHYLAXIS AGAINST MILK INFECTION 
 
 As prophylaxis against milk infection certain precautions are 
 necessary, and it should be the duty of physicians to educate public 
 sentiment in regard to their importance as a means of restricting the 
 spread of infectious and dietetic diseases. 
 
 For transportation from the country to the city, milk is usually 
 taken from the farms in forty-quart tin cans, which should be filled 
 full and tightly covered to prevent churning and souring. Some 
 railways supply refrigerator milk cars, which are hung upon specially 
 constructed springs, to prevent as far as possible agitation of the 
 cans. At some dairies the milk is put, directly after milking, into 
 glass bottles previously sterilised by washing and steaming, which 
 are then tightly corked. If pails, pans, or cans are used, their abso- 
 lute cleanliness must be insured by frequent careful washing and by 
 occasional scalding with hot water. This destroys germs or ferments 
 which would otherwise contaminate the fresh milk and soon sour 
 it. The bottles are sealed and stamped " Certified Milk " before 
 being sent to market. 
 
 Many large dairies now employ a veterinarian, whose duty it is to 
 daily examine all the cows and report on their health, and on the 
 hygienic condition of the stables, yards, etc. 
 
 Nothing is more disgusting than allowing the manure-besmirched 
 tails of ungroomed cows to contaminate the hands of milkers, or the 
 milk itself, and yet this is constantly happening. 
 
 The question of prophylaxis is of such universal interest that 
 the admirable rules formulated by Vaughan are here quoted in full : 
 
 " a. The cows should be healthy, and the milk of any animal 
 which seems indisposed should not be mixed with that from the 
 healthy animal. 
 
 41 b. Cows must not be fed upon swill or the refuse from brew- 
 eries or glucose factories, or upon any other fermented food. 
 
 " c. Milch cows must not be allowed to drink from stagnant pools, 
 but must have access to fresh pure water. 
 
 " d. The pasture must be freed from noxious weeds, and the barn 
 and yard must be kept clean. 
 
 " e. The udders should be washed and then wiped dry before 
 each milking. 
 
 " /. The milk must be at once thoroughly cooled. This is best 
 done in the summer by placing the milk can in a tank of cold water 
 or ice water, the water being of the same depth as the milk in the 
 can. It would be well if the water in the tank could be kept flow- 
 
ANIMAL FOODS 69 
 
 ing, and this will be necessary unless ice water is used. The tank 
 should be thoroughly cleaned each day to prevent bad odours. The 
 can should remain uncovered during the cooling and the milk should 
 be gently stirred. The temperature should be reduced to 6o° F. or 
 lower within an hour. The can should remain in cold water until 
 ready for delivery. 
 
 " g. Milk should be delivered during the summer in refriger- 
 ated cans or in bottles about which ice is packed during trans- 
 portation. 
 
 " h. When received by the consumer it must be kept in a clean 
 place and at a temperature some degrees below 6o° F. 
 
 " If all the milk used in the artificial feeding of infants could be 
 obtained and marketed with the care demanded by the above rules, 
 milk infection would be practically unknown and the sterilisation 
 of the infant's food would be unnecessary." 
 
 USES OF MILK 
 
 The following are the more important uses of milk : 
 
 1. As an infant food. 
 
 2. As a food for adults. 
 
 3. As a source of special food products and derivatives, such as 
 koumiss, cream, butter, and cheese. 
 
 4. As a diuretic. 
 
 5. For its soothing effect on diseased mucous membranes of the 
 alimentary canal. 
 
 6. To loosen cough (when given hot). 
 
 7. As a prophylactic against lead poisoning. 
 
 8. As a vehicle for the administration of other foods. 
 
 9. As a vehicle for the administration of medicines. 
 
 10. For rectal injection. 
 
 The first three of these uses are so important that they will 
 receive separate detailed consideration (see Diet in Infancy, page 
 748, Adaptation of Milk for the Sick, page 73, and Milk Deriva- 
 tives, page 93) ; the others may be briefly referred to here. 
 
 4. The diuretic action of milk in some persons is very pro- 
 nounced, while in others it is not noticeable. It is due to the two 
 ingredients, water and lactose or milk sugar. The water acts by 
 increasing the volume of blood and the renal blood pressure. The 
 lactose probably acts directly by stimulating the renal epithelium. 
 
 Lactose has been employed with doubtful success as a diuretic 
 in dropsies and some forms of renal disease. The dose is twenty to 
 thirty grains. 
 
 The mineral salts and the water of milk are speedily absorbed 
 by the mucous membrane of the stomach, and in some persons this 
 process is so rapid that milk taken by the tumblerful into an empty 
 
70 FOODS AND FOOD PREPARATIONS 
 
 stomach has a very decided diuretic effect within an hour. This 
 action may be further promoted by drinking a cup of black coffee. 
 
 5. Milk is undoubtedly soothing to the mucous membranes of the 
 alimentary canal. It is often the only variety of food which can be 
 borne by an inflamed or irritable stomach or in some forms of intes- 
 tinal disease. It is equally soothing in the rectum. 
 
 6. A few sips of hot milk or hot milk and Vichy will often allay 
 an irritable cough, and favour the expectoration of tenacious bron- 
 chial mucus. 
 
 7. Milk is sometimes employed among type founders as pro- 
 phylactic against lead poisoning. It is claimed by Hirt that if a 
 quart or two be drunk daily, poisoning never occurs. 
 
 8. As a vehicle for administration of other foods for invalids, such 
 as egg albumin, beef-meal, meat juice, peptonoids, cocoa, spirits, etc., 
 milk is most useful. 
 
 9. As a vehicle for the administration of many medicines and 
 insoluble powders, such as calomel, disagreeable-tasting drugs, like 
 potassium iodide, salicylates, opium, etc., milk is often very service- 
 able. Sulphonal given in hot milk acts better than if prescribed 
 alone. 
 
 10. Milk is employed in nutritive enemata, alone or with beef 
 juice, beef peptonoids, spirits, etc. From one to two or more ounces 
 are given at a time, after cleansing the rectum. A little laudanum 
 may be added, and a towel should be held against the perinaeum to 
 aid in the retention of the milk. When the circumstances admit, it 
 is advisable to pass a long catheter and inject the milk through it as 
 far as the sigmoid flexure, while the patient is supported upon the 
 hands and knees. The higher up the milk is injected, the more read- 
 ily it is absorbed, and the circulation of the rectum is such, that 
 whatever ingredients of the milk are taken up by the venous capilla- 
 ries of the lower portion pass to the vena cava, whereas the ingre- 
 dients absorbed by the superior haemorrhoidal or the sigmoid vessels 
 are carried directly to the vena porta and liver, where they are as- 
 similated more promptly. The lymphatic capillaries also assist in 
 the absorption. 
 
 The simple mucous secretions of the rectum have no proper di- 
 gestive action upon milk (Czerny). but they may sometimes cause 
 putrefaction of its albuminous matter, with formation of tyrosin, 
 indol, etc. (Marckwald). It therefore facilitates absorption to have 
 the milk previously digested by pepsin or pancreatin. Patients hav- 
 ing ulcer or carcinoma of the stomach, any intestinal obstruction, or 
 irritant vomiting, may be kept alive for many weeks by the exclusive 
 use of nutrient milk enemata. (See Food Enemata.) 
 
 Attempts to get milk into the circulation by rubbing it into the 
 skin and by soaking portions of the body in milk baths have proved 
 of no avail, for it is not absorbed in that manner. 
 
ANIMAL FOODS 7 1 
 
 The intravenous injection of milk has been occasionally used in 
 cholera collapse, post-partum haemorrhage, etc., and in some few 
 cases it has been found satisfactory, but since saline injections have 
 proved more efficacious, those of milk have been abandoned. Milk 
 has also been injected into the peritoneal cavity, but without much 
 benefit. It has been given hypodermically in doses of four grammes 
 (Menzel). One patient was kept alive sixty-three days in this man- 
 ner (Whittaker). The milk thus injected is absorbed within an hour. 
 
 MILK DIGESTION 
 
 Normal Digestion. — Milk is not altered in the mouth, but on 
 reaching the stomach the casein is precipitated by a curdling fer- 
 ment, called rennin. The curds, or coagulae, vary in size and tough- 
 ness according to the quality of the milk, its degree of dilution, and 
 other circumstances. 
 
 The gastric hydrochloric acid also coagulates milk by neutralis- 
 ing the alkali which holds the casein in solution. Hence milk be- 
 comes really a solid food almost as soon as it enters the stomach. 
 In coagulating, the curds entangle the fat globules, but they are 
 soon dissolved by the ferment of the gastric juice (pepsin) and con- 
 verted into peptones or intermediate products called albumoses. 
 The fat globules are again liberated, their albuminous envelopes are 
 dissolved, and they coalesce to larger droplets, in which condition 
 they pass with the chyme into the intestine. The usual period for 
 the digestion of milk in the stomach by normal gastric juice occupies 
 about three hours. 
 
 The salts and water of the milk, and possibly to some extent the 
 sugar, are absorbed in great part from the stomach wall. In proof 
 of this is the fact that the diuretic action of milk is often obtainable 
 within half the time required for the complete digestion of the al- 
 buminoids. When not absorbed by the stomach they pass into the 
 intestine and are absorbed through the villi. 
 
 Those curds which are not fully dissolved by the gastric juice 
 may enter the duodenum, where their digestion is completed by the 
 pancreatic juice. The latter saponifies the fat which is absorbed by 
 the lacteals of the villi. In the digestion experiments of C. H. Woods 
 and L. H. Merrill (U. S. Department of Agriculture Bulletin Xo. 85, 
 1900) the digestibility of milk casein was always increased by the 
 addition of bread to the milk. 
 
 Rennin. — Rennet is the name given to an infusion of the middle 
 stomach of the calf in brine which possesses special milk-curdling 
 power which is due to a ferment called rennin. 
 
 This milk-curdling ferment is believed to be developed by the 
 action of acids from an antecedent material called zymogen. Rennin 
 is not obtainable from the human stomach in large quantity, but it 
 
72 FOODS AND FOOD PREPARATIONS 
 
 undoubtedly exists in the gastric juice, for pure pepsin has scarcely 
 any curdling action upon milk ; moreover, milk may curdle in either 
 neutral or alkaline media in which pepsin is inert. Rennin is most 
 active in an acid medium, but it also works in the alkaline pancre- 
 atic juice. It possesses little proteolytic power. It is believed to 
 exist more abundantly in the infant stomach than in that of the adult. 
 
 Rennet may be prepared as a powder ; it is sold by grocers in 
 alcoholic solution, and when added to milk which is gently warmed, a 
 light coagulum is formed, causing the milk to partially solidify. The 
 coagulum contracts and squeezes out fluid, which constitutes whey. 
 The rennetised milk when flavoured with vanilla or powdered cinna- 
 mon or nutmeg makes an agreeable invalid food or dessert, which is 
 highly nutritious, for it still contains all the original ingredients of 
 milk. 
 
 Abnormal Digestion. — In cases of indigestion from various causes 
 the curds may remain undissolved in the stomach, eventually irritat- 
 ing it and causing vomiting, or they may pass along the intestine 
 and be voided unaltered in the stools. This occurrence is more fre- 
 quently noticed in young infants than in adults. 
 
 Milk which disagrees in the stomach forms large and somewhat 
 tough coagulse of casein, which are with difficulty dissolved by the 
 gastric juice. Many substances may be added to milk which by 
 their mechanical presence will prevent this occurrence, and hence 
 favour the action of the gastric juice. Excessive acidity of the stom- 
 ach due either to hypersecretion of hydrochloric acid or the presence 
 of organic acids, especially lactic, derived from the food or fermenta- 
 tion processes, modifies the digestion of milk ; the lactose is altered 
 into lactic acid and the casein is promptly coagulated. The alkaline 
 salts of milk are split up and phosphoric acid is liberated, and com- 
 plicated fermentative changes ensue which are as yet imperfectly 
 understood. All this causes more or less gastro-enteric irritation, 
 resulting in diarrhoea. 
 
 When milk or cheese remains too long in the stomach or intes- 
 tine a further fermentation is excited accompanied by a neutral or 
 alkaline reaction, and which results in the final production of butyric 
 acid, and sometimes of other substances, such as leucin, tyrosin, and 
 ammonia. But while free hydrochloric acid exists in the contents of 
 the stomach, the organic acids — lactic, butyric and acetic — which are 
 associated with milk fermentation are unlikely to develop. 
 
 Cow's milk may readily become acid from alteration in the rela- 
 tive amount of potassium biphosphate and the two-thirds phosphate 
 of potassium. The former, if present in excess, hastens coagulation 
 and an acid reaction. When warm the milk may again become alka- 
 line (Soxhlet, Heintz). 
 
 These facts explain the frequent necessity of using antacids, such 
 as lime water or sodium bicarbonate, with infant milk food. Mucous 
 
ANIMAL FOODS 73 
 
 fermentation of the proteids makes the milk slimy, and it becomes 
 stringy on boiling. 
 
 Milk, according to Rubner's experiments, yields more bulky resi- 
 due in the feces than either eggs or meat, yet its nutritive ingredi- 
 ents are very perfectly absorbed. From 8 to 10 per cent approxi- 
 mately of the solids of milk is eliminated in the stools. 
 
 ADAPTATION OF MILK FOR THE SICK 
 
 When patients object to the taste of milk alone, they can be often 
 induced to take large quantities by using it in various combinations 
 or preparations, or by disguising its taste. Many patients when or- 
 dered a milk diet positively assert that they cannot endure the taste 
 of milk ; that it always nauseates them, or that it makes them bilious 
 and constipated, and excites headache. They say, perhaps, that they 
 have faithfully tried to drink it before, and never could tolerate it ; but 
 scarcely any one person has ever tried all the different methods of 
 taking milk, and it does not follow that because it once disagreed 
 several years before it will again. The objection to the taste can 
 always be overcome by a little tact and perseverance, and there are 
 very few persons who cannot assimilate a more or less exclusive milk 
 diet for a few days or weeks if the milk is properly given, and, if 
 necessary, artificially digested for them. Their previous unhappy 
 experience is probably due to having taken a large dose of undiluted 
 rich milk which promptly coagulated, soured, and was rejected, ex- 
 citing all the distaste which they have treasured against it. 
 
 When, as in some febrile cases or in acute Bright's disease, a milk 
 diet is imperative, such patients should begin with but a teaspoonful 
 or two at a time, repeating it once in ten or fifteen minutes. If milk 
 is only taken slowly enough into the stomach, and mingled on the 
 way with saliva, like other food — eaten rather than drunk — it is im- 
 possible for it to form the large tough curds that it does when poured 
 down by the tumblerful, like a dose of salts. By degrees the patient 
 will be convinced of his ability to retain it, and then the dosage may 
 be increased; making such further changes in the preparation of it 
 as occasion demands. 
 
 In all cases where there is a tendency for milk to disagree it is 
 better to give it alone to the patient, by which means various expe- 
 dients used to increase its digestibility may be better tested. Patients 
 will often digest both milk and beef broth or milk and whisky when 
 these substances are given at alternating intervals of one or two 
 hours, whereas if taken in conjunction they give rise to dyspepsia. 
 
 The methods of altering milk to suit the taste or digestive re- 
 quirements are so numerous that it will be found convenient to group 
 them under the following headings, although the classifications are 
 somewhat arbitrary and here and there may overlap : 
 7 
 
74 FOODS AND FOOD PREPARATIONS 
 
 I. Methods of altering the taste of milk. 
 
 II. Methods of improving the digestibility of milk. 
 
 III. Methods of predigestion. 
 
 IV. Methods of sterilisation and preservation. 
 
 The first method beguiles the patient into taking larger quantities 
 of milk without tiring of it ; the second aims at preventing the for- 
 mation in the stomach of dense tough coagulae which are difficult of 
 solution and digestion by an enfeebled gastric juice ; the third, by 
 artificial digestion, relieves a weak stomach of much labour; the 
 fourth prevents the accession of poisonous germs which would 
 excite malfermentation and indigestion. 
 
 I. Methods of altering the Taste of Milk 
 
 When patients object to the taste of raw milk or tire of it, it may 
 be flavoured in a variety of ways. When there is no objection on 
 the score of the nervous system, a teaspoonful or two of black coffee 
 is one of the best means at hand, or a little of the extract of coffee 
 may be added. Very weak tea may be preferred. Caramel is an- 
 other excellent flavouring substance which may be freely employed, 
 and ginger is also used. Other patients may take a little chocolate 
 or cocoa or cocoa nibs infusion with their glass of milk. Some 
 prefer the addition of common salt or a little black pepper. The 
 various meat extracts, fluid or solid (see Meat Preparations, pages 
 801, 804), may often be used to advantage. When alcohol is not 
 contraindicated many patients are willing to drink much milk 
 in the form of weak punches, or as eggnog in which cognac, 
 whisky, sherry, or rum may be employed to disguise the pure- 
 milk taste. 
 
 The various malt extracts are enjoyed by some when given in 
 milk, and their disagreeable sweetness is thereby removed. A tea- 
 spoonful of malt may be added to a pint of milk which is gently 
 warmed for half an hour, after which it is boiled for twenty minutes. 
 This prevents the formation of large curds. 
 
 None of these additions materially affect the nutritive value of 
 milk, and the occasional variety which may be secured by experi- 
 menting with different substances will usually overcome all preju- 
 dices. I have often induced patients to take large quantities of 
 junket flavoured with a little spice (see Receipts for Invalid Foods), 
 not realising that they were really eating only pure milk which had 
 passed into the first stage of digestion. Patients who object to milk 
 because they have to drink so much fluid may take the same quan- 
 tity in the form of junket because they can eat it with a spoon. 
 
 Much milk may be disguised sometimes in custards, gruels, etc., 
 where there is no objection to the addition of other easily digestible 
 foods. 
 
ANIMAL FOODS 75 
 
 II. Methods of improving the Digestibility of Milk 
 
 1. Skimming. 
 
 2. Boiling. 
 
 3. Dilution with water. 
 
 4. Dilution with alkaline and aerated waters. 
 
 5. Dilution with amylaceous foods. 
 
 6. Addition of alkalies, acid and other substances. 
 
 1. Skimmed milk is the residue after removal of the cream. It 
 contains water, 90.63 per cent ; proteid, 3.06 per cent ; fat, 0.79 per 
 cent ; sugar, 4.77 per cent, and a residue of salts. It thus retains 
 almost 10 per cent of solids. 
 
 Skimmed milk is well digested by those patients whose stomachs 
 do not tolerate fat in any form, but it will not long support life, and 
 attempts which have been made to cure certain diseases by a 
 skimmed-milk diet have signally failed. Donkin advocated its use to 
 the extent of six to eight pints daily. 
 
 It may be employed temporarily in the milk cure for Bright's 
 disease, dropsies, and in the treatment of neurotic hysterical cases. 
 
 Yeo advises gouty subjects to drink ten minutes before each meal 
 a breakfastcupful (eight ounces) of hot skimmed milk and water with 
 the addition of a small saltspoonful each of potassium bicarbonate 
 and salt. This is a good means of prescribing an alkali, but there 
 is no special advantage in the skimmed milk. 
 
 2. Boiling. — Boiled milk exhibits a thin scum of albumin upon the 
 surface which entangles some of the fat globules, and which is quickly 
 replaced by another after removal. This scum should not be served 
 to invalids. There is much discussion as to whether infants should 
 ever be given raw cow's milk, or only that which has been previously 
 boiled, and authorities are divided upon the matter. Certainly in 
 most cases raw milk, if pure, provokes no harm. Boiling the milk 
 arrests the development of germs and fungi with which it may have 
 become contaminated, and may thus prevent the spread of some 
 diseases, and it retards the process of " souring " and coagulation. 
 Boiling expels about 3 per cent of gases — carbon, nitrogen, and 
 oxygen (Hoppe) — and the loss of oxygen diminishes the formation 
 of lactic acid and consequent souring. It alters the taste of the milk 
 somewhat, and makes it " flat." The flatness is removed by agitating 
 the milk with air by pouring it back and forth into two cups held 
 a little distance apart ; or it may be removed by the addition of any 
 aerated water. As a rule, boiled milk is preferred hot, but some 
 persons enjoy it cold. 
 
 It is a prevalent idea that milk is in general more digestible if 
 boiled than if raw, but the results of experiment do not wholly 
 confirm this view. Crolas has demonstrated that boiling has no 
 influence upon either the lactose or casein, but it slightly in- 
 
y6 FOODS AND FOOD PREPARATIONS 
 
 creases the free soluble phosphates, which he regards as an ad- 
 vantage. 
 
 Radnitz found by experiment that young animals absorb 9.4 per 
 cent of albuminoids from fresh milk, but only 5.7 per cent from 
 boiled milk, hence a larger quantity of the latter must be drunk to 
 obtain the same nourishment which is derived from raw milk. 
 
 According to Vasilieff, the envelopes of the oil globules are al- 
 tered by heat, and he claims that 50 per cent less fat is absorbed. 
 This seems too high an estimate in view of clinical observation. 
 
 Occasionally patients are made bilious and constipated by the use 
 of boiled milk who digest it better raw, but the converse is also true : 
 it is a matter of idiosyncrasy. It has decided advantage in diar- 
 rhceal diseases, probably through the absence of germs and gases. 
 In some cases it may be combined with thin chocolate or cocoa. 
 
 " Scalded milk " is heated to about 150 F., or practically " Pas- 
 teurised," by pouring on boiling water. Thus treated, milk remains 
 fresh a little longer than when raw. 
 
 3. Dilution with Water. — The dilution of milk is accomplished by 
 adding plain water, either hot or cold, in the proportion of one part 
 to two or three of milk. If the milk is exceptionally rich in cream 
 and casein this simple means will often be sufficient to ensure its 
 better digestion, for the curds become both smaller and softer. 
 
 4. Dilution with Alkaline or Aerated Water. — Lime water may be 
 added in the proportion of two to four or more tablespoonfuls to 
 each tumbler of milk, taken cold. In cases with much acidity of the 
 stomach the lime water should be mixed in the proportion of one half 
 or even two thirds. When so given, the taste of the milk is so little 
 altered that very few patients object to it, and some even find it 
 more agreeable. If diarrhoea or nausea is present they are controlled 
 to some extent, but on the other hand constipation is increased by 
 the use of lime. When the latter exists it is better to dilute with 
 Vichy or carbonic-acid water. If lime water is added to neutralise 
 the acidity of cow's milk the temperature of the mixture should not 
 be raised above that of Pasteurisation — 160 to 170 F. — because the 
 albuminoids are more or less decomposed in a boiling alkaline solu- 
 tion. It is better to separately sterilise the lime water and add it 
 afterwards. 
 
 Barley water may be used as a diluent for milk in diarrhcea, but 
 oatmeal water is better for constipation. 
 
 Aerated waters, such as carbonic-acid water, alkaline Vichy, 
 bottled plain soda, or Apollinaris, may all be added to milk, in any 
 desired proportion. In cases of fever four ounces of a mixture made 
 with equal parts of the diluent may be given every hour, or eight 
 ounces every two hours, up to two and a half or three pints of milk 
 per diem. 
 
 Most of these waters are best used with cold milk, but for many 
 
ANIMAL FOODS JJ 
 
 persons hot milk and Vichy make a very agreeable combination, 
 which is often soothing to the obstinate cough of bronchitis. The 
 gaseous waters relieve the " flatness " of the milk, and prevent the 
 after-taste of it in the mouth, of which many patients complain. The 
 mixtures with Vichy and lime water are especially serviceable where 
 extreme irritability of the stomach is present with a tendency to the 
 immediate rejection of all fluids. 
 
 5. Dilution with Amylaceous Foods. — Any form of starchy food — 
 flour, arrowroot, etc. — serves as a mechanical diluent of milk by 
 mingling with it and preventing the precipitation of tough curds. 
 Bread and milk, or crackers and milk, serve the same purpose, and, 
 being semisolid, have the further advantage that they must be eaten 
 slowly and mixed with saliva. 
 
 When infants vomit their milk it may be temporarily attenuated 
 with either barley water or oatmeal water added instead of plain 
 water, and in the same proportion — i. e., one third or one half. The 
 much-extolled starchy " infant foods " are less useful as foods than 
 they are as diluents of milk, and if used temporarily with the latter 
 object solely in view, they are less liable to produce rickets, scurvy, 
 gastric catarrh, and other maladies. Whenever amylaceous sub- 
 stances are selected to dilute milk for infants they should first be as 
 far as possible converted into dextrin and glucose, for gummy dex- 
 trin, saccharine, or even gelatinous materials are all better than crude 
 starchy foods. 
 
 For adults a tablespoonful of Mellin's or Nestle's food dissolved 
 in an ounce of hot water and added to a glass of milk is both pala- 
 table and nutritious in cases of phthisis or scrofula. 
 
 6. Addition of Alkalies, Acid and Other Substances. — The addition 
 of alkalies to milk renders it much more digestible for some persons. 
 In hyperacidity of the stomach or in the presence of abnormal fer- 
 mentation alkalies are beneficial as neutralising agents. On the other 
 hand, in cases in which the gastric juice is very feeble or absent, 
 artificially digested milk may prove more serviceable. 
 
 The admixture of alkalies by reducing the acidity of the gastric 
 juice makes the casein coagulate more slowly, and in flocculi rather 
 than in large coagulse. 
 
 Salt may be added — a saltspoonful to the tumbler of milk. This 
 improves its digestibility for most persons, and renders it less likely 
 to cause biliousness. Sodium bicarbonate, ten grains, or a salt- 
 spoonful to the tumbler of milk, prevents malfermentation in the 
 stomach. If hyperacidity of the stomach exists, sodium bicarbonate 
 may prove better than lime water, which is but slightly antacid, for it 
 contains but a half grain of lime to the ounce. On the other hand, 
 if the gastric juice is too feeble to digest milk easily, it is sometimes 
 a disadvantage to attenuate it still further with quantities of lime 
 water, and sodium bicarbonate should be substituted to check the 
 
78 FOODS AND FOOD PREPARATIONS 
 
 acid fermentation of the milk which the hydrochloric acid of the 
 gastric juice fails to control. An excellent combination for an irri- 
 table stomach is made by adding five or ten grains of this salt and 
 two grains of cerium oxalate to each glass of milk. The cerium oxa- 
 late has a sedative and tonic action upon the mucous membranes and 
 tends to allay nausea and irritation in the stomach. 
 
 Other substances sometimes added for gastric ulcer, etc., are 
 sodium phosphate, saccharated lime, or a teaspoonful of milk of 
 magnesia to the pint. A few drops of liquor potassse to the pint of 
 milk are recommended by Bulkley for infants having eczema. 
 
 Starr gives the following receipt for making saccharated lime for 
 diluting milk for infants : 
 
 Slaked lime, one ounce ; refined powdered sugar, two ounces ; 
 mix, triturate, add distilled water, one pint. Shake occasionally for 
 some hours in a bottle, let stand, and siphon out the fluid. 
 
 Roberts recommends a powder containing 10 grains each of so- 
 dium bicarbonate and common salt, and 5 grains of light magnesia, 
 to be added to a tumblerful of one third hot water and two thirds 
 hot milk. 
 
 Edes strongly recommends the addition of hydrochloric acid to 
 milk. Twenty minims of the dilute acid of the pharmacopoeia are 
 stirred slowly, drop by drop, into a pint of milk which is gently 
 warmed. A fine flocculent coagulum of casein floats in the whey, 
 and the digestibility of the milk is improved, while a flat or disagree- 
 able taste is avoided. 
 
 Gelatin. — Gelatin may be employed in small quantity as an at- 
 tenuant of milk. Starr gives the following receipt for its use : 
 
 Soak a piece of white gelatin an inch square in half a cupful 
 of cold water for three hours. Put the cup in a saucepan of 
 water and boil until the gelatin dissolves. When cold it forms 
 a jelly. For infants one or two teaspoonfuls may be put into 
 each nursing bottle of milk. 
 
 III. Methods of Predigestion 
 
 1. Peptonised milk. 2. Pancreatinised milk. 3. Koumiss, kefir, 
 matzoon, etc. 
 
 1. Peptonised Milk. — The object of peptonising milk is to com- 
 plete a portion of the digestive process outside of the body, and 
 thereby relieve the alimentary canal of this work. A great variety 
 of preparations of pepsin, peptonising powders, etc., are offered in 
 market. 
 
 In general they are pure, but they vary somewhat in rapidity and 
 strength of action. The powder may be added some time before 
 the milk is swallowed, and in this event it can only act in conjunc- 
 tion with dilute hydrochloric acid. If added to the milk at the time 
 
ANIMAL FOODS 79 
 
 of swallowing, the normal acid of the gastric juice supplies the 
 proper reaction. 
 
 The process of artificial peptonising consists in adding one of 
 the numerous preparations of pepsin obtained at the pharmacist's to. 
 fresh acidulated milk, and allowing it to stand in a bottle immersed 
 in warm water at approximately the body temperature. A fermen- 
 tation results in which the casein is more or less completely con- 
 verted into albumoses. 
 
 If the process be too long continued, further fermentation results, 
 and the milk becomes very bitter. It is therefore checked after a 
 few minutes, either by boiling the milk, which has the effect of de- 
 stroying the pepsin, or by keeping it upon ice until ready for use, 
 which inhibits the action of the ferment. 
 
 Either peptonised or pancreatinised milk may be prepared in 
 quantity for use by infants or invalids during the day, and if there 
 is an ice chest to keep it in, it is better to do so, for then it is more 
 uniform in composition. If ice is not at hand, the preparation 
 should be freshly made for use each time, otherwise it will become 
 bitter and spoil. 
 
 2. Pancreatinised Milk. — Of recent years the use of pepsin for 
 predigestion of milk has been gradually superseded by that of pan- 
 creatin, which acts best in an alkaline medium. This ferment, like 
 pepsin, may be preserved almost indefinitely in powdered form. 
 Milk thus prepared is slightly yellow and less opaque than raw milk. 
 The process may be conducted as follows : 
 
 Add a pint of fresh milk to a gill of cold water in a clean ves- 
 sel. Put in a tubeful of Fairchild's "peptonising powder " (pancre- 
 atic extract 5 grains, and sodium bicarbonate 15 grains), or, instead 
 of the pancreatic extract, substitute 1 to 2 drachms of " pancreatic 
 solution " made by Parke, Davis & Co., stir well, and place in warm 
 (not boiling) water for half an hour or until a slight bitter taste is 
 present. 
 
 This taste means that fermentation has proceeded far enough. 
 To allow it to continue will make the milk unpalatable, and it is 
 almost impossible to disguise the bitterness. Boiling for two or 
 three minutes stops all further fermentation, and the milk should 
 then be placed on ice until ready for use. Such milk will keep well 
 for several hours. 
 
 When used, serve alone cold, or add carbonic-acid water to dis- 
 guise the taste. For adults a little coffee may be used for the same 
 purpose. 
 
 Pancreatinised Milk Gruel. — To a pint of cold fresh milk add a 
 pint of thick milk gruel, boiling hot. The gruel may be made of 
 sago, pearl barley, arrowroot, oatmeal, wheat flour, or other farina- 
 ceous food, according to taste. The temperature of the mixture 
 should be about 125 F. Add a tubeful of peptonising powder (15 
 
8o FOODS AND FOOD PREPARATIONS 
 
 grains), and place on the side of the stove for two or three hours, 
 avoiding great heat. Then boil to stop the fermentation. Strain, 
 and keep on ice ready for use. The gruel disguises admirably the 
 taste of the milk. 
 
 When pancreatinisation is long continued the casein is completely 
 digested, but the milk becomes too bitter for use. 
 
 Legumin. — Legumin is a vegetable ferment which is said to make 
 milk highly digestible for invalids by converting casein into a sol- 
 uble albuminoid. This substance, which was lately introduced by 
 Bovet, is also given as a food. 
 
 3. Koumiss. — Koumiss (spelled also koumys and kumyss) is milk 
 artificially prepared by simultaneous lactic acid and alcoholic fer- 
 mentation. It was originally made by the natives in the steppes of 
 southeastern Russia and other eastern countries as a refreshing and 
 slightly intoxicating beverage. Of late years the idea has been ad- 
 vanced that it has some beneficial or curative influence in chronic 
 diseases, such as phthisis, chronic bronchitis, chronic gastro-intestinal 
 catarrh, and other wasting diseases, and as a result the manufacture 
 of koumiss has been extensively introduced into the United States, 
 and at many pharmacies it can be obtained daily, freshly prepared, 
 in pint or quart bottles. It is probable that a large share of the 
 benefit claimed for the native " koumiss cure " is attributable, like 
 most " cures," to the favourable climate in which the patients live, 
 especially during the months of May, June, and July, where the air 
 is dry, clear, and aromatic. 
 
 Very advanced cases, and those having active fever, may not be 
 benefited by the " cure," but koumiss may be given them at home. 
 Koumiss is of great service as an easily digested food for many cases 
 of obstinate gastric irritation and severe vomiting. In the latter it 
 may be often tolerated when no other nutriment is retained. Its 
 uses are therefore various both for infants and adults, and there are 
 often cases in which it agrees better than pancreatinised milk or milk 
 prepared in any other way. 
 
 The Manufacture of Koumiss. — The manufacture of koumiss may 
 be conducted by several different processes. In southeastern Rus- 
 sia, especially in south Samara, the milk of a certain breed of mares is 
 used, which is particularly rich in milk sugar but poor in fat and 
 casein, and the animals are fed upon grasses which contain this sugar- 
 forming material in abundance (Karrick). 
 
 Mare's milk, as compared with cow's, contains much more sugar 
 (6 per cent) and less casein and fat (less than 3 per cent) (Biel). 
 
 The mares are light-coloured animals, unbroken, and are guarded 
 with greatest care, not being allowed dry food, such as oats and hay. 
 Pastured among mountains containing salt beds, they have access to 
 running water, in which they can bathe frequently. They have large 
 udders and abundant milk secretion, which is milked from four to 
 
ANIMAL FOODS 8 1 
 
 eight times daily. The best koumiss is made in the early summer by 
 pouring fresh milk into smoked leather bottles or sabas, to which 
 is added a little sour cow's milk or old dry koumiss ferment. The 
 skins are kept at a temperature about equal to the body heat and 
 are frequently shaken for thorough mixing, and fermentation is 
 allowed to proceed for three or four days. 
 
 In the United States koumiss is manufactured from cow's milk 
 by the addition of some artificial ferment. Such home-made koumiss 
 may be prepared as follows : 
 
 Take 2 teaspoonfuls of wheat-flour dough, 2 tablespoonfuls of 
 millet flour, 1 tablespoonful of honey, 1 tablespoonful of beer yeast. 
 Mix into a thin paste with milk. Place in a warm place to ferment. 
 When fermented, put into a linen bag and hang in a covered jar with 
 sixteen pounds of fresh milk. Let stand for twenty-four hours, or 
 until the milk becomes acid, at a temperature of 86° to 90 F. Skim, 
 decant, agitate for an hour, bottle and cork tightly, protecting the 
 corks with wire fastenings. Keep in a refrigerator. Absolute clean- 
 liness must be insisted upon throughout all the various manipula- 
 tions; otherwise different forms of fermentation will result (Stange). 
 
 Properties. — Koumiss when shaken froths readily. It has, when 
 fresh, a slightly sour odour, agreeable bitter taste, and acid reaction. 
 The specific gravity is 1.018 to 1.029. During fermentation alcohol 
 is developed from the milk sugar, which forms lactic acid and glu : 
 cose, the latter making alcohol and carbonic acid. The alcohol may 
 reach 2.5 per cent, but koumiss made from cow's milk may not con- 
 tain above 1 per cent. Koumiss becomes stronger in both taste and 
 smell after keeping for a day or two. It is highly sensitive to tem- 
 perature changes, and easily putrefies. 
 
 There are two varieties of koumiss prepared which differ in de- 
 gree of fermentation and in their exhilarating and intoxicating 
 properties. The lighter form contains less alcohol than the heavier, 
 in which fermentation has proceeded further. 
 
 The following analysis by Stange illustrates the changes in com- 
 position which koumiss undergoes by prolonged fermentation : 
 
 Table of the Percentage Composition of the Several Strengths of Koumiss 
 
 (Stange) 
 
 
 Mare's 
 milk. 
 
 KOUMISS— DURATION 
 
 OF FERMENTATION. 
 
 
 6 hours. 
 
 18 hours. 
 
 30 hours. 
 
 4 days. 
 
 
 51 
 
 23 
 19 
 
 5 
 
 3-8 
 18.5 
 
 3-9 
 
 18.8 
 22.5 
 18.9 
 
 4-5 
 
 6.0 
 19-5 
 
 5-6 
 16.3 
 22.6 
 20.0 
 
 4.0 
 
 70 
 
 30.0 
 
 6.4 
 
 20.0 
 
 IQ.O 
 
 4.0 
 
 II .O 
 
 Alcohol 
 
 30.0 
 6.4 
 
 Lactic acid 
 
 
 Albumin 
 
 
 Fat 
 
 I9;0 
 
 4.0 
 
 Salts 
 
 
£2 FOODS AND FOOD PREPARATIONS 
 
 The casein, after being first precipitated, is converted into pep- 
 tones and an acid albumin. It should be remembered that the com- 
 position of koumiss is always changing unless the fermentation be 
 constantly held in check by extreme cold. Koumiss grows more 
 and more acid and keeps but a short time when exposed to the 
 air. If spoiled, it may produce severe symptoms of ptomaine 
 poisoning. 
 
 Koumiss is prepared in tablet form under the name of koumysgen, 
 each tablet, it is claimed, containing 30 per cent of soluble casein. 
 The tablets keep indefinitely in air-tight bottles, and when dissolved 
 in water form a cooling effervescing food, possessing similar proper- 
 ties with koumiss, and it is cheaper. It is doubtful, however, whether 
 any preparation can be made to reproduce all the peculiarities and 
 advantages of fresh koumiss, which is so variable and delicate a 
 -substance. 
 
 Koumiss Cure. — The " koumiss cure " consists in taking a large 
 quantity of koumiss — in some cases 15 to 20 tumblerfuls a day — in 
 combination with nourishing albuminous food. If perfectly fresh it 
 may be drunk warm, but if it is to be kept for some time it is better 
 to drink it cold. Koumiss which is either too fresh or which has not 
 been kept clean may cause flatulency, colic, and diarrhoea, but old 
 koumiss has the opposite effect upon the bowels, and, like milk, gives 
 rise to constipation. Koumiss resembles whey in being strongly diu- 
 retic and diaphoretic, and thus relieves the mucous membranes of 
 congestion. It also alleviates thirst, strengthens the action of the 
 heart, and improves the vascular tone, general nutrition, and com- 
 plexion. The solids of the urine are increased during its use. The 
 use of koumiss is said to be contraindicated in renal and vascular 
 diseases, gout, plethora, and chronic constipation. 
 
 At first but two or three tumblerfuls of koumiss are allowed daily 
 until the stomach becomes accustomed to it ; then patients are made 
 to drink a glass at frequent intervals during the day and sometimes 
 as often as once every half hour. Some patients can digest very 
 large quantities of koumiss, and as much as to litres have been taken 
 in twenty-four hours, but less is used now than formerly; patients 
 do not often exceed 6 or 8 litres a day, and for the average from 2 
 to 4 is quite enough. Tender beef and abundant butter, cream, and 
 a moderate supply of bread compose the basis of the other foods 
 allowed. Sweets, salads, and other beverages than koumiss are for- 
 bidden. 
 
 The treatment should be commenced slowly in order to accustom 
 the digestive system to the fermented drink, which otherwise may 
 excite diarrhoea. The latter accident may be counteracted by lime 
 water or some simple remedy, such as bismuth. 
 
 The koumiss prepared from milk in the United States does not 
 seem to possess the peculiar properties and extraordinary nutritive 
 
ANIMAL FOODS 83 
 
 value which is attributed to it when made from mare's milk in Rus- 
 sia, on which patients are said to gain rapidly in weight. In various 
 Russian cities there are special institutions designed for carrying out 
 the koumiss cure, and which are supplied with the genuine article 
 from the steppes. 
 
 Special koumiss cures are not in vogue in this country, but in 
 southeastern Russia there are several establishments, notably in the 
 districts of Orenberg and Samara, where patients go for treatment 
 during several months in summer, and derive great improvement. 
 Like other popular ' k cure " resorts in Europe, these establishments 
 furnish the patient with suitable light and varied amusement during 
 the progress of his treatment, which is highly beneficial, by diverting 
 the mind and relieving an otherwise monotonous regime. While un- 
 dergoing the koumiss cure, patients are made to live outdoors as 
 much as possible, and tent life with free exercise is no doubt a very 
 important adjunct to the treatment when it can be obtained. The 
 climate is both hot and dry, and the elevation is high. 
 
 The koumiss cure is particularly available for chronic catarrh of 
 the respiratory and alimentary canal, and in the first stage of pul- 
 monary tuberculosis. It is also especially recommended for general 
 debility resulting from pronounced anaemia, and for various diatheses, 
 such as scrofula, rhachitis, etc. The large percentage of carbonic 
 acid which is produced by koumiss fermentation, together with the 
 alcohol present, acts as a stimulant to the gastric mucous membrane, 
 favourably affects digestion, and lessens irritability of the stomach. 
 Among other effects produced by the use of koumiss may be men- 
 tioned occasional drowsiness and lassitude. This food is also said 
 to possess some aphrodisiac influence. 
 
 Kefir. — Kefir is another form of fermented milk which resembles 
 koumiss, and has long been used in the Caucasus. 
 
 Kefir contains three varieties of ferments which produce com- 
 plex fermentation processes resulting in the formation of alcohol, 
 lactic acid, modified albumins, and peptones. The casein of milk is 
 in great part digested by them, and the portion which remains is 
 precipitated in flocculi instead of heavy curds. The milk sugar is 
 almost completely converted into alcohol and carbonic-acid gas, 
 which bubbles to the surface. Kefir has a sour taste, due to the 
 organic acids which it contains. 
 
 Zoolak. — Zoolak, formerly called Matzoon, is a form of milk in 
 which lactic-acid fermentation has been produced by a ferment much 
 used in Syria. It has the same general properties and effects with 
 koumiss, and is an excellent invalid food. 
 
 Lactone is an unfermented milk preparation freed from fat, steril- 
 ised and rendered effervescing by means of carbonic-acid gas. Ac- 
 cording to the late Charles Rice, chemist of Bellevue Hospital, 100 
 parts by weight contain : 
 
84 FOODS AND FOOD PREPARATIONS 
 
 Fat o. 10 
 
 Casein and albumin 5-37 
 
 Milk sugar 5 . 80 
 
 Salts 1 . 20 
 
 Water 87 . 53 
 
 100.00 
 
 IV. Methods of Sterilisation and Preservation 
 
 1. Sterilisation. 2. Pasteurisation. 3. " Humanised milk." 4. 
 Modified milk. Milk laboratories. 
 
 1. Sterilised Milk. — The sterilisation of milk is accomplished by 
 heating it up to the boiling point, 212 F. In a vacuum this may be 
 accomplished by a temperature a few degrees lower. 
 
 The construction of steam sterilisers for milk, beef tea, or other 
 foods is based upon a very simple plan. It is a familiar fact that 
 the steam which rises from water heated in a tin or copper can con- 
 denses in drops on the lid, and this condensed vapour drips back 
 along the sides of the can. If the lid is raised a little and is made 
 somewhat larger than the can, the condensed steam will drip down 
 on the outside of the can instead of the inside. If a second larger 
 can be inverted like a hood or jacket over the first, the steam con- 
 densed between the two cans drips back and may be made to rejoin 
 the water from which it started. In this way a kind of perpetual 
 motion is kept up so long as a flame is applied beneath the water to 
 vapourise it. Bottles containing the food to be sterilised are sus- 
 pended in racks in the upper part of the inner chamber in the at- 
 mosphere of steam, and their contents soon acquire the temperature 
 of boiling water, 212 F. 
 
 Siebert removes the grosser impurities of milk by placing it on a 
 thick layer of sterilised absorbent cotton in a clean glass funnel. A 
 quart of milk will pass through in ten or fiteen minutes. 
 
 Mobrun preserves milk for six months by warming it in a tin re- 
 ceptacle, the only opening of which is through a lead tube. The 
 milk is rendered sterile by the heat, and all air is driven out through 
 the tube, which is then compressed and soldered. 
 
 The taste of sterilised milk is peculiar and resembles that of 
 boiled milk. If put in bottles which have been sterilised by boiling 
 water or steam, by stopping them with pledgets of absorbent cotton 
 which have been baked, the milk will keep fresh for a number of days 
 — long enough to be carried upon a voyage to England or across the 
 continent. 
 
 Milk drawn by clean hands fresh from the cow into bottles which 
 have been sterilised by boiling water is germ-free, and need not be 
 further treated ; but the milk usually served in cities from large cans 
 which have been hawked about the streets has passed through sev- 
 eral receptacles and been exposed to the air. (See Milk Adultera- 
 
ANIMAL FOODS 85 
 
 tion and Impurities, p. 61.) It is better always to keep milk germ- 
 free, but it is absolutely necessary to do so in summer if it is to be 
 fed to infants. In 1899 sterilising apparatus was introduced at the 
 Children's Hospital, Randall's Island, New York city, with the imme- 
 diate effect of reducing the annual infant death rate from 44.36 to 
 19.86. It is often advisable to sterilise milk for feeding to typhoid- 
 fever patients and others in whom asepsis of the alimentary canal is 
 of paramount importance. If milk be too long sterilised it becomes 
 of a brownish hue, owing to the conversion of its lactose into 
 caramel. 
 
 It is suggested by Barlow that prolonged sterilisation of milk 
 may lessen its antiscorbutic powers for young infants, but scurvy in 
 infants is due also to other causes, such as feeding with artificial 
 foods, and prolonged exclusive plain milk diet for adults reduces 
 them to a condition resembling scurvy. (See Typhoid Fever, Milk 
 Diet.) 
 
 According to Leeds, the following alterations are produced in 
 milk by sterilisation at 212 F. : 
 
 1. The amylolytic ferment is destroyed. 
 
 2. The casein coagulates less readily by rennin. 
 
 3. The digestibility of casein by the gastric and pancreatic juices 
 is somewhat retarded. 
 
 4. The fat is less promptly absorbed than normally from the in- 
 testine. 
 
 5. If the heating is continued for some time, the milk sugar is de- 
 stroyed. 
 
 The mineral salts of milk are also dissociated in some degree 
 from their organic compounds. 
 
 In churning sterilised milk, butter forms more slowly than 
 from raw milk, a period two or three times longer being required. 
 Hirsch attributes this to toughening of the albuminoid envelopes 
 (of lactalbumin) of the fat globules, which is produced by the 
 heat. 
 
 For these several reasons an infant to be fully nourished on ster- 
 ilised milk requires more of it than of raw milk. 
 
 Practically, in normal stomachs of either infants or adults these 
 changes are not sufficiently pronounced to seriously interfere with 
 the digestibility of the milk, but dyspeptic and catarrhal conditions 
 of the stomach, especially in infants, make it highly sensitive to very 
 slight modifications in the composition and reaction of milk. In 
 quite recent years it has been proved that the method of Pasteurisa- 
 tion is preferable to sterilisation, and it is now much more in vogue 
 except where milk has to be prepared to keep for several days. 
 (See 2. Pasteurised Milk, p. 86.) 
 
 The directions for predigestion combined with sterilisation of 
 milk at the Philadelphia Hospital are thus given by Hirst : 
 
86 FOODS AND FOOD PREPARATIONS 
 
 " I. Have the nursing bottles prepared clean every morning. 
 
 " 2. Take cream, five ounces ; milk, two and a half ounces. 
 
 " 3. Put in skillet ; add pancreatin powder (pancreatin, two and a 
 half grains ; sodium bicarbonate, five grains) ; heat over alcohol flame 
 for six minutes ; stir and sip constantly ; do not overheat. 
 
 " 4. Of this mixture put in each bottle six drachms (for a two- 
 ounce bottle). Use funnel. 
 
 " 5. Add to each bottle ten drachms of sugar solution. (Make 
 sugar solution by dissolving an ounce of sugar of milk (one powder) 
 in a pint of warm water.) 
 
 " 6. Stopper the mouth of each bottle with dry baked cotton and 
 sterilise for twenty minutes. 
 
 " 7. Set aside to cool. 
 
 " 8. Before use put bottle in warming cup ; apply nipple imme- 
 diately before giving it to infant." 
 
 The alimentary canal of the newborn infant is sterile — it con- 
 tains no bacteria — but after the first few passages of meconium two 
 species of bacilli and one of micrococci are found (Escherich, Bes- 
 lau), which disappear with the meconium. There are but two species 
 of bacteria found in the stools of healthy nursing infants, the Bac- 
 terium lactis aerogenes, obtained from the ileum below the duodenum, 
 and Bacillus coli communis, from the colon. 
 
 In diarrhceal conditions other bacteria, to the number of forty 
 species, have been found (Booker). Their action in different dis- 
 eases is not yet differentiated, but they are associated more or less 
 directly with malfermentation and the formation within the intes- 
 tines of gases and irritable or poisonous products. Many of these 
 species thrive and are reproduced in hot weather outside the body 
 in milk, in the atmosphere, and upon diapers and utensils. This 
 explains the importance of absolute aseptic cleanliness in every- 
 thing that pertains to the nursing and feeding of infants — cleanliness 
 of the breasts and nipples, of the nurse's hands, of all receptacles for 
 milk or other foods, of the child's body, and prompt removal and 
 disinfection of soiled diapers or clothing. 
 
 Most of these bacteria grow best in milk, and the diarrhoeal dis- 
 eases which are caused by and associated with triem are absolutely 
 preventable when the methods are understood of avoiding milk in- 
 fection, and of sterilisation when it is infected. Vaughan says with 
 proper emphasis : "If parents were willing to pay for wholesome un- 
 infected milk half the fancy price which they readily give for some 
 prepared baby food, their children would be better nourished and 
 disease among them would be less frequent." 
 
 2. Pasteurised Milk. — Pasteurised milk is similarly prepared to 
 sterilised milk, and is, in fact, sterile, but the temperature is only 
 raised for twenty minutes to 167 F., instead of the boiling point, 
 212 F. It is somewhat more easily digested than sterilised milk, 
 
ANIMAL FOODS 8/ 
 
 but it does not keep so long and spoils in one or two days. It has 
 the advantage of tasting more like fresh milk. 
 
 Cleansing Milk Bottles. — Both sterilised and Pasteurised milk 
 should be warmed by placing the milk bottles in warm water without 
 opening them. If the bottles are to be used again they should be 
 rinsed and left standing full of water to which one or two teaspoon- 
 fuls of borax or soda have been added. Before rilling with milk 
 they should be washed with a fresh swab and hot soapsuds, rinsed 
 again with boiled water, and kept for at least twenty minutes in boil- 
 ing water, or they may be placed in a steam sterilising apparatus 
 under pressure. Rubber nipples for infants' bottles must be kept in 
 borax water and rinsed several times daily. Rubber tubing should 
 be discarded. 
 
 The heat of Pasteurisation is sufficient to destroy all bacteria 
 likely to be present without so much alteration of the properties of 
 the milk as occurs in sterilisation. 
 
 Different experimenters have shown that the tubercle bacillus in 
 milk is destroyed by a ten-minutes' exposure at 167 F., whereas the 
 germs of cholera, pneumonia, and typhoid fever may be quickly de- 
 stroyed in milk at 140 F. (Van Geuns). 
 
 Freeman has shown by experiments that — 
 
 " 1. Pasteurisation of milk at 75 C. (167 F.) affords a safeguard 
 against the deleterious effects of any bacteria which it may contain, 
 without interfering with its nutritive qualities. 
 
 " Pasteurisation at about 75 C. (167 F.) destroys efficiently the 
 germs of cholera, typhoid fever, diphtheria, and tuberculosis as well 
 as the Streptococcus pyogenes, the Staphylococcus pyogenes aureus, and 
 the Bacillus coli communis!' 
 
 The Bacillus acidi lactici is also prevented from acting after ex- 
 posure to a temperature of 160 F. 
 
 It is found that by immersing bottles of milk in water which has 
 just been removed, while boiling, from the fire, a fairly uniform 
 temperature of 167 F. is obtained. Naturally, the relation between 
 the volume of water used and the quantity of milk must be properly 
 balanced, and various forms of graduated receptacles are sold which 
 make the process very easy and simple. 
 
 A graduated covered pail, into which the boiling water is poured, 
 is fitted with a rack to submerge enough bottles of milk for the day's 
 use, and this is all that is necessary. After half an hour's exposure 
 to the heat the milk, as in the case of sterilised or pancreatinised 
 milk, is set in a refrigerator until ready for use. 
 
 Under some conditions both sterilised and Pasteurised milk form 
 smaller curds than raw milk, although this is not the case with the 
 coagulse formed by gastric juice (Freeman). 
 
 The poor in New York city are now supplied with cheap Pasteur- 
 ised milk through the philanthropy of Mr. Nathan Straus, who in 
 
88 FOODS AND FOOD PREPARATIONS 
 
 1893 opened the first milk depot for dispensing pure milk and Pas- 
 teurised milk, at a cost of but one and a half cent for an eight-ounce 
 bottle. A sterilised nipple is also furnished with each bottle. The 
 bottles have sloping necks, to facilitate cleansing, and spheroidal bot- 
 toms to prevent them from being left standing about uncorked. In 
 an account of this system by Dr. Freeman he states that : 
 
 " In addition to Pasteurised ordinary milk and Pasteurised modi- 
 fied milk, a Pasteurised milk diluted with barley water and sweet- 
 ened with cane sugar, and containing also table salt, has been intro- 
 duced at the suggestion of Dr. Jacobi. The formula used is : 
 
 Table salt ± oz. 
 
 White cane sugar 10 oz. 
 
 Milk 1 gal. 
 
 Water 1 gal. 
 
 " This barley milk will be dispensed in six-ounce bottles." 
 
 3. Humanised Milk. — Humanised milk is really Pasteurised milk 
 but with a permanent alkaline reaction and partial predigestion. 
 Leeds claims the credit for the origin of the idea of this form of milk, 
 and his formula is : 
 
 Milk £ pint. 
 
 Water £ " 
 
 Cream 4 tablespoonfuls. 
 
 Peptogenic milk powder 1 large measure. 
 
 Heat to 160' to 170 F. for ten to twenty minutes. 
 
 Instead of cream, some other' form of fat may be added for invalids, 
 such as olive or cod-liver oil or cacao butter. 
 
 The name " humanised milk " is applied somewhat indefinitely 
 to various preparations of cow's milk in which the attempt is made 
 to approach more nearly the composition of human milk by lessen- 
 ing the casein and increasing the sugar and fat. These prepara- 
 tions are partially predigested, but the pancreatinisation is stopped 
 before it has proceeded far, so that the infant stomach shall still 
 have some work to do. 
 
 Another good mixture designed to resemble human milk is that 
 of Meigs : 
 
 Cream 2 tablespoonfuls. 
 
 Milk 1 tablespoonful. 
 
 Lime water 2 tablespoonfuls. 
 
 Water 3 
 
 Milk sugar . . | teaspoonful. 
 
 4. Modified Milk. Milk Laboratories. — The establishment of milk 
 laboratories having in view the object of modifying cow's milk for 
 infant and invalid feeding has demonstrated the practical value of 
 this work. Such milk is now called " modified milk." The first 
 
PLATE I. 
 
 Centrifugal 
 Separator. 
 
 Sterilizer. 
 Capacity 500 pints. 
 
 Care of Modifying Materials. Aseptic Precautions. 
 
 Milk Room and Coolers for 
 modifying materials. 
 
 Special Sterilizers for 
 returned packages. 
 
 MILK LABORATORY (INTERIOR). 
 (From Paediatrics, by T. M. Rotch, M. D.) 
 
 
ANIMAL FOODS 89 
 
 laboratory founded in Boston during iSo^-'o/}, upon the sugges- 
 tions of Dr. Rotch, completely fed about twelve hundred infants and 
 was patronised by more than one hundred and fifty physicians in its 
 first year. Many similar laboratories have subsequently been estab- 
 lished. The milk is derived from carefully selected animals kept 
 at farms where their food, stabling, drinking water, and pasture are 
 under the scientific supervision of a veterinary surgeon. 
 
 It is now generally acceded that infants thrive better in the long 
 run upon mixed milk derived from several cows than by the exclusive 
 use of milk from a single animal, which is more likely to vary with 
 the condition of the cow at different times ; but it is possible to avoid 
 all variation in milk and keep it at a standard which can be graded to 
 correspond with the increasing age of the infant, by the employ- 
 ment of proper means in the milk laboratories, where milk can be 
 prepared with its ingredients mixed with the accuracy of a medicinal 
 prescription, while its freshness and purity are absolutely insured. 
 If desired also, the milk may be predigested in the laboratory, and 
 sweet whey and other materials derived from fresh milk may be 
 obtained there. 
 
 Physicians are furnished with blank forms upon which they can 
 definitely prescribe the composition of the milk which they wish to 
 order for any individual case. A sample prescription form from the 
 Briarcliff Laboratory is herewith appended : 
 
 
 Per cent. 
 
 
 Remarks. 
 
 Fat 
 
 Milk sugar 
 
 Proteids 
 
 Mineral matter 
 
 
 
 Number of 
 feedings ? 
 
 Amount at 
 
 each feeding? 
 
 Infant's age ? 
 
 Total solids 
 Water 
 
 
 
 IOO.OO 
 
 Infant's weight ? 
 
 Alkalinity. 
 
 Raw. Pasteurised ° F. Sterilised 
 
 Ordered for 
 
 Date. Signature. 
 
 M. D. 
 
 " If the physician does not care to mention the especial per- 
 centage, he can ask for percentages which will correspond to the 
 analysis of human milk, and he can then vary any or all of these 
 percentages later, according to the need of the especial infant pre- 
 scribed for " (Rotch). 
 
 In order to prepare modified milk by Rotch's method it is neces- 
 sary to have: I. Pure cream containing the fat. 2. Pure milk con- 
 
 
90 FOODS AND FOOD PREPARATIONS 
 
 taining the albuminoids and no fat. 3. Distilled water. 4. A 20 
 per-cent solution of milk sugar made fresh daily with distilled water 
 5. Lime water. 
 
 The milk and cream are separated completely by an apparatus 
 made to revolve 6,800 times per minute, so that they may be recom 
 bined in any desired proportion. The resulting cream has an aver- 
 age of 35 per cent of fat, but the percentage may vary between 45 anc 
 18, hence analysis should be made whenever accuracy is essential 
 After separation of the cream the milk is modified according to th( 
 formula prescribed for each case, and Pasteurised. 
 
 Rotch gives the following sample prescriptions for modified mill 
 to be sent by the physician to the laboratory : 
 
 5 (1) A girl 6 years old : duodenal jaundice. 
 
 Fat o . 50 
 
 Milk sugar 6.00 
 
 Albuminoids 4 . 00 
 
 Give 4 ounces every two hours. 
 Send 12 tubes, each 4 ounces ; lime water, ^V- 
 Note. — This patient made a rapid recovery. No medicines were given. 
 
 5 (2) A boy 6 weeks old : healthy. 
 
 Fat 3.00 
 
 Milk sugar 7 . 00 
 
 Albuminoids 1 . 50 
 
 Send 12 tubes, each 2 ounces. 
 Lime water, ^$. 
 Pasteurise at 167 F. 
 
 5 (3) A boy 6 months old : healthy. 
 
 Fat 4 . 00 
 
 Milk sugar 7.00 
 
 Albuminoids 2 . 00 
 
 Send 8 tubes, each 6 ounces. 
 
 Lime water, yq. 
 
 Pasteurise at 167°. 
 
 1$ (4) A girl 4 months old : albuminoid digestion weak. 
 
 Fat 4.00 
 
 Milk sugar 7 . 00 
 
 Albuminoids 0.75 
 
 Send 8 tubes, each 4 ounces. 
 
 Lime water, - 2 V 
 
 Pasteurise at 167 . 
 
 3 (5) A boy 6 months old : sugar digestion weak. 
 
 Fat 3 . 00 
 
 Milk sugar 4.00 
 
 Albuminoids 2 . 00 
 
 Send 8 tubes, each 6 ounces. 
 
 Lime water, ^ ~- 
 
 Pasteurise at 167 . 
 
ANIMAL FOODS 91 
 
 I£ (6) A girl 4 months old : summer diarrhoea. Food has to be sent out of town 
 by express. 
 
 Fat 2 . 00 
 
 . Milk sugar 5 . 00 
 
 Albuminoids 1 . 00 
 
 Send 20 tubes, each 1 ounce and I drachm. 
 At time of each feeding add lime water, 3 drachms. 
 Sterilise at 212 . 
 Note. — In this case the diarrhoea had not been sufficiently studied to determine 
 whether it was putrefactive or fermentative, so that a safe general prescription was 
 sent to begin with. The lime water had to be introduced at each feeding on 
 account of the 212 sterilisation necessitated by the hot weather and the distance 
 to be sent. 
 
 An ingenious measuring glass is recommended by L. Emmet 
 Holt for the home modifying of milk. The glass, which is sold under 
 the name of the " Materna " (Estraus), holds sixteen ounces and has 
 seven panelled sides. On one side is graduated the quantity of 
 separate ingredients of normal milk and on each of the other 
 panels is graduated the ratio of ingredients of milk modified 
 to suit a certain age of infancy. Milk sugar is placed in the 
 bottom of the glass, water is added to a marked level, then, in 
 turn, lime water, cream, and milk. The formulas given are the 
 following (Holt) : 
 
 Formula 
 
 I 
 
 2 
 
 3 
 
 4 
 
 5 
 
 
 6 
 
 Fat 
 
 ■2% 
 
 2i% 
 
 3% 
 
 $J> 
 
 A% 
 
 
 zk% 
 
 Sugar 
 
 6% 
 
 6% 
 
 6% 
 
 7% 
 
 7% 
 
 For this Formula 
 
 34* 
 
 ProteiJs 
 
 0,6% 
 
 o,8# 
 
 i% 
 
 itf 
 
 ■2.% 
 
 6 see special 
 
 instructions 
 
 below. 
 
 2# 
 
 
 3d day to 
 
 2d wk. to 
 
 6th wk. to 
 
 nth wk. 
 
 5th mo. to 
 
 9th mo. to 
 
 
 14th day. 
 
 6th wk. 
 
 nth wk. 
 
 to 5th mo. 
 
 9th month 
 
 12th mo. 
 
 Milk parts 
 
 if 
 
 2 
 
 4* 
 
 6 Milk parts 
 
 94 
 
 Cream 
 
 T JL 
 
 If 
 
 2 
 
 2 
 
 2 Cream 
 
 1 
 
 Lime water " 
 
 
 
 1 
 
 1 
 
 f Barley gruel " 
 
 5* 
 
 Water 
 
 I2| 
 
 Hi 
 
 Hi 
 
 8f 
 
 7\ Gran, sugar " 
 
 i 
 
 Milk sugar " 
 
 1 
 
 
 I 
 
 1 
 
 ii 
 
 
 
 Directions for Formula 6 
 
 Sugar. — In formula 6 granulated sugar should be used instead of milk sugar. 
 Introduce the same into the vessel to the line thus marked. 
 
 Barley Gruel. — In formula 6 barley gruel should be used instead of water and 
 filled to the line thus marked. Barley gruel should be prepared as follows : 
 
 To one tablespoonful of pearl barley (after soaking several hours) add one pint of 
 water, a pinch of salt, and boil for five or six hours, adding water as it boils away. 
 Strain through muslin. Or add : 
 
 One rounded tablespoonful of Robinson's barley flour ; rub up with cold water, and 
 add to one pint of boiling water; cook fifteen minutes, stirring, and strain if lumpy. 
 
 According to Rotch, " certain breeds of cows are better than 
 others for copying human milks." 
 
92 FOODS AND FOOD PREPARATIONS 
 
 List of Breeds best Adapted for Modified Milk, with Analyses (Rotch) 
 
 
 Fat. 
 
 Milk 
 
 sugar. 
 
 Albumi- 
 noids. 
 
 Mineral 
 matter. 
 
 Total solids. 
 
 Water. 
 
 Durham 
 
 Per cent. 
 4.O4 
 4.O9 
 3-89 
 
 2.88 
 4.01 
 3-69 
 
 Per cent. 
 4-34 
 4.32 
 4.4I 
 
 4-33 
 4-36 
 
 4-35 
 
 Per cent. 
 4.17 
 4.04 
 4.OI 
 
 3-99 
 4.06 
 4.O9 
 
 Per cent. 
 0.73 
 O.76 
 
 0.73 
 O.74 
 O.74 
 
 0-73 
 
 Per cent. 
 13.28 
 13.21 
 I3.O4 
 II.94 
 13.17 
 
 12.86 
 
 Per cent. 
 86.72 
 86.79 
 86.96 
 
 88. 06 
 86 83 
 87.14 
 
 Devon 
 
 Ayrshire 
 
 Holstein-Friesian 
 
 American grades 
 
 Common natives 
 
 The Jersey cow may yield more than 6 per cent of fat. 
 
 " The time of the year, the food and care given to the cattle, the 
 month of lactation, and manner of milking — all exert such a profound 
 influence, that the fat mav be lower than 2.5 per cent or as high as 
 8 per cent " (C. E. Woodruff, U. S. A.). 
 
 Many so-called " milk foods " are sold for infant and invalid 
 use. Their object is to furnish a ready-made substitute for fresh 
 milk, which is easy of preparation even by an unintelligent nurse. 
 Generally speaking, the continued use of such foods, especially for 
 young growing infants, is to be condemned whenever fresh milk is 
 obtainable, but in travelling at sea, or wherever good milk is not 
 procurable, and in other emergencies, they may be resorted to with 
 advantage, until more favourable conditions obtain. Analyses of 
 some of the best known of these foods are appended below, and 
 compared with the composition of mother's milk. 
 
 Name of Food. 
 
 Ideal mother's milk. 
 
 Malted milk 
 
 Nestle's milk food.. 
 Carnrick's soluble food 
 Lactopreparata. . . 
 Lactated food. . . . 
 
 Malted milk 
 
 Nestle's milk food. 
 Carnrick's soluble food 
 Lactated food.. . . , 
 Carnrick's soluble food Stutzer. 
 Lactated food " 
 
 Analysed 
 by. 
 
 ISr,*-. 
 
 Rach. 
 
 Leeds. 
 
 4.0046. 
 3.2746, 
 4.5137. 
 '5-9330. 
 
 15.80,63. 
 J7.8028. 
 I2.18 50. 
 4.7238. 
 |3-42;27. 
 J7.7629. 
 5.1728. 
 |6.52 25. 
 
 Dex- 
 trin. 
 
 Starch. 
 
 io.33 35 
 16.09 5. 
 '40. 
 
 137. 
 
 9-35 36. 
 
 4i- 
 
 52. 
 
 Fat. 
 
 Albu- 
 mi- 
 noids. 
 
 23-39 
 6.78 
 
 5-37 
 2.96 
 
 I2.35|i4 
 1.82 13 
 3.30 16 
 1.91 
 
 7-45 
 1.64I11 
 
 5-53JI6 
 2.19 9 
 
 10 
 
 Ash. 
 
 2.44 
 3-90 
 
 1-59 
 3.02 
 3-66 
 2-77 
 3.13 
 
 i-59 
 4.42 
 2.61 
 3.00 
 2.26 
 
 Solubility in 
 water. 
 
 Very soluble. 
 Insoluble. 
 
 Soluble. 
 Soluble. 
 
 Lacto preparata is a preparation of pure selected milk from which 
 the cream has been removed by centrifugal force, and for it is sub- 
 stituted cacao butter, which keeps better and is quite nutritious. 
 Lime water is then added and the mixture is sterilised, evaporated, 
 powdered, and sealed hermetically in cans. 
 
 The other foods of the list above given all contain considerable 
 starch, and will therefore be described in the section upon Prepared 
 Farinaceous Foods. 
 
ANIMAL FOODS 93 
 
 Gustav Gaertner's Mother Milk, according to Theodore Escherich, 
 contains in percentages, albumin, 1.76; cream, 3.0 to 3.5; lactose, 
 2.5 ; ash, 0.35, thus closely approximating the composition of human 
 milk, except that it has less sugar. The fresh cow's milk is mixed 
 with sterilised water and placed in a centrifugal separator to re- 
 move impurities and separate the superfluous casein, without remov- 
 ing the fat, to form proportions more closely resembling those of 
 human milk. The casein curds of this prepared milk are much more 
 flocculent than those of the original cow's milk. By this process the 
 milk also loses a half of the original salts and sugar, but the latter is 
 easily added again when desired. The milk is sealed hermetically 
 in tin cans, in which it keeps fresh for a year or two. 
 
 Milk Derivatives 
 
 The principal foods derived from milk which are in common use 
 are : 
 
 1. Condensed milk. 2. Cream. 3. Butter. 4. Buttermilk. 5. 
 Cheese. 6. Whey. 
 
 1. Condensed Milk. — Condensed milk is prepared by slowly 
 evaporating the water of milk by moderate heat in vacuo to the con- 
 sistence of honey. There are two varieties : the " plain," which is 
 condensed to about one fourth of its bulk and superheated, and to 
 which little or no sugar is added ; a stronger, more condensed sort, 
 with which cane sugar is mixed in excess. Such milk yields from 
 39 to 48 per cent of sugar among its solid ingredients, but some- 
 times as much as 75 per cent is added. A good deal of the Swiss 
 condensed milk sold in market, as well as that made in this country, 
 contains 40 per cent of sugar. 
 
 The sugar prevents fermentation and decomposition, and when 
 condensed milk is put up while hot in hermetically sealed tin cans it 
 will keep fresh for years. It will even remain fresh for several days 
 after a can is opened. It is soluble in water added to any degree of 
 dilution. Condensed milk is largely used for the nourishment of 
 infants, especially among the poorer classes. They thrive upon it 
 for a time, occasionally even better than on raw milk, and it makes 
 them fat, owing to the extra sugar which it contains. It does not 
 constipate, and may be even slightly laxative. But although such 
 babies may appear robust, their flesh is not firm, they develop poorly, 
 are unable to resist disease, and become rhachitic. 
 
 Condensed milk should be diluted ten times for a child a month 
 or two old, and cream should be added in liberal proportion. 
 
 The formula recommended by Starr is : 
 
 Condensed milk 3 j ", 
 
 Cream f § ss. ; 
 
 Hot water f | ijss. 
 
94 FOODS AND FOOD PREPARATIONS 
 
 This milk, when diluted, speedily undergoes lactic-acid fermen- 
 tation and causes diarrhoea and thrush. 
 
 Condensed milk has been used with advantage in the treatment 
 of dysentery (Hiibner) and as a prophylactic against scurvy. It is 
 serviceable on long voyages and expeditions where fresh milk can- 
 not be obtained for use with tea, coffee, etc. 
 
 Unsweetened condensed milk made of fresh Swiss Alpine milk, 
 and sold under various brands in this country, is prepared by evapo- 
 ration by heat sufficiently strong to render the milk aseptic, so that 
 no preservative materials are added. The water is reduced from 
 the normal standard of 88 per cent to about 61 per cent. It is open 
 to the same objections as the use of sterilised milk (see Sterilised 
 Milk, p. 85), but it is better for infants than those forms of condensed 
 milk in which preservation is secured by the addition of too large a 
 proportion of cane sugar. An analysis of one brand of this milk 
 is given by Professor Goodfellow, as follows : 
 
 Water. 61.3 
 
 Casein 9.1 
 
 Albumin .' 1.5 
 
 Fat II. 7 
 
 Lactose 14.3 
 
 Salts (mineral matter) 2.1 
 
 100. o 
 
 Milk may be preserved for some time in hermetically sealed cans 
 or bottles without previous condensation, but a separation of the 
 cream eventually takes place, and butter forms in the can. 
 
 2. Cream. — Cream is the fat of milk, which, by virtue of its light 
 specific gravity, floats to the top of vessels in which milk is allowed 
 to stand for some hours. The globules collect in a yellow layer of 
 varying thickness. The rise of the cream is retarded by coagulation, 
 but favoured by a cool temperature and by richness of the milk. 
 Cream is best obtained by placing the milk in broad, shallow pans. 
 The fatty material is complex, and consists of glycerides of stearic, 
 palmitic, myristic, oleic, butyric, and soluble fatty acids. Churning 
 the milk causes the globules of fat to coalesce in small lumps and 
 form butter. It is a popular fallacy that a little warm water added 
 to milk increases the cream formation. It lessens the specific 
 gravity of the milk and hastens the floating of the globules, but the 
 ultimate quantity of cream is not affected. If the cream falls below 
 5 per cent of the volume of milk, the milk has been watered. The 
 normal average quantity of cream is over 8 or 9 per cent, but 
 there may be above 20 per cent. The breed, age, and feed of 
 the cow have a marked influence upon the quantity of cream. 
 Alderney milk is rich in fat ; longhorns give proportionately more 
 casein. 
 
ANIMAL FOODS 95 
 
 The milk which comes from the cow towards the end of milking 
 contains more cream than that which is first drawn. This fact should 
 be borne in mind by those who use milk drawn direct from the cow 
 into separate small vessels. Afternoon milk is richer than morning- 
 milk in both protein and fat. 
 
 Centrifugal or Separator Cream. — Cream may be separated from 
 milk by centrifugal force. A small and large drum are placed one 
 within the other, leaving a space of a few inches between. The 
 inner drum is made of porous material. It is filled with milk and 
 set in rapid revolution. The lighter cream remains in the inner 
 drum, while the other ingredients are thrown with such violence 
 against the porous wall that they are forced through it into the outer 
 drum. It is claimed that the cream is more thoroughly separated 
 in this manner than when it is allowed to rise on standing, and the 
 process is far more rapid. Separator cream does not remain fresh 
 so long as that obtained by natural means, for it is separated at a 
 temperature favourable to the growth of bacteria. 
 
 Condensed or evaporated cream, which is offered in market, con- 
 sists of about one fourth cream and three fourths other ingredients 
 of milk, the whole milk having been evaporated by machinery. It 
 is therefore a natural product, easily digestible on account of the 
 dilution of the cream with the nitrogenous ingredients of the milk, 
 and, unlike much condensed milk, it is not artificially sweetened. It 
 is sometimes mixed with malt extract. 
 
 Clotted or Devonshire cream is skimmed from heated milk, so that 
 the albumin is coagulated with it. It is warmed over a slow fire not 
 above 150 F. Fothergill wrote, " Devonshire cream is delicious 
 with preserved ginger, while cream and maraschino form a nutritive 
 drink for the affluent consumptive." 
 
 In cooking, suet is sometimes added to replace cream and impart 
 additional colour and flavour to milk. 
 
 Cream is one of the most wholesome and agreeable forms of fat. 
 It is often eaten too rich, and may disagree on that account, whereas, 
 diluted with an equal bulk of water or of lime water, it is well borne. 
 It is an excellent substitute for cod-liver oil in tuberculosis, for, al- 
 though not quite so digestible, most persons prefer to take it. It is 
 an excellent food in tuberculosis and long-continued suppurative dis- 
 eases, such as empyema or tubercular joint diseases. It should be 
 avoided in flatulent dyspepsia, in most forms of gastric disease, 
 obesity, and gallstones. 
 
 It is useful as a substitute for milk when diarrhoea or maras- 
 mus, etc., occurs in infants. It should be considerably diluted when 
 so given. 
 
 The addition of strong liquors to cream lessens its digestibility 
 just as heat does, for alcohol coagulates and toughens the proteid 
 envelopes of the fat globules. 
 
gb FOODS AND FOOD PREPARATIONS 
 
 Ice cream, when very simply made, is nutritious, and may be 
 allowed many patients. It is soothing to inflamed throats and en- 
 joyed by convalescents from fevers, and children who object to milk 
 will often take it. It should be eaten very slowly, so that it may 
 become well warmed in its passage to the stomach ; otherwise it 
 retards digestion. 
 
 3. Butter. — Butter is made from cream by the mechanical rup- 
 ture of the albuminous envelopes which inclose the fat globules. 
 The globules then adhere together in small masses. The rupture 
 is accomplished by churning, and after the butter is of sufficient 
 density, salt in small proportion is added, and the butter is " worked " 
 over with a spatula and frequently washed. 
 
 An average sample of good butter contains: Water, 11.83 P er 
 cent; fat, 82.76 per cent; casein, 0.18 per cent; milk salt, 5.22 per 
 cent (Konig). The fats comprise six neutral varieties, four of which, 
 being volatile, give to it taste and odour (Chevreu). 
 
 The quantity of casein in butter can be roughly estimated by 
 melting a specimen in a test tube, when the casein forms a layer at 
 the bottom. 
 
 Butter should not have less than 0.5 to 2 per cent nor more 
 than 8 per cent of salt added. 
 
 Perfectly fresh butter made without salt is comparatively taste- 
 less and keeps poorly. The decomposition of its nitrogenous ma- 
 terial liberates a ferment which separates fatty acids and glycerin. 
 
 Butter is adulterated by dealers by beating it up with water and 
 by adding other fats, especially suet and oleomargarine. The sophis- 
 tication with water is easily detected by melting, when the sample 
 separates into two layers. 
 
 Fresh butter if kept too long, especially in hot weather, soon 
 becomes rancid, bitter, and unwholesome. 
 
 Butter which contains too much water and too many ingredients 
 other than the fat has not been sufficiently " worked," and is also 
 likely to become rancid and cause violent gastric derangement. 
 Very thorough washing of butter when first made will remove much 
 of its proteid substance and tend to prevent its fermentation ; and 
 fresh butter which has once become rancid may be rendered less so 
 by melting and shaking it in boiling water which is several times re- 
 newed and then pouring it into ice-cold water. It is then called 
 " smalt." The addition of salt to butter in the strength of twenty to 
 twenty-five grammes per kilogramme postpones or prevents the fer- 
 mentation, and sugars or sirups in which the butter may be immersed 
 have the same effect. So also does protecting it from atmospheric 
 air in hermetically sealed jars set in cold water, or simply keeping 
 it under fresh water which is renewed two or three times a day. 
 Sometimes weak solutions of tartaric or acetic acid, three grammes 
 to the litre (Hayem), are employed for this purpose. 
 
PLATE II. 
 
 Butter x 40. 
 
 BUTTERINE X 40. 
 
 ANIMAL FATS, MAGNIFIED. 
 
 {From Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau). 
 
 •MOTO BY CLJFFOKl) RICHARDSON. 
 
ANIMAL FOODS 97 
 
 Pure fresh-butter fat is not crystalline, but old or rancid butter 
 fat becomes so. 
 
 Strong-tasting butter is not necessarily unwholesome, for the 
 flavour may have been derived from the cow having fed upon dead 
 leaves or turnips, and butter is even more sensitive than milk in 
 transmitting unpleasant flavours. 
 
 Butter will not support life for any length of time when taken 
 alone, although 100 grains furnish 837 calories. Carnivora fed 
 upon an exclusive diet of meat and fat do not grow fat, there- 
 fore the original Banting treatment for obesity (see Obesity) has 
 been modified by Ebstein and others by the free addition of butter 
 to the diet. Taken in connection with other foods, however, butter 
 is a highly digestible and nutritious food, and is often fattening, and 
 it has been wittily said that " if bread is the staff of life, butter is its 
 golden head." 
 
 In weak stomachs the digestion of butter is improved by spread- 
 ing it thoroughly in thin layers upon bread, or allowing it to soak 
 into hot toast. It is thus prevented from floating about in the man- 
 ner which coats the food and walls of the stomach and retards gastric 
 secretion (Brunton). Most persons eat about an ounce a day of but- 
 ter, but many eat double that quantity. Its annual production in the 
 United States exceeds one billion pounds. 
 
 The use of oleomargarine and butterine as substitutes for butter 
 are described under the heading Fats and Oils. 
 
 4. Buttermilk. — Buttermilk is the residual milk left after churn- 
 ing and removing the fat. It is wholesome and diuretic, and makes 
 a capital beverage for those patients who fancy its peculiar sour 
 taste. It contains albumin and finely coagulated casein, salts, water, 
 and sugar, which is largely converted into lactic acid. Its fuel value 
 is about that of skimmed milk — 165 calories per pint — and its com- 
 position resembles skimmed milk, but it contains a little less pro- 
 tein and carbohydrate and a little more fat. A pint of it contains 
 as much nourishment as two ounces of bread or a large potato 
 (A. C. True). It should be drunk fresh, for it soon decomposes. 
 Some patients can digest it who are unable to take ordinary milk. 
 In those disorders in which the digestion of protein and fats is poor 
 it may be better borne than milk. 
 
 It is of especial value in chronic gastric catarrh with atrophy of 
 the gastric glands (Eulenburg). A " buttermilk cure " is sometimes 
 practised after the manner of the " whey cure " (see Dietetic 
 " Cures "), but buttermilk cannot long be depended upon as an ex- 
 clusive diet. 
 
 5. Cheese. — Cheese is the casein of milk separated by rennet, 
 which includes some of the fat and salts, but the potassium salts are 
 removed by the rennet. There are many varieties, prepared in dif- 
 ferent ways, but the two chief classes are hard cheeses and soft 
 
9 8 
 
 FOODS AND FOOD PREPARATIONS 
 
 cheeses, the former being pressed and salted. Cheese forms a highly 
 nutritious food and an important article of commerce. In countries 
 where meat is scarce and dear the peasantry consume large quanti- 
 ties to supply the nitrogenous element of their diet, and, weight for 
 weight, cheese contains about twice as much protein as meat 
 (Parkes). They use for this purpose the heavier, less highly fla- 
 voured cheeses. The wealthy classes eat cheese more as a condi- 
 ment, taken after meals, and therefore they require higher flavoured 
 varieties, which please the palate and excite the secretion of gastric 
 juice. Eaten in moderation, such cheeses are an aid to digestion. 
 Taken with milk, cheese tends to reduce the size of the coagulae in 
 the stomach. Old " poor " cheese — 1. e., cheese made without fat, 
 consisting of almost pure casein — is difficult to masticate thor- 
 oughly, and is slowly dissolved in the gastric juice, hence it is slowly 
 digested. It may act as a gastric irritant and be hurried into the 
 intestine to excite indigestion there. Such cheese may be rendered 
 more digestible by cooking it after grating with bicarbonate of potas- 
 sium in the proportion of a quarter of an ounce to the pound of 
 cheese. Cheese which retains some fat is friable, light, and easy of 
 digestion. 
 
 About 250,000,000 pounds of cheese are annually produced in the 
 United States alone, and much so-called foreign cheese is produced 
 in this country. 
 
 The kinds of cheese differ somewhat in composition, but in gen- 
 eral they may be said to contain from 35 to 55 per cent of water and 
 from 10 to 20 per cent of fats, 20 to 30 per cent of casein, and about 
 6 per cent of salts. 
 
 Cheese is rich in fat or in flavour according as it is made from 
 whole or skimmed milk. Cream cheese contains about yy per cent 
 of fat, and the highly flavoured Roquefort, Edamer, Cheshire, and 
 Emmenthaler, or Schweizer cheeses have a similar quantity, and are 
 nutritive when they can be digested. 
 
 Bauer's analysis of cream cheese places the fats much lower, and 
 the casein is also at a minimum. 
 
 Bauer s Analysis of Cream Cheese 
 
 
 Water. 
 
 Nitrogenous 
 matter. 
 
 Fat. 
 
 Extractives. 
 
 Ash- 
 
 Cream cheese 
 
 35.75 
 46.82 
 48.02 
 
 7 .i6 
 
 27.62 
 32.65 
 
 30.43 
 
 20.54 
 
 8 41 
 
 2-53 
 2.97 
 6.80 
 
 4 13 
 3-05 
 4.12 
 
 Skimmed milk 
 
 Cheese is usually prepared from sweet milk. The coagulation is 
 accomplished in a few minutes by the addition of the ferment rennin 
 with gentle heat (120 F.). The heat secures firmer coagulation. 
 Casein may also be coagulated by acids. A little salt is added ; the 
 curd is strongly pressed in a mould, and the expressed fluid is called 
 
ANIMAL FOODS 99 
 
 " whey/' The curd is then salted and dried on the surface by fre- 
 quent turning in the air. The harder cheeses are made under higher 
 temperature and pressure. Cheese is kept for a time to " ripen," by 
 fermentation or decomposition. If the decomposition goes too far, 
 it develops leucin and tyrosin. The casein may become soluble in 
 water, producing soda albuminate and peptones. The " riper " a 
 cheese the greater is its value as a condiment. 
 
 During the ripening volatile fatty acids are evolved from the fatty 
 matter present, which occasion the odour and flavour. The casein 
 also undergoes change, and is partially converted into fat (Foster). 
 It may putrefy and evolve ammonia, or even become poisonous. 
 Ripening, when not carried too far, makes cheese more friable, and 
 hence more digestible. 
 
 Cream cheese is fresh, and usually not ripened, but Neuchatel is 
 ripened. 
 
 Pot cheese is eaten fresh after the whey has been expressed. It 
 contains : Water, 60.27 P er cent I casein, 24.84 per cent ; fat, 7.33 per 
 cent ; ash, 4.02 per cent ; milk sugar and lactic acid, 3.54 per cent. 
 
 The quality of cheese depends upon the richness of the milk in 
 fat. In the richest cheeses made of whole milk, such as Stilton, 
 double Gloucester, Gorgonzola, and Roquefort, cream is added. 
 Single Gloucester, American, and similar cheeses are made from 
 milk from which the cream has been removed. Dutch, Suffolk, and 
 Parmesan cheeses are also made from skimmed milk, and are " poor." 
 Being nearly pure casein, they are hard to digest in bulk. These 
 latter varieties keep well, and become hard enough to be grated. 
 Fat separates the flocculi of casein and makes cheeses soft, friable, 
 and rich, but they sooner decay. 
 
 The tw r o soft cheeses most used in this country are Camembert 
 and Brie. 
 
 Camembert is a cheese made of whole milk, which is very care- 
 fully dried under regulated temperature. It requires three or four 
 weeks to ripen. This cheese, as well as the following variety, is 
 made in St. Lawrence County, Pa., as well as in Europe. 
 
 Brie cheeses are manufactured in three grades of richness, accord- 
 ing to whether the milk is whole, partly skimmed, or skimmed. 
 
 Roquefort is a hard cheese made in the department of Aveyron 
 from goat's milk, partly skimmed and coagulated with rennin. The 
 curd is then pressed for half a day, dried for ten or twelve days, and 
 ripened in caves. This cheese is streaked with bluish lines, which are 
 formed by the addition of a mould which grows on stale rye bread. 
 This cheese is also made along the shores of the Great Lakes in this 
 country, where conditions of climate, pasturage, and water favour its 
 production. 
 
 Gruyere was originally a hard Swiss cheese, but is now made also 
 in France and elsewhere. It is dry, aerated with large holes, and it 
 
 L.ofC. 
 
IOO FOODS AND FOOD PREPARATIONS 
 
 can be crumbled. It is manufactured in three grades, according to 
 the degree of skimming of the milk, and the curd is cooked a short 
 time before it is pressed. It has a somewhat saltish taste. 
 
 Gorgonzola is a Piedmontese cheese made with hot and cold curds 
 from two milkings, which do not perfectly unite, but which form 
 minute interstices m which a green mould called " parsley " grows 
 and imparts a high flavour (Clark). The curd is hung in hempen 
 cloths to ferment. It is well salted. 
 
 In the United States much of the cheese manufactured is of the 
 common sort called " American cheddar," but Neuchatel, Stilton, 
 pineapple, and other more highly flavoured varieties are also exten- 
 sively produced. " Swiss " cheese is made in Ohio and Wisconsin. 
 An imitation cheese is also prepared from a mixture of one part lard 
 and two or three parts milk, mixed or emulsionised at 140 F. This 
 emulsion is then added with buttermilk to skimmed milk, so that the 
 finished product contains about 14 per cent of lard (Caldwell). 
 
 Toasted cheese is one of the most indigestible articles of diet, 
 unless the cheese is new, " poor,"' and cut thin. " Welch rarebits " 
 are notoriously difficult of digestion, although highly nutritious when 
 absorbed. It is an old saying of such cheese that it is " gold in the 
 morning but lead at night." 
 
 Certain low organisms, moulds, fungi, etc., flourish in cheese and 
 make it very irritant to the stomach. Such are the Aspergillus glauctts 
 and S porendoneum casci, both of which give a red colour, the cheese 
 mite (A cams domesticus) and the maggots of a fly (Piophilia casei). 
 Bad cheese has been known to produce poisonous symptoms (see 
 Ptomaine Poisoning) resembling those of poisoning by sausage 
 meat. 
 
 Plasmon is an albumin food made from milk from which the fat 
 has been removed. It is practically a dried form of casein. It is 
 a tasteless, odourless, white, dry powder, soluble in water. It may 
 be given every hour or two in teaspoonful doses in ten tablespoonfuls 
 of water, or with an equal quantity of sugar an ounce of plasmon 
 may be stirred into half a pint of boiling milk (C. Virchow). It may 
 be added to broths and gruels, or to such starchy foods as boiled 
 rice or mashed potatoes. This food contains over 90 per cent of 
 pure protein in very digestible form. Plasmon biscuits and a plas- 
 mon chocolate are also manufactured. 
 
 Nutrose or casein-sodium is a form of milk casein which may 
 be added in half-ounce doses to broths, gruels, or cocoa, in which it 
 is soluble. It contains, according to Bruno Oppler, about 90 per 
 cent of pure proteid. It furnishes a small volume of feces when this 
 is desirable after operations upon the intestines. 
 
 Sanose is an albuminous food consisting of 80 per cent of pow- 
 dered casein and 20 per cent of egg albumin. It is a white, odour- 
 less, tasteless powder forming an emulsion in water. It may be given 
 
ANIMAL FOODS IOI 
 
 in milk, cocoa, purees, or soups. From two to six tablespoonfuls 
 may be given daily. 
 
 6. Whey. — Whey is the residuum of milk from which the casein 
 and fat have been removed as cheese by the action of rennin or other- 
 wise. It contains, in addition to water, salts, especially of potassium, 
 a little lactalbumin, and lactose. It is apt to turn sour, but is fairly 
 digestible even then, and its taste may be disguised by the addition 
 of nutmeg and sugar. 
 
 It makes a palatable, mildly diuretic drink, which is enjoyed by 
 invalids. In Europe several " whey cures " have been established 
 for the treatment of renal disease, dropsical affections, etc., but 
 whey is not in any case a specific, and its dietetic value is greatly 
 overrated. 
 
 Yeo gives the following simple directions for the preparation of 
 whey for invalids : Boil a pint of milk with one to two teaspoonfuls 
 of lemon juice, strain in muslin, and express all fluid from the curd. 
 Break the curd up first, and much fat and some finely divided casein 
 will go into whey. Add beef tea or milk juice, or tgg yolk in hot 
 water. 
 
 Eggs 
 
 About nine billion eggs are produced annually in the United 
 States (Clark). Eggs contain all the ingredients necessary to sup- 
 port life and develop the organism. Like milk, they constitute a 
 complete food, for out of an egg the entire structure of the bird — 
 its bones, nerves, muscles, viscera, and on some birds even feathers 
 — are developed previous to hatching. The inner portion of the 
 shell is dissolved by phosphoric acid to furnish phosphates for the 
 bones. 
 
 The average weight of a hen's egg, according to Bauer, is 50 
 grammes, or about 2 ounces, divided as follows : Shell, 7 ; white, 27 ; 
 yolk, 16 grammes. The eggs of pullets are smaller than those of 
 old hens. 
 
 Composition of a Hens Egg (Lawes and Gilbert) 
 
 Fresh weight 1.8 ounce. 
 
 Dry weight o . 45 
 
 Fat o. 198 
 
 Mineral matter o . 025 
 
 Nitrogen o . 036 
 
 Carbon o 275 
 
 Or in percentage : 
 
 Water 70 . 00 per cent. 
 
 Dry matter 30 . 00 " 
 
 100.00 per cent. 
 
 Nitrogen 2 . 00 per cent. 
 
 Carbon I7«5 2 
 
102 FOODS AND FOOD PREPARATIONS 
 
 In artificial digestion experiments it is customary to estimate 
 about four hundred grains of albumin to the egg. 
 
 Hens' eggs principally are used for food, but the eggs of ducks, 
 geese, and guinea-fowl are also eaten, and occasionally those of such 
 wild birds as the plover and sea birds. Along the Texan coast the 
 eggs of gulls, terns, and herons were formerly gathered for food, 
 those of the gull and murre on the Farallone Islands off the coast of 
 California, and those of the laughing gull off the eastern coast of 
 Virginia. Terrapin eggs are eaten with the flesh of the animal, and 
 various forms of fish eggs are esteemed for food, as those of the 
 sturgeon (caviare) and shad (roe). 
 
 The shell of a hen's egg weighs about one hundred grains. Its 
 colour bears no relation to the nutrient value of the egg, but white 
 shells are heavier than brown. An egg consists approximately of — 
 
 Shell — ii parts Carbonate of lime. 
 
 Yolk — 32 parts : Proteid ( vitellin) 15.7 per cent. 
 
 Fat 33-3 ' 
 
 Ash 1.1 ;< 
 
 Water 49.5 
 
 Total calories *. 1,705 
 
 White— 57 parts : Proteid 12.3 per cent. 
 
 Fat 2 
 
 Ash 6 " 
 
 Water 36. 2 
 
 Total calories , 250 
 
 The yolk is very complex. Besides the proteid vitellin, it con- 
 tains three fats, colouring matter, nuclein, lecithin, and salts of iron, 
 calcium, magnesium, and potassium. 
 
 Egg albumin is not pure, but consists of four albuminoid and 
 mucoid bodies, the chief of which is ovalbumin, together with a trace 
 of carbohydrate. The phosphorus equivalent is 0.03 per cent phos- 
 phoric acid (C. F. Langworthy), whereas that of trie yolk exceeds 
 1 per cent. 
 
 If the absorption of eggs from the intestine is delayed, decom- 
 position ensues with production of sulphuretted hydrogen and am- 
 monia, which cause considerable gastro-enteric disorder. The yolk 
 of egg is particularly responsible for this. It is therefore a matter 
 of great importance to serve only eggs which are absolutely fresh 
 to invalids. No egg having an odour of stale, old straw should ever 
 be offered. There are two simple methods by which the nurse may 
 test the freshness of an egg : 
 
 1. Hold the egg between the hands so that the light of a candle 
 shines through it. If fresh, it is more transparent in the centre ; if 
 stale, at the ends. 
 
 2. Make a solution of two ounces of common salt in a pint of 
 
ANIMAL FOODS IO3 
 
 water. An egg one day old will sink in this solution, but will not 
 quite reach the bottom ; an egg three days old will barely float be- 
 neath the surface, and an egg a fortnight old will float above the 
 surface, only partially dipping beneath it (Siebel). This difference 
 is due in part to loss of water, which after ten days equals 1.60 per 
 cent; after twenty days, 3.16 per cent; and after thirty days, 5 per 
 cent. It is also due in part to development of gases of putre- 
 faction. 
 
 With some persons eggs have a slight aphrodisiac effect, and 
 they also promote costiveness. They should not be eaten in the 
 following diseases : Flatulent dyspepsia, gastric dilatation, or any 
 form of severe gastric derangement, severe acute Bright's disease. 
 The flavour of eggs is modified by the food of the hen, those 
 from hens fed on nitrogenous food instead of carbohydrates have 
 poor odour and flavour and small yolks. An excess of onions 
 in the hen's diet imparts the strong odour and taste of the vege- 
 table to the eggs, about fifteen days after such food has been eaten. 
 Eggs packed in stale bran or straw, or kept near decaying apples, 
 acquire a bad flavour. Micro-organisms may penetrate the egg- 
 shells and give rise to fermentation and decomposition. 
 
 Raw Eggs. — Whole raw eggs are very popular in dietetics at 
 present, and they are often prescribed when a nutritious, highly con- 
 centrated diet is desired, and in cases of tuberculosis, some forms of 
 anaemia, and various wasting diseases ; sometimes from eight to ten 
 or twelve are given daily if they can be digested. They may be 
 advantageously combined for such purposes with milk and salt or 
 cod-liver oil, meat broths, soups, and purees. Beaten white of egg 
 may be added to coffee, cocoa, wine, cream, or sweetened water. 
 
 Eggnog is very nutritious, and is extensively prescribed in some 
 non-febrile diseases, especially for the forced alimentation of phthisis 
 and melancholia, and there are occasional cases of bilious habit in 
 which eggs can only be digested when beaten 'in wine, but the com- 
 bination of egg, milk, and sugar with alcohol, which constitutes 
 eggnog, may produce nausea and vomiting in a feeble stomach, 
 particularly in fever. For this reason whole eggs are unfit for 
 fever patients, and if eggs are employed at all for them, the whites 
 only should be used, prepared in the manner described in the fol- 
 lowing section : 
 
 Egg Albumin, when eaten raw or almost raw and properly diluted 
 with milk or water, is well absorbed. It may also be predigested, 
 and it should be flavoured with lemon juice, or sherry or other wine, 
 coffee, cocoa, or cream, and sweetened water; otherwise it is taste- 
 less and disagreeable, and but few can continue to eat it in any con- 
 siderable quantity. (See Receipts, Preparations of Eggs.) When 
 the fresh white egg albumin is beaten it incloses bubbles of air 
 which expand by heat when the albumin is mixed with dough, mak- 
 9 
 
104 FOODS AND FOOD PREPARATIONS 
 
 ing it porous, as in the case of sponge-cake. Old eggs lose this 
 quality of frothiness. 
 
 Egg albumin is used by Ewald to prepare fresh albuminate of 
 iron. He adds two tablespoonfuls of a solution of one part of white 
 of egg in two of water, to a teaspoonful of a 2- or 3-per-cent solution 
 of ferric chloride. To be taken through a tube. 
 
 Protogen is an uncoagulable form of egg albumin prepared by 
 action of formalin. It may be given either by mouth or in nutrient 
 enema. 
 
 The Cooking of Eggs. — Albumin, or the " white " of an egg f is 
 altered physically but not chemically by processes of cooking. At 
 about 1 34 F. delicate fibrillar of coagulated albuminous material be- 
 gin to stretch through the substance, and they increase with the 
 temperature up to 160 F. The fibrillar are so numerous that the 
 entire mass is coagulated, but is still of a soft or gelatinous con- 
 sistence. 
 
 It has been observed by Tarchnoff that the coagulum thus formed 
 in the eggs of birds which, like the chick, are hatched with feathers, 
 becomes white and opaque, whereas that of the eggs of birds which, 
 like the plover, are hatched without feathers, is more transparent. 
 If the coagulated albumin is heated still further, it becomes more 
 and more dense, hard, dry, and brittle. When heated beyond the 
 boiling point, or 212° F., it forms a very tenacious, gluey substance, 
 which can be used as a cement for mending broken china. 
 
 Eggs baked in puddings or in any other manner form one of 
 the most insoluble varieties of albumin possible. A raw egg is ordi- 
 narily digested in the stomach in one and a half hour, but a baked 
 egg requires from three and a half to four hours. 
 
 The principle involved in this account of the cooking of an egg 
 is further illustrated by the process of overcooking beefsteak. When 
 strong heat is too long applied in the process of broiling, the albumin 
 of the meat becomes dried, shrivelled, and comparatively tasteless ; 
 and eggs cooked for persons with delicate digestions, instead of being 
 " boiled " in water at 212 F., should be placed in water at a tem- 
 perature between 170 and 180 F., and immersed for fully ten min- 
 utes, at the end of which time they will be found of a uniform 
 gelatinous consistence, very palatable, and not too tough to be 
 readily acted upon by the gastric juice. If a cooking thermometer 
 is not at hand, the water may be previously brought to the boiling 
 point and then set aside, when in a moment or two it will cool to 
 the proper temperature. This should be a little above the coagula- 
 tion point of the egg albumin (134 F.), because the process of rais- 
 ing the temperature of the egg is a slow one, and the water loses 
 heat in warming the egg (Williams). Eggs cooked in this manner 
 are found to have the yolks more firmly coagulated than the white, 
 which remains quite tender. A practical way of attaining the above 
 
ANIMAL FOODS 105 
 
 result is to pour a quart of recently boiled water over two eggs in 
 a bowl and let them stand for ten or twelve minutes. 
 
 Another excellent way to cook an egg, as suggested by Henry, 
 is to immerse a teacup in boiling water until it becomes thoroughly 
 heated. It is then removed and the egg is broken and dropped 
 into it, and the cup may be wrapped in a cloth. Sufficient heat is 
 retained by it to cook the egg without water and remove any raw 
 taste. 
 
 The yolk really coagulates at a lower temperature than the white, 
 although as eggs are commonly cooked it does not have an oppor- 
 tunity to coagulate first. The former is composed of albumin and 
 casein with fat (Lehmann). In the ordinary rapid cooking of eggs 
 in boiling water the white is firmly set before there is time for the 
 temperature of the interior of the egg to be thoroughly raised, and 
 consequently the yolk is softer than the white. The shell of the egg 
 facilitates the process of slow cooking of the albumin by protecting 
 the interior and preventing the escape of the contents by solution, 
 just as in the cooking of fish or flesh in water, the latter should 
 be hot enough to immediately form an external coagulum of albu- 
 min sufficiently dense to prevent the diffusion of albuminous mate- 
 rial and salts into the water; 
 
 Custards composed largely of eggs, although unfit for active 
 fever, are very useful adjuncts to a convalescent dietary in recovery 
 from typhoid fever or other acute diseases. 
 
 In the making of omelettes and " scrambled " eggs the white is 
 thoroughly mixed with the yolk, and the egg is more digestible than 
 when fried or cooked so much that the albumin is hard. 
 
 Preservation of Eggs. — Eggs decompose from the admission of 
 germs through their porous shells. To prevent this occurrence it 
 is necessary to protect the eggs from contact with air. When first 
 laid, eggs have a protective mucilaginous coating, which is, how- 
 ever, removed by washing. They may be coated with varnish, 
 paraffin, tin foil, butter, glycerin, vaseline, or any fat or oil not liable 
 to become rancid. A 2- or 3-per-cent solution of salicylic acid may 
 be added to the oil. Packing in sawdust or bran also excludes the 
 air to a slight extent. Lime with cream of tartar preserves eggs, but 
 alters their taste. 
 
 According to C. F. Langworthy (U. S. Department of Agricul- 
 ture Bulletin No. 128, 1901) the best preservative substance is a 10- 
 per-cent solution of water-glass, in which eggs will keep fresh for 
 three and one half months. Eggs also preserve their freshness for 
 as much as a year in cold storage at 30 to 40 F. Eggs so stored 
 must be turned twice a week to prevent gravitation of the yolk, 
 causing its adhesion to the shell. 
 
 Eggs are also preserved by drying, canning, and similar processes, 
 when designed for shipment upon long voyages. 
 
106 FOODS AND FOOD PREPARATIONS 
 
 Evaporated or desiccated eggs are dried in vacuo or otherwise by 
 currents of warm air. Salt or sugar may be added, and the eggs are 
 ground. Such eggs keep well, and are often used by bakers. 
 
 Meats 
 
 The Consumption of Meat. — The universal consumption of meat 
 by civilised man is of more recent origin than is generally supposed. 
 McCulloch states (Statistical Account of the British Empire, vol. ii, 
 p. 502) that " so late as 1763 the slaughter of bullocks for the supply 
 of the public markets was a thing wholly unknown even in Glasgow, 
 though the city had then a population of thirty thousand." 
 
 In the past decade or two the consumption of meat has increased 
 enormously, especially in England, owing to the development of 
 cheap refrigerating processes, canning, and increased facilities of 
 transportation of live cattle. The beef from Australian and New 
 Zealand cattle is obtainable in London, and that of Texan cattle in 
 New York in a state of perfection and cheapness which far exceeds 
 that of animals raised close at hand. In London during the last 
 twenty years of the nineteenth century the per capita consumption of 
 meat rose from 112 to 122 pounds. There is a popular belief that 
 the eating of meat increases both bodily vigour and mental capacity, 
 and that a man fed upon animal food is livelier, keener, and stronger 
 than the exclusive vegetarian. (See Animal and Vegetable Foods 
 Compared, p. 33.) This comparison may not hold in all cases, nor 
 with all people and tribes of man — as, for example, the Japanese and 
 many African tribes — but it applies very well to those who have to 
 meet the exigencies of advanced civilisation. Liebig, in extolling 
 the advantages of a liberal meat diet, wrote : " It is certain that three 
 men, one of whom has had a full meal of meat and bread, the second 
 cheese or salt fish, and the third potatoes, regard a difficulty which 
 presents itself from entirely different points of view." 
 
 It is true, however, that too much meat is eaten by many persons 
 for maintenance of the best health. The annual per capita consump- 
 tion of meat has almost doubled during the past half century. It is 
 estimated in pounds as follows: In the United States, 120; England, 
 105; France, 74; Germany, 69. 
 
 Very large quantities of meat — much more than is necessary for 
 sustenance — are absorbed when eaten, although a few undigested 
 muscle fibres may appear in the stools. 
 
 A meat diet, if long continued, tends to produce scurvy, and the 
 absence of meat favours the occurrence of anaemia in many persons. 
 In general, those diseases in which an exclusive meat diet, or a diet 
 composed almost exclusively of animal food, with perhaps a mini- 
 mum of dry bread, is found beneficial, are the following: Flatulent 
 dyspepsia, chronic gastritis and gastric catarrh and dilatation, dia- 
 
ANIMAL FOODS 
 
 I07 
 
 betes, intestinal dyspepsia, phosphaturia, obesity, and some cases of 
 chronic dysentery. Meat should also enter largely into the diet of 
 consumptives and anaemic subjects. 
 
 It is well to prohibit the consumption of meat in fevers, acute 
 and severe chronic Bright's disease, gout and rheumatism, and to 
 reduce it in lithaemia and oxaluria. 
 
 Composition of Meats. — Meat from any animal is composed of 
 muscular fibres, but it necessarily contains those structures which 
 were intimately associated with them, such as connective tissues, 
 blood vessels, nerves, and lymphatic vessels, and more or less adipose 
 tissue. Meat which is very fat contains comparatively little water, 
 as well as less nitrogenous matter than lean meat. 
 
 In one hundred parts of flesh there are, according to Schloss- 
 berger and v. Bibra : 
 
 Water 
 
 Solids 
 
 Soluble albumin, colouring matter . . 
 
 Glutin 
 
 Alcoholic extract 
 
 Fats 
 
 Insoluble albumin, blood vessels, etc 
 
 Ox. 
 
 77-50 
 
 22.50 
 
 2.20 
 
 1.30 
 
 1.50 
 
 i7-5o 
 
 Pig. 
 
 78.30 
 
 21.70 
 
 2.40 
 
 0.80 
 
 1.70 
 
 Man. 
 
 Fowl. 
 
 Carp. 
 
 74-45 
 
 77-30 
 
 79.78 
 
 25-55 
 
 22.7 
 
 20.22 
 
 1-93 
 
 3-0 
 
 2-35 
 
 2.07 
 
 1.2 
 
 I.98 
 
 3-7i 
 
 1.4 
 
 3-47 
 
 2.30 
 
 
 I. II 
 
 15-54 
 
 16.5 
 
 13-31 
 
 Composition of Various Meats 
 
 Constituents. 
 
 Nitrogenous matters 
 
 Fat 
 
 Carbohydrates 
 
 Saline matters 
 
 Non-nitrogenised organic matters, 
 
 and loss 
 
 Water 
 
 Total 
 
 Lean 
 beef 
 
 (Pavy). 
 
 Fat 
 beef 
 
 (Pavy). 
 
 Lean 
 
 mutton 
 (Pavy). 
 
 Fat 
 mutton 
 (Pavy). 
 
 19-3 
 3.6 
 
 I4.8 
 29.8 
 
 18.3 
 4.9 
 
 12,4 
 31- 1 
 
 5-i 
 
 4.4 
 
 4.8 
 
 3-5 
 
 72.0 
 
 5I-0 
 
 72.O 
 
 53-o 
 
 100. 
 
 IOO. O 
 
 100.0 
 
 100. 
 
 Veal 
 (Pavy). 
 
 16.5 
 
 15.8 
 
 4-7 
 63.O 
 
 Constituents. 
 
 Nitrogenous matters 
 
 Fat 
 
 Carbohydrates 
 
 Saline matters 
 
 Non-nitrogenised organic matters, 
 
 and loss 
 
 Water 
 
 Total 
 
 Fat 
 
 pork 
 
 (Pavy). 
 
 Dried 
 
 bacon 
 
 (Pavy). 
 
 Calves' 
 liver 
 
 (Payen). 
 
 Fois 
 gras 
 
 (Payen). 
 
 9.8 
 48.9 
 
 2-3 
 
 39-o 
 
 8.8 
 
 73-3 
 2.9 
 
 15.0 
 
 20.I0 
 5.58 
 0-45 
 1-54 
 
 72.33 
 
 13-75 
 
 54-57 
 
 6,40 
 
 2.58 
 
 20.70 
 
 100. 
 
 100. 
 
 IOO.OO 
 
 100.00 : 
 
 Sheep's 
 kidneys 
 (Payen). 
 
 I7.250 
 2.125 
 
 I. IOO 
 
 1.325 
 78.200 
 
108 FOODS AND FOOD PREPARATIONS 
 
 Raw Meats. — -There is a prevalent fashion of prescribing raw- 
 meat, and in some diseases, such as dysentery or chronic gas- 
 tritis, it is useful, but it should not be given with the idea that it 
 possesses any special curative virtue from the fact of being raw. 
 Beef, mutton, and ham are all eaten in this condition. Meat is dis- 
 tasteful to most persons in this state and soon palls upon the appe- 
 tite, and may excite positive loathing. There is a natural aversion 
 to raw flesh among even the lowest tribes of man, who only consume 
 their meat raw from excessive hunger or when fire is unobtainable. 
 Even the primitive Australian savage cooks his reptiles and worms. 
 Raw meat has no advantage either in digestibility or nutrient power 
 over moderately cooked or " underdone " meat. Some danger has 
 been attributed to eating raw meat on account of the possibility of 
 acquiring intestinal worms through it, but the fear of this is much 
 exaggerated. 
 
 On the other band, meat is easily altered and made innutritious 
 by prolonged cooking. Overdone meat is indigestible and tasteless. 
 
 If meat is too long boiled it becomes insipid and useless as an 
 aliment, and the resulting soup is not a full substitute for it. Meat 
 should never be cooked during rigor mortis. 
 
 Hall and Kane both declared that in their arctic experience 
 fresh raw meat was a preventive of scurvy, but that cooked meat 
 was not. 
 
 Digestibility of Meats. — Among the circumstances which affect 
 the digestibility and nutrient power of meats are the age at which 
 the animals eaten were killed, and the care bestowed upon them in 
 feeding, shelter, and transportation. Animals which have been 
 underfed, ill-treated, and worried yield very inferior meat. 
 
 Almost all meat is tougher immediately after killing, and im- 
 proves on being kept for a day or two. Violent exercise is believed 
 to increase the tenderness of the meat of hunted animals. 
 
 In general, the flesh of young is more digestible than that of old 
 animals, provided they are not still suckling. 
 
 It would be convenient if meats and animal foods of all kinds 
 could be arranged in a table of comparative digestibility, but such 
 tables are necessarily inaccurate, if not actually misleading, owing 
 to the great variations produced by the character of the particular 
 samples of food used, by the time and manner of cooking, by the 
 condition of the digestive organs, and by personal idiosyncrasy. No 
 two tables of this kind given by different authors are found to agree 
 in all respects. 
 
 The following table is offered as an average of the ease of diges- 
 tibility of animal foods, the time required for the completion of gas- 
 tric digestion being the chief standard, but some foods may be well 
 enough digested although they require half an hour or so longer time 
 than others. 
 
ANIMAL FOODS IO9 
 
 Table of Comparative Digestibility {commencing with the Most Digestible, 
 and ending with the Least Digestible of Meats and Other Common Ani- 
 mal Foods) 
 
 Oysters. 
 
 Soft-cooked eggs. 
 Sweetbread. 
 
 White fish, boiled or broiled, such as 
 bluefish, shad, red snapper, weakfish, smelt. 
 Chicken, boiled or broiled. 
 Lean roast beef or beefsteak. 
 Eggs, scrambled, omelette. 
 Mutton, roasted or boiled. 
 Squab, partridge. 
 Bacon (crisp). 
 
 Roast fowl, chicken, capon, turkey. 
 Tripe, brains, liver. 
 
 - Roast lamb. 
 ' Chops, mutton or lamb. 
 
 Corned beef. 
 
 Veal. 
 
 Ham. 
 
 Duck, snipe, venison, rabbit, and other 
 game. 
 
 Salmon, mackerel, herring. 
 
 Roast goose. 
 
 Lobsters and crabs. 
 
 Pork. 
 
 Smoked, dried, or pickled fish and 
 meats in general. 
 
 The table given below is published by E. Jessen as the result of 
 giving test meals of single articles of food. The stomach was first 
 cleansed and emptied by siphonage, then a hundred grains of meat 
 were introduced with eight ounces of water. Samples of the di- 
 gested stomach contents were from time to time withdrawn, and the 
 complete disappearance of all muscular fibre when examined by the 
 microscope occurred as follows : 
 
 Beef, raw, chopped fine 2 hours. 
 
 Beef, half cooked i\ " 
 
 Beef, well cooked 3 " 
 
 Beef, thoroughly roasted 4 '' 
 
 Mutton, raw 2 " 
 
 Veal, cooked i\ n 
 
 Pork, cooked 3 " 
 
 These estimates fall somewhat below those of other writers, and 
 for comparison he gives the time for digestion of six hundred cubic 
 centimetres of raw cow's and goat's milk as three and a half hours, 
 and that of boiled milk as four hours, which is too long. 
 
 Beef. — The composition of beef varies with the feeding of the 
 animal. A young steer from two and a half to five years old fur- 
 nishes the best meat. If the animal is lean the meat may yield from 
 70 to 75 per cent of water and about 20 per cent of nitrogenous 
 material, furnishing about 415 calories per pound, with 2 or 3 per 
 cent of fat ; but if very fat when killed, the percentage of both water 
 and nitrogenous material is considerably reduced, while that of the 
 fat may be as high as 25 per cent, or even more. As a general aver- 
 age, one third of beef is nutritious material, the remainder is water 
 and bone. 
 
 Beef fat is composed of glycerides of fatty acids. It melts at 
 from 41 ° to 50 C. Stearic and palmitic acids are present in the 
 proportion of three to one of oleic acid. 
 
110 FOODS AND FOOD PREPARATIONS 
 
 The equivalent of beef is sometimes stated in terms of other 
 foods. A pound of lean beef is believed to equal in nutrient value 
 two and a half pints of milk, half a pound of bread, and about three 
 eggs, but these are only approximate figures. 
 
 Fresh beef can be eaten longer continuously than any other kind 
 of meat. In this respect it resembles bread and rice. Attempts 
 have sometimes been made on wagers to eat quail or partridge three 
 times a day consecutively for a month, but disgust is sure to follow 
 after a week or two, no matter how much such food is varied in the 
 cooking, and by the end of a month it may excite extreme loathing, 
 and even nausea and vomiting. 
 
 Chipped beef is prepared, like corned beef, by pickling for a 
 month, when it is smoked for two days and dried for a fortnight, 
 after which it is sliced thin by machinery and is ready for packing. 
 
 Beef Preparations for the Sick. — Beef is so important a food for 
 well and sick alike that many attempts have been made to improve 
 its digestibility for the latter. 
 
 Most of these efforts are aimed at concentrating the meat by re- 
 moving all indigestible connective-tissue fibre, the muscle sheaths, 
 sarcolemma, and blood vessels. 
 
 In some cases the process of concentration is carried still further 
 and water is driven off by evaporation, or some of the active prin- 
 ciples of the meat are extracted and condensed. Sometimes the 
 meat is predigested. Different meats may be prepared in these ways, 
 but the best lean beef free from coarse fibre is usually preferred. 
 
 It is impossible within the limits of this work to even name all 
 the meat extracts, powders, etc., that have been produced, but a 
 few of the typical ones which are most in use will be described below. 
 
 It was long ago shown by Schiff that many fluid substances, such 
 as meat extract, soups, peptones, and even vegetable purees when 
 taken at the commencement of a meal, on being absorbed into the 
 blood, favour the flow of gastric juice. This is true also of peptones 
 injected into the rectum, so the effect is not wholly due to local stim- 
 ulation of the inner surface of the stomach. 
 
 Much attention has of late been given to the predigestion of 
 meat, and especially to the production of albumoses, which are more 
 soluble and assimilable than undigested meat albumin, and which are 
 said to possess greater nutritive property than peptones. 
 
 The beef extracts made in this country usually have a less dis- 
 agreeable taste and odour, and are lighter in colour than those made 
 of South or Central American beef. 
 
 In general, about three grammes of meat extract constitute a 
 good soup ration, and such preparations are often valuable for addi- 
 tion to invalid soups and broths when thickened with eggs, rice, sago, 
 pearl barley, macaroni, ground toast, etc. 
 
 The preparations of meat for the sick are both solid and fluid. 
 
ANIMAL FOODS III 
 
 Solid Meat Preparations. — Scraped meat is best made from tender 
 beefsteak, broiled for a few minutes over a brisk fire, but rare roast 
 beef or mutton chops may be used. With a dull knife or an iron 
 spoon the pulp is scraped out. The indigestible and less nutritious 
 connective-tissue sheaths of the muscle fasciculi are broken and left 
 behind, while the fibres themselves (or their myosin) are obtained 
 in the form of a soft unirritating mass which is readily acted upon 
 by the gastric juice. The pulp may be run through a sieve. It is 
 then salted, and it may be made into little balls and browned just 
 before eating. This is done by placing the balls on a hot frying pan, 
 which is not greasy, and turning them over so that the outside be- 
 comes well seared. They should then be set aside on a cooler part 
 of the stove or oven and allowed to remain until the raw red colour 
 of the interior turns slightly to drab. 
 
 Some patients prefer to eat the meat lightly cooked, spread as 
 a sandwich between thin slices of bread and butter. This meat 
 may be fed to infants in their second year, and the meat balls and 
 sandwiches are invaluable in the treatment of chronic gastritis, dila- 
 tation of the stomach, typhoid convalescence, and other affections. 
 
 Mosquera's beef meal is made by digesting fresh tender lean beef 
 with pineapple juice until the muscle fibre is almost completely con- 
 verted into peptones. After digestion the preparation is desiccated. 
 Chittenden's analysis of this meal shows it to contain 90 per cent of 
 nutriment, 13 per cent of which is fat and 7 7 per cent is protein. Of 
 the latter, almost half consists of albumoses and peptones fit for 
 prompt absorption. The remaining portion is believed to be in a 
 condition in which it is more digestible than plain meat. The beef 
 meal is tasteless and odourless, which are decided advantages, as 
 it can be flavoured according to preference. It should be salted, 
 and it may be added to broths and soups. D. D. Stewart advises 
 its use with equal parts of sugar and cocoa. This mixture is added 
 to hot mlik. 
 
 Mosquera's beef jelly is made in a similar manner, but is evaporated 
 to the consistence of a solid extract. Analysed by Ludwig, it was 
 found to contain only 3 per cent of insoluble material, and of the 
 soluble portion 53 per cent consists of albuminoids which were nearly 
 all peptones. It is of pleasant taste and odour, and is highly nutri- 
 tious. Dissolved in boiling water, it may be given alone with a pinch 
 of salt or added to re-enforce any broth, gruel, consomme, beaten 
 eggs, or milk. The beef jelly is even more digestible than the meal. 
 It is sometimes combined with cocoa. 
 
 The beef meal and jelly are both excellent for use in gastritis, 
 gastric catarrh, ulcer, and carcinoma, and many forms of enfeebled 
 assimilation. 
 
 Bcnger's peptonised beef jelly is another good beef preparation 
 much in vogue in England for the same purposes as Mosquera's 
 
112 FOODS AND FOOD PREPARATIONS 
 
 preparations. It may be taken cold or dissolved in hot water as a 
 concentrated beef tea, representing a large amount of meat fibre. It 
 is a useful stimulant for the aged who have feeble digestive power. 
 It may be given to them in teaspoonful doses. 
 
 Tropon is a condensed proteid preparation of granular consist- 
 ence, said to contain 89 per cent of protein (Kleine). It is tasteless, 
 insoluble, and may be added to milk, broth, rice, or other food, and 
 several drachms may be given daily. 
 
 Darby's fluid meat is a moist extract which has a strong meaty 
 taste. It can be eaten spread on thin bread and butter or cracker, 
 or it may be dissolved in hot water. 
 
 Powdered beef is made as follows : 
 
 Chop lean beef into small pieces, dry on a water bath or in an 
 oven with a slow fire, and powder in a coffee mill or with a machine 
 constructed for the purpose. Do not overdry. This powder can be 
 mixed with hot water or any form of soup, milk, chocolate, grog, or 
 punch. In process of drying, which occupies from five to twenty- 
 four hours, the meat loses rather more than four fifths of its weight 
 (Huggard). 
 
 Dujardin-Beaumetz's " grog de la pondre de viande " is prepared as 
 follows : Take two tablespoonfuls of meat powder, three dessert- 
 spoonfuls of essence or sirup of rum punch, and add milk enough to 
 make quite fluid. In this way he claims that the equivalent of three 
 and a half pounds of meat may be given daily. 
 
 Debove, Dujardin-Beaumetz, and Peiper strongly recommend 
 powdered meat for forced alimentation (see Suralimentation in 
 Phthisis) to replace feeding by the stomach tube. 
 
 Professor Finkler, of Bonn, has made a proteid food which he 
 claims — 
 
 " 1. Has the greatest amount of albumin possible up to 90 per 
 cent. 
 
 " 2. Is digestible up to almost its entire weight. 
 
 " 3. Can be made equal in amount for each day. 
 
 " 4. Keeps well indefinitely in all climates. 
 
 " 5. Its flavour and taste do not interfere with that of other food. 
 
 " 6. Its price is the lowest possible." 
 
 This food consists of the nitrogenous parts of meat, fish, and 
 legumes. It is odourless, tasteless, and forms a light yellow granular 
 powder. Konig's analysis of this food follows : 
 
 Protein. 89.87 per cent. 
 
 Water 8.89 " 
 
 Ash 1.24 " 
 
 Fat 0.20 " 
 
 Beef blood. — Dried beef blood, powdered, has been recommended 
 by Regnard and others for use by addition to soups and various 
 
ANIMAL FOODS II3 
 
 forms of foods. The taste and odour of dried blood is disagreeable, 
 and the idea of eating it in any form is repugnant to most persons. 
 
 It has also been used for rectal injection, but I have always ob- 
 served it to cake inside the bowel, and there is very little evidence 
 that it is absorbed at all. 
 
 Meat lozenges are prepared by Mason as a convenient and port- 
 able form of condensed food. Soup lozenges and capsules are also 
 made. 
 
 Beef peptonoids are prepared in powdered form by several manu- 
 facturers ; one variety contains predigested and sterilised beef, milk, 
 and gluten. 
 
 Rudisch's beef peptone (or sarco-peptone) is a dark-brown, semi- 
 solid paste, having a strong meaty odour and flavour. One pound 
 of this preparation represents eight pounds of fresh lean beef. In 
 addition to the extractive materials which are obtainable in ordinary 
 beef tea, it contains predigested proteids in a form suited for prompt 
 absorption. It may be eaten spread upon crackers or toast, or it 
 may be dissolved in chocolate or almost any suitable fluid, either 
 hot or cold. It is given in doses varying from half a teaspoonful 
 or less for young children, up to a teaspoonful or tablespoonful for 
 adults. If its flavour when dissolved in water alone is disagreeable 
 or becomes tiresome, it may be altered by giving it ice cold, or by 
 the addition of salt, celery salt, pepper, or Worcestershire sauce, and 
 for children it may be sweetened with sugar. It is often added to 
 milk, sherry, eggnog, gluten, and farinaceous gruels of oatmeal, rice, 
 or arrowroot, or it may be used to re-enforce soups, broths, and 
 jellies. 
 
 The Maltine Company furnish a similar preparation which con- 
 tains 70 per cent of albuminous material with phosphates, fat, and 
 carbohydrates. 
 
 The South American beef extract is a predigested preparation 
 which, by the analysis of Kemmerich, contains, with other proteid 
 matter, a large proportion — over 27 per cent — of albumoses and 
 peptones, ready for immediate absorption. 
 
 Somatose is a granular predigested meat powder which, accord- 
 ing to analysis reported by Hildebrandt, contains 90 per cent of albu- 
 moses (deutero- and hetero-albumose), and is free from peptones. It 
 is of a yellowish colour, amorphous, finely granular, having but faint 
 taste and odour. Dissolved in water, it forms a clear, light yellow or 
 brownish solution, almost tasteless. It is not precipitated by heat 
 or by strong acids. The latter, in fact, redissolve a precipitate 
 which is formed by very weak acids. It is claimed for it that it is 
 eight times as nutritious as meat, but estimates of this kind applied 
 to artificial foods are always fallacious. Of course for an invalid 
 who cannot digest any meat such preparations are indefinitely 
 " stronger," but for those who can assimilate meat they are much 
 
114 FOODS AND FOOD PREPARATIONS 
 
 weaker. Somatose can be injected in hypodermic solution without 
 local irritation. It may be given as fine powder with bread and 
 butter or spread upon toast. It is also administered like similar 
 preparations in milk, mucilage, soup, cocoa, or coffee. When mixed 
 with such substances it should be first stirred into a thin paste with 
 an equal volume of the fluid and then added to the remainder. 
 
 It is well tolerated by irritable stomachs and is speedily absorbed, 
 and it possesses the advantage of having a less disagreeable taste 
 than many preparations of meat. 
 
 Eskay's Food is an albuminised food suitable for emergency 
 feeding of infants and for adults with disordered stomach or bowels. 
 
 Fluid Meat Preparations. — Beef juice contains serum, lymph, and 
 blood. It is prepared as follows : A tender, thick, juicy beefsteak is 
 broiled for several minutes over a quick fire so as to coagulate the 
 outside and retain the juice well within. It is then cut into small 
 pieces an inch or two in diameter and squeezed in a common lemon 
 squeezer or, better, in a meat press, which is sold in hardware shops 
 for this special purpose. The juice is salted, and for adults a little 
 pepper may be added. It is best served warm, but if preferred it may 
 be eaten frozen. This preparation is quite nutritious, although less 
 so than scraped beef. 
 
 When beef is chopped and squeezed under great pressure, juice is 
 obtained from it in the proportion of two hundred and thirty grammes 
 per one thousand of meat, but only about 6 percent is albumin (Bauer). 
 
 Fresh beef juice is serviceable for feeding in many cases of severe 
 gastric disturbance with vomiting and pain ; also in typhoid fever, 
 and for feeding infants at the end of the first and in the second year. 
 From one to three tablespoonfuls may be given at once, and it forms 
 a good introduction for the stomach to solid food. It is usually 
 much to be preferred to any of the foregoing extracts and other 
 preparations. If desired, it may be pancreatinised like milk (see 
 Pancreatinised Milk, p. 79). 
 
 Beef Tea. — The nutritive strength of beef tea has formed a sub- 
 ject for much discussion. The assertion is often made that it is a 
 comparatively useless preparation, and it is said that a pint of it con- 
 tains scarcely a quarter of an ounce of anything. Hassell estimates 
 that fourteen pounds and a half of beef would be required to make 
 enough tea to counterbalance the daily nitrogenous waste of one man. 
 If rightly made, however, it may be nutritious, although the quan- 
 tity of albuminous material which can be dissolved in it at any time 
 is much less than that which exists in a similar volume of milk or in 
 an egg. The preparation of beef tea should be conducted as follows : 
 Tender lean raw beef is chopped into small pieces about a quarter of 
 an inch in diameter and macerated in cold water for five or six hours. 
 The water is to be added in the proportion of a pint to a pound of 
 lean beef; ten drops of hydrochloric acid are then added, and the 
 
ANIMAL FOODS 11$ 
 
 solution is gradually heated up to 160 F., but not more, for from 
 fifteen to thirty minutes. This is best accomplished by placing the 
 vessel in a larger outer vessel of boiling water. The water of the 
 outer vessel communicates its heat to the inner one, but the contents 
 of the latter does not boil because the evaporation from its surface 
 prevents its temperature from rising to that of the outside water, 
 which is nearer the fire. Various forms of water baths, which the 
 French call " bain marie " or milk scalders, are sold which are con- 
 veniently adapted for the process of making beef tea. 
 
 The prolonged soaking of meat in cold water dissolves its mineral 
 ingredients — chiefly chlorides and sulphates of potassium, and also 
 extractives, principally creatin and creatinin and some lactid acid 
 derived from the muscle fibres. There may also be a little albumin 
 present, but the albumin of meat or muscle is very sparingly soluble 
 in simple aqueous solutions, and hence it does not diffuse out readily 
 into the water, but the addition of hydrochloric acid converts the in- 
 soluble myosin into an acid albumin called syntonin, which is soluble 
 in water. 
 
 In making beef tea, more or less fat is apt to be derived from the 
 meat which floats upon the surface and presents a very unappetising 
 appearance. This should always be skimmed or strained, and if it 
 collects on cooling, the operation can be repeated. A crust of bread 
 dipped beneath the surface will remove the supernatant layer of fat. 
 The materials which are present in beef tea prepared in this manner 
 are not very nutritious, but they are mildly stimulating to the mucous 
 membrane of the stomach and to the nervous system, and it is prob- 
 able that they are for the most part absorbed directly from the gastric 
 mucous membrane without passing beyond into the intestine. 
 
 It is always desirable to give special attention to the proper fla- 
 vouring of food for fever patients. In cases where a fluid diet is 
 necessitated for many days in succession, much depends upon the 
 willingness of the patient to take the food offered him, and a dread 
 of too frequently recurring intervals of feeding and the positive 
 dislike which the monotonous taste of certain meat preparations 
 begets, react unfavourably upon the digestion. It is advisable to 
 consult the individual taste of patients in this regard, and when they 
 positively assert that they cannot take beef tea or bouillon or meat 
 extracts in any form, their opposition may often be overcome by 
 adding the expressed juice of some fresh vegetables of which they 
 are fond. Carrots, turnips, celery, parsnips, and endives may be 
 boiled alone or with an aromatic herb, such as parsley or green mint, 
 and afterwards chopped fine and their juice expressed by squeez- 
 ing them in a muslin bag. Such juices added to beef tea and broth 
 impart an altogether different flavour, which may be varied from time 
 to time by changing the vegetables (Yeo). 
 
 The total quantity of albuminous material which can be obtained 
 
Il6 FOODS AND FOOD PREPARATIONS 
 
 in the manner above described in a reasonable bulk of fluid is very 
 little, but in febrile conditions it is usually good for the patient to 
 ingest abundant water, and there is no objection to part of the fluid 
 being taken in the form of beef tea. On the other hand, if patients 
 have absolute anorexia they are soon wearied by the effort of swal- 
 lowing, and it is preferable to give nitrogenous food in some more 
 concentrated form. 
 
 In fever, albuminous and gelatinous solutions aid in maintaining 
 strength and diminish the tendency to exhaustion, and for this pur- 
 pose the chief value of beef tea and beef essences is found to ex- 
 ist, rather than for furnishing additional substance to the tissues. 
 
 The objections to the use of beef tea are that its preparation re- 
 quires time and care, and the taste soon becomes monotonous. It 
 may be advantageously given, however, with vegetable extracts or 
 beaten eggs, or gelatin may be put in to stiffen the mass into a jelly, 
 which, when properly seasoned, is palatable. It may also be thick- 
 ened with broken crackers, and with the addition of a little butter, 
 pepper, and salt, it becomes much more nutritious ; or sago, arrow- 
 root, or chocolate may be mixed with it. 
 
 For infants the tea may be made weaker than for adults by using 
 half a pound of lean rump steak to the pint of water. 
 
 Bouillon, or the French pot au feu, is of little more value as an ali- 
 ment or heat producer than beef tea or extractum carnis. It is a 
 good vehicle for giving beaten or dropped eggs, flour, etc. It stim- 
 ulates the nerves, but in a much less degree than alcohol. It has the 
 advantage over the latter and over condiments that it is never poi- 
 sonous. A good meat puree may be made by adding a tablespoon- 
 ful of scraped beef to three or four tablespoonfuls of bouillon, warm- 
 ing over a brisk fire until the meat turns of a faint drab colour, and 
 seasoning with pepper and salt or a little butter. 
 
 Beef broth is agreeable to invalids, but on the whole it is less nu- 
 tritive than that made from chicken, veal, or mutton. As ordinarily 
 made, it contains, besides salts and extractives, -J per cent each of fat 
 and albumin and i per cent of gelatin. 
 
 Liebig's extract of meat, or extractum carnis, consists of the 
 flavouring extractive matters such as kreatin, isolin, decomposable 
 haematin, and salts. Some of these substances are excrementitious, 
 and on this account Masterman compares it to urine, although it 
 contains less urea. 
 
 A pound of mutton is represented by two fifths of an ounce of 
 the extract. It contains no albumin or fibrin, and has in all but 2 
 per cent of solids, hence its nutritive power is practically nil, but when 
 regarded as a stimulant and so used, it removes fatigue, strengthens 
 the action of the heart and nervous system, and improves the func- 
 tional activity of the stomach, and in this manner aids the digestion 
 of foods. There is no occasion for taking it in large quantities, and 
 
ANIMAL FOODS 117 
 
 when this has been done, symptoms of slight ptomaine poisoning 
 have been observed, such as heaviness and stupor (Yeo). The ex- 
 tract has the advantage of keeping for years without decomposition, 
 and it has been found that sometimes in cases of shock, especially 
 after wounds received on the battlefield, its stimulant action has 
 been considered almost equal to that of alcohol, and, bulk for bulk, 
 it is certainly greater. 
 
 Johnson's fluid beef is a digestible preparation, somewhat less dis- 
 agreeable in taste than many extracts of meat. 
 
 Valentine's meat juice is a much-used preparation which resembles 
 Liebig's somewhat in its properties. 
 
 Valentine's meat juice is a clear fluid of a deep claret-colour, hav- 
 ing a meaty odour and strong meaty taste. It is prescribed in doses 
 of one half to two teaspoonfuls, diluted in eight times its bulk of 
 cold water, or it may be mixed with cracked ice. Its taste, which is 
 disagreeable to many patients, is easily disguised by the addition of 
 half a tumblerful of milk, or it may be mixed with light, farinaceous 
 gruels (after they have cooled to 130 F.), or used to re-enforce soups 
 and broths or cod-liver oil. Like Liebig's extract, it may be given 
 by the rectum. An ounce of this preparation is said to represent 
 the concentrated pure juice of two pounds of the best lean beef or 
 the condensed essence of three fourths of a pint of natural expressed 
 beef juice. Among other ingredients it contains haemoglobin and 
 some albumin. It keeps well in all climates when tightly corked. 
 It should not be diluted with hot water, strong liquors, or acid medi- 
 cines, as these substances alter it and lessen its value. It may be 
 given in champagne and in tea which is not too hot. 
 
 Bovinine is the concentrated expressed juice of raw lean beef ob- 
 tained without use of heat or acid. It is claimed that each ounce 
 represents nearly one pound of beef, that it contains 26 per cent 
 of coagulable albumin, and that it keeps well without decomposition 
 owing to the addition of glycerin and alcohol. It is said to contain 
 Ggg albumin also. It may be given per os in doses of a teaspoonful 
 or more, or in ounce doses with pancreatin for rectal injection. Not 
 being predigested, it may be pancreatinised like milk just before its 
 administration in cases where it is desirable to give absolute rest to 
 an irritable or ulcerated stomach. 
 
 Bovinine has been used topically for injection around indolent 
 ulcers with the idea of improving local nutrition, but it is doubtful 
 whether this procedure is of any value. 
 
 Beef Peptones. — There are innumerable fluid preparations of pep- 
 tonised beef which are recommended for invalid consumption ; but, 
 as a rule, they are not so good as those which are freshly made by 
 the addition of pancreatin powder, although their use saves time and 
 trouble. They may be sometimes employed to tide over an emer- 
 gency after a severe operation or collapse from haemorrhage, un- 
 
n8 
 
 FOODS AND FOOD PREPARATIONS 
 
 controllable emesis, etc. The use of peptones for invalid foods is 
 open to the objection that after a short time they excite disgust, 
 and may cause vomiting and diarrhoea. The more complete the 
 conversion of albumin into peptone the more bitter it becomes. 
 
 Voit, Politzer, Gerlach, and others maintain that true peptone 
 possesses little if any nutritive power, and that the albumoses can 
 be directly absorbed from the alimentary canal without further fer- 
 mentation into peptones. 
 
 Of the numerous commercial preparations sold under the general 
 names of peptones, peptonoids, predigested meat extracts, etc., those 
 have proved the most nutritious which, in reality, contain the least 
 peptone, and the most albumose. 
 
 Bread and beef peptone, or panopeptone, is a preparation in which 
 wheat starch and beef are both predigested and preserved in sound 
 sherry. It may be taken cold in doses of one to four teaspoonfuls 
 iced, or with carbonic-acid water, or wines, but it should not be 
 mixed with milk or other foods. Beef peptonoids are also mixed 
 with predigested milk and gluten. 
 
 Summary. — Most of these preparations are given in doses of 
 one or two tablespoonfuls once in four hours. Usually they are 
 tired of soon, and do not support life long, for, beyond the means 
 employed of condensation of food by evaporation of water and com- 
 pression, it is not possible to " concentrate " nourishment very much. 
 Making food assimilable and more useful is another matter from 
 concentrating it in the sense that it can be made to support an able- 
 bodied man and supply him with energy for a day's work, for ex- 
 ample, of mountain climbing. 
 
 Neither does such predigested aliment represent concentration 
 for an invalid ; the bulk of food given is certainly reduced, and its 
 assimilation may be improved, but it does not convey into the body 
 any phenomenal quantity of latent force units or of heat units. It 
 is important to understand this fact ; otherwise serious misconcep- 
 tions arise as to the actual amount of nutrition which a patient fed 
 exclusively on peptonoids and similar food preparations is receiving. 
 
 The following analyses illustrate the comparative composition of 
 some of the preceding preparations as given by Chester : 
 
 Composition of Meat Extracts 
 (Albert H. Chester.) 
 
 
 Water. 
 
 Organic 
 matter. 
 
 Ash. 
 
 Soluble 
 albumin. 
 
 Alcoholic 
 extract. 
 
 
 18.27 
 40.65 
 37. CO 
 41 .20 
 
 54-40 
 
 58.48 
 
 39-35 
 55-65 
 50.40 
 31.84 
 
 23-25 
 19.50 
 
 7-35 
 8.40 
 
 13-75 
 
 O.05 
 LIT 
 I.IO 
 I.17 
 0.44 
 
 44.II 
 I3.I8 
 10.13 
 
 15-93 
 26.32 
 
 Benger's extract of beef 
 
 Johnston's fluid beef 
 
 
animal foods u9 
 
 Various Meats 
 
 Beef tongue is a tender form of meat, but it contains rather too 
 much fat to agree well with delicate stomachs. 
 
 Veal. — Veal, especially when obtained from animals killed too 
 young, is usually tough, pale, dry, and indigestible ; but when the 
 animals are slaughtered at the right age the meat is sometimes 
 tender, and is regarded by many as nutritious. It differs consider- 
 ably from beef in flavour, and contains more gelatin. Veal broth 
 is nutritious, and affords a wholesome variety in the dietary for the 
 sick. When too much is given it may excite diarrhoea. Veal is 
 much more used for invalids in Germany than elsewhere, although it 
 figures less conspicuously in hospital dietaries there now than for- 
 merly. Bauer declares it to be more digestible than beef, but Pavy 
 says, referring to both veal and lamb, " they are meats that it is 
 desirable to avoid, generally speaking, in case of dyspepsia," and 
 this opinion is prevalent in America as well as in England. Veal 
 contains more water and less fat and protein than ox flesh. 
 
 Mutton. — Mutton is rated as more digestible than beef by Eng- 
 lish writers upon dietetics. That can hardly be said to be the case 
 in this country, where the quality of beef has been so much im- 
 proved of late years, and where average mutton is not so tender as 
 in England. For example, Balfour writes in his work upon the 
 Senile Heart (1894) : " We also recommend meat with short fibre, 
 such as chicken, rabbit, game, mutton, or well-grown lamb, in prefer- 
 ence to such meats as beef, whose fibres are long and tough." Fat 
 mutton is richer in fat than beef, and is certainly less digestible than 
 lean beef. 
 
 Undoubtedly tough mutton is quite as difficult of digestion as 
 tough beef, and it is harder to obtain it tender. Mutton fat contains 
 a larger percentage of stearic acid, which makes it firmer and less 
 digestible than beef fat. Fat mutton is more likely to disagree with 
 those whose digestion is enfeebled. When properly assimilated after 
 digestion, mutton possesses equal nutrient value with beef. 
 
 Mutton should not be eaten until the sheep is at least three years 
 old, and the best English mutton is obtained from animals which are 
 six years of age. Mutton broth is wholesome and suitable for the 
 sick. It may be given in typhoid and other fevers. It is somewhat 
 constipating. 
 
 Lamb. — Lamb, when very tender and of just the right age, is 
 quite as digestible as beef or mutton, but the flesh contains too large 
 a proportion of fat — more than is present in veal. Good lamb is ex- 
 pensive, and, on account of the uncertainty of the character of the 
 meat, it is not usually to be recommended for invalids. 
 
 Venison. — Venison is a tender meat with short fibres, which is 
 very digestible when obtained from young deer, but it is regarded as 
 
120 FOODS AND FOOD PREPARATIONS 
 
 somewhat stimulating to the stomach, and it is often eaten when 
 aged to a degree which, while some think it improves the flavour, 
 unfits it for dyspeptics. The meat corresponds very closely in chemi- 
 cal composition to lean beef. 
 
 Pork is a tender-fibred meat, but it is notoriously indigestible 
 on account of the high percentage of fat present, which may exceed 
 37 per cent, or considerably more than the quantity of its nitro- 
 genous material. Pork ribs may have as much as 42 per cent of fat. 
 The fat is composed chiefly of palmitic and oleic glycerides. 
 
 Ham and Bacon. — Bacon is much more digestible than pork, and 
 ham occupies an intermediate position. " On an average, 100 
 grammes of ham give 30 of albuminates and 32 of fat ; the salt ranges 
 between 7 and 10 per cent " (Bauer). 
 
 In Germany, and especially at Carlsbad and other mineral springs, 
 ham- is much prescribed in invalid dietaries. It is often given 
 scraped or " rasped." Bauer says (Dietary of the Sick, p. 91) : " The 
 flesh of the hog seems to be better adapted for smoking than that 
 of other animals, and long experience compels us to recognise 
 smoked ham as one of the wholesomest forms of meat. Whether 
 boiled or eaten raw, it seems, as a rule, to be more easily digested 
 by weak organs than almost any other." An opposite view is preva- 
 lent in England and America, where it is less used for the sick. So 
 distinguished a dietitian as Pavy omits mention of it in his book 
 upon Food and Dietetics. Ham is much more digestible when thor- 
 oughly boiled, cut thin, and eaten cold. It should not be fried for 
 invalids. Hot ham fat is very indigestible. 
 
 If cut thin and cooked crisp, fat bacon is friable and easily 
 broken into small particles during digestion. It can often be eaten 
 by dyspeptics, and forms an excellent variety of fatty food for con- 
 sumptives. According to Letheby, prime bacon should not lose 
 over one tenth of its weight by boiling, and ham should lose less. 
 It furnishes ample body heat, and is a valuable ingredient of the 
 army emergency ration. In the ordinary ration of armies or in- 
 stitutions it proves less monotonous than corned beef or boiled 
 beef. Besides its food value, its presence in the ration makes it 
 possible to use various foods which could not otherwise be as easily 
 cooked. When our troops in the Philippines were deprived of bacon 
 in their ration, it was found that they were spending their wages to 
 buy lard for frying. 
 
 Horseflesh is a nutritious meat for those who are not fastidious. 
 It is consumed in large quantities by the poor in France (where over 
 5,000 tons are eaten annually in Paris alone), and to some extent 
 in Denmark, Sweden, Germany, and Austria. It has never found 
 favour in England or the United States, and most of the horse- 
 flesh butchered in this country is canned for consumption by for- 
 eigners. 
 
ANIMAL FOODS 121 
 
 Rabbit has white meat, and Belgian hare meat is partially white, 
 but they are not proper invalid foods. 
 
 Fowl. — Chicken is among the most digestible of meats for inva- 
 lids, whether cooked by broiling, roasting, or boiling. The white 
 meat is more easily digested than the dark, although it differs but 
 slightly in chemical composition. Dark meat contains more ex- 
 tractives and a little more nitrogenous material than white meat. The 
 breast of chicken may be given to a typhoid convalescent or a patient 
 recovering from any severe illness before beef and mutton are 
 allowed. Chicken broth is almost universally liked, and when 
 thickened with rice, and sometimes with an egg, it forms a highly 
 desirable invalid food. 
 
 Turkey and capon are somewhat less digestible than chicken, the 
 meat being of tougher fibre. 
 
 Young pigeons are quite digestible, and the breast of a squab may 
 be given to a convalescent from fever before other meat is allowed. 
 
 Tame ducks and geese are indigestible unless quite young and 
 tender, on account of containing too much fat. Goose meat may 
 sometimes hold over 40 per cent of fat, with which it is thoroughly 
 infiltrated. 
 
 Game, such as the flesh of partridge, grouse, woodcock, snipe, 
 prairie chicken, etc., is by many persons preferred when it is " high " 
 — that is, when it has been kept long enough for putrefactive changes 
 to occur. These may originate in the meat itself or in the viscera 
 which have not been removed and from which the odour and flavour 
 of commencing putrefaction are derived, and penetrate the meat. 
 When the meat itself is not perfectly fresh it may produce violent 
 gastro-intestinal disorder, but many persons with good digestive 
 organs are not disturbed by the consumption of such food in modera- 
 tion, provided it is well cooked. The process of cooking disinfects 
 it by heat. The fat of old birds is too strongly flavoured, and their 
 meat is tough. Young birds are digestible if properly cooked. 
 
 Animal Viscera. — Animal viscera are eaten to some extent in this 
 country, and some of them are digestible, although none are as nutri- 
 tious as good meat, and they contain but little nitrogen. With the 
 exception of sweetbread, and in some cases the thyroid gland, they 
 should not be given to the sick. 
 
 Sweetbread is most useful in the invalid dietary. It consists of the 
 pancreas of the calf, called by butchers " stomach sweetbread " to 
 distinguish it from the thymus gland of the same animal, called also 
 the " neck " or " throat sweetbread." Either gland is tender and 
 digestible, the thymus somewhat more so than the pancreas, which 
 has larger, more " stringy " blood vessels. 
 
 The thyroid gland has been lately shown to possess remarkable 
 power in regulating disordered nutrition in cases of myxcedema, 
 chronic skin diseases, etc. It is usually given as a powdered extract 
 
122 FOODS AND FOOD PREPARATIONS 
 
 in five-grain doses, but it is sometimes cooked fresh and eaten as a 
 food. 
 
 Tripe, made from the third stomach of the cow, when tender and 
 well cooked, is easy to digest, although somewhat too fat. It con- 
 tains about 1 6 per cent of fat and 13 per cent of albuminoids — 
 rather more than most viscera. 
 
 The heart is sometimes eaten, but the meat is tough and unde- 
 sirable. 
 
 Liver and kidneys are eaten more than any other viscera. If 
 cooked too long they become very hard and tough. Calf's liver is 
 always better flavoured and more tender if the animal has had fresh 
 milk for food and not boiled skimmed milk and slops. Tender liver 
 is more easily digested than kidney, and is fairly nutritious. It 
 should not be allowed diabetics. These foods are often fried or 
 stewed in rich sauces or " devilled," all of which are indigestible 
 modes of cooking. 
 
 Brains are fairly digestible, but not nutritious ; they contain too 
 much fat and cholesterin for invalids. 
 
 Blood has sometimes been used as a fluid food. At one time 
 there was a fashion among consumptives of going to the abattoirs 
 to drink it warm, in the belief that it had some specific curative 
 value for tuberculosis. This, however, is not the case, and it 
 nauseates most persons to taste it, if not to look at it. 
 
 Isinglass— Gelatin 
 
 Isinglass is derived from the membrane of the swimming blad- 
 der of the sturgeon, but that of other fishes is occasionally used. 
 It is not very soluble in the crude state, but is hygroscopic and 
 swells very much in cold water. It dissolves in boiling water, and 
 when the water is evaporated again hardens. 
 
 Gelatin. — Gelatin is a substance the potential energy of which 
 is calculated as being even more than that of some fats and albu- 
 minates, yet in the body it is very inferior in the production of force. 
 It is obtained from bones, ligaments, and other connective tissues. 
 
 It is a curious and interesting property of gelatin that used alone 
 it fails to have much nutritive power, but in proper combination 
 with other foods it is a useful aliment. " By the addition of gelatin 
 very large quantities of albumin can be spared in the body or devoted 
 to increase of bulk, just as by the supply of fats and carbohydrates " 
 (Bauer). 
 
 Gelatin itself takes no part in repair and growth of tissues — it 
 must be regarded solely as an " albumin-sparer." It cannot, there- 
 fore, replace albumin, the loss of which still goes on to some ex- 
 tent even when gelatin is eaten in large quantity. It also slightly 
 spares the consumption of non-nitrogenous materials. This is a 
 
ANIMAL FOODS 123 
 
 question of considerable importance in the feeding of invalids, be- 
 cause, while many jellies are easily digested and are agreeable to the 
 palate, it is useless to burden the stomach with them if they do not 
 possess nutritive properties in proportion to other foods, and the 
 matter must therefore be discussed somewhat in detail. The " Bone 
 Soup Commission " of the French Academy of Sciences was consti- 
 tuted to determine the nutritive value of prolonged boiling of bones 
 in order to obtain, if possible, an inexpensive form of aliment for 
 hospital patients. The commission made elaborate researches, the 
 result of which showed that animals which were fed exclusively upon 
 gelatin rapidly deteriorated in strength and weight, and finally suc- 
 cumbed to starvation. Subsequent experiments upon gelatin have 
 been conducted by many physiologists with these conclusions: 1. 
 Gelatin is innocuous, and its exclusive use will not support life. 2. 
 Mixed with other foods, it promotes nutrition and is easily digested 
 and absorbed. 3. To some extent it saves waste of albuminous 
 tissues. 
 
 Since bones consist of nearly two thirds of their weight of gela- 
 tin, the latter may be advantageously used as an inexpensive 
 means for furnishing variety in the diet by addition to meat broths 
 and jellies, pea and bean soups, etc. M. Edwards says that the 
 proper proportion for such mixtures should be at least one fourth 
 of meat soup to three fourths of gelatin soup. The bones them- 
 selves may be broken and made to yield fat and gelatin for soup 
 " stock." The amount of nourishment which they afford is ex- 
 tremely little, and they are mainly of service for economic reasons 
 to save waste. 
 
 Edible birds' nests are not true gelatin, but a Chinese food 
 product allied to mucin. 
 
 Gelatinous substance may be obtained from boiling for several 
 consecutive hours such material as calves' feet, sheep's trotters, ox 
 tails, etc., and after clarifying, straining, and concentrating, very 
 palatable jellies may be made, to which chicken or mutton is added 
 for invalid use. 
 
 Calf's-foot jelly and calf's-head jelly, if not made too rich by added 
 ingredients, make suitable invalid dishes, especially when flavoured 
 with sherry or Rhine wine. Ox-tail soup is too rich for the sick. 
 
 Pure white gelatin is insipid, and is almost impossible to eat in 
 considerable quantity unless it is well seasoned. If free from all 
 gluey taste and odour, and prepared with coffee or lemon juice, or 
 other fruit flavours, it makes an easily digested invalid food. Or it 
 may be combined with eggs or milk as blancmange, or with soup. 
 The addition of meat extracts to it improves the taste, and the ad- 
 mixture of wine, like good sherry, alters the taste rather by the in- 
 troduction of its aromatic principles than by the alcohol itself, which 
 is largely evaporated from the jelly. 
 
124 FOODS AND FOOD PREPARATIONS 
 
 " Well-prepared jellies, not containing too much acid or pungent 
 spices, are very useful foods for invalids, and may be administered 
 with advantage in febrile states " (Bauer). 
 
 Dry gelatin contains 17.3 per cent of nitrogen, which is even a 
 larger proportion than is contained in albumin; consequently urea 
 excretion is decidedly increased by gelatin feeding. Diuresis is 
 also produced, and the desire for liquid is intensified, so that a large 
 proportion of gelatin in the diet causes decided physiological effects. 
 
 Fish 
 
 Fish vary both in digestibility and nutritive qualities. The chief 
 differences are in regard to coarseness of fibre and the quantity of 
 fat present. Fish meat is less stimulating, sustaining, and satisfying 
 than that of birds or mammals. 
 
 Eels contain the largest proportion of fat, which amounts to 28 
 per cent. Herring have 7, salmon about 6.5, while sole has but 0.25 
 per cent (Konig). Mackerel, trout, and shad have considerable fat. 
 
 Fish which, like the salmon, are rich in flavour and in fat, while 
 they may be very nutritious, are much less easy of digestion than are 
 the simpler varieties, such as sole or flounders and codfish. Dried 
 codfish can be eaten on long sea voyages day after day without the 
 repulsion which is soon excited by the continuous diet of the more 
 highly flavoured fatty fish. 
 
 The flesh of many fish contains a large percentage of water, be- 
 sides gelatin. 
 
 The following fish, in the order named by Walker, have the 
 largest percentage of albuminoids : Red snapper, whitefish, brook 
 trout, salmon, bluefish, shad, eels, mackerel, halibut, haddock, lake 
 trout, striped bass, cod, flounder. 
 
 All fish are best in their proper season, for out of season they 
 deteriorate from change in food or other causes, and are less nutri- 
 tious, besides possessing inferior flavour, and sometimes disagreeable 
 odour. They should be eaten as fresh as possible, for there are few 
 alimentary substances capable of exciting so violent gastro-intestinal 
 disturbance as decomposing fish. The practice of preserving fish 
 frozen or packed in ice is open to the objection that the cold pre- 
 vents malodours from revealing commencing putrefaction. Vivid 
 red gills and fulness and brightness of the eye are a good test of 
 freshness. 
 
 It is a popular fallacy that fish constitute a good " brain food " 
 on account of their containing a large percentage of phosphorus, a 
 prominent ingredient of nerve tissue ; but in reality many fish con- 
 tain less of this element than meat, and neither Eskimos nor other 
 aboriginal tribes who live largely upon fish are noted for intellec- 
 tuality. 
 
ANIMAL FOODS 125 
 
 Some fish contain different species of tapeworm, but they are 
 seldom if ever transmitted to man. 
 
 Fish having white meat constitute an excellent food for invalid 
 diet, and when cooked by boiling or broiling (not frying) they may 
 be given to convalescents and to those with feeble gastric powers. 
 
 The most digestible fish are fresh sole, whiting, bluefish, white- 
 fish, bass, red snapper, fresh codfish, halibut, shad, and smelt. Pavy 
 says : " Of all fish, the whiting may be regarded as the most delicate, 
 tender, easy of digestion, and least likely to disagree with a weak 
 stomach. The haddock is somewhat closely allied, but has a firmer 
 texture and is inferior in flavour and digestibility." 
 
 Crimping is a process sometimes applied to fresh fish, like the cod, 
 by which the firmness of the flesh, as well as its flavour, is increased. 
 As soon as caught, the fish is incised transversely by numerous deep 
 cuts. On being plunged into ice-cold water, the muscle fibres con- 
 tract firmly and so remain. 
 
 As a rule, dried, smoked, or pickled fish should not be given to 
 invalids, although thoroughly boned and desiccated or " shredded " 
 codfish is quite tender. The latter process is now conducted by ma- 
 chinery, and thus prepared the fish requires less prolonged soaking 
 and cooking. 
 
 Fish roe is not very nutritious, and it serves mainly as a relish. 
 Shad roe, thoroughly cooked, is not objectionable, but sturgeon's 
 roe or caviare, which is sometimes used as an " appetiser," is capable 
 of arresting digestion, especially when old, black, or rancid. Caviare 
 contains, according to analyses by Konig and Brimmer, water, 45.05 ; 
 proteids, 31.90; fat, 14.14; salts, 8.91 per cent. 
 
 It must not be forgotten that some persons cannot digest fish of 
 any kind, or at most can take but one or two varieties without pro- 
 voking an attack of dyspepsia or biliousness. A few tropical fish are 
 poisonous, and constitute an exception to the general edibility of 
 vertebrate animals. (See Fish Poisoning.) 
 
 There are no diseases in which a fish diet possesses specific 
 value, but often in chronic Bright's disease, lithsemia, gout, or 
 other conditions in which it is undesirable to give much meat, 
 it is very serviceable as a compromise. 
 
 Crustaceans 
 
 Lobsters, crabs, and shrimps, although they constitute a whole- 
 some food, when absolutely fresh, for those in health, should never 
 be admitted to an invalid dietary. They are all scavengers of the 
 sea, and crabs not thoroughly cleaned or imperfectly cooked may be 
 poisonous from contamination with putrid matter, although their 
 own flesh is good. Soft-shell crabs are by no means always " soft " 
 when eaten, and their shells furnish a large bulk of indigestible res- 
 
126 FOODS AND FOOD PREPARATIONS 
 
 idue, which may prove irritating. I recall one fatal case of appendi- 
 citis caused by them. 
 
 Lobsters are highly poisonous to some persons even when fresh, 
 and especially if eaten with other food they may excite nausea, 
 vomiting, and even gastro-enteritis. In others they may cause urti- 
 caria or aggravate existing skin eruptions. 
 
 Persons who live at a distance from the seashore are apt, in 
 making occasional visits to seaside resorts, to gratify a fondness for 
 crustaceans, fish, and shellfish food by an excessive indulgence in 
 " shore dinners," which result disastrously with stomachs unaccus- 
 tomed to such diet ; but the evil effects are fortunately temporary. 
 
 Shellfish 
 
 Oysters, clams, and mussels are very nutritious food, and the for- 
 mer at least, when fresh and when eaten raw or properly cooked, 
 are an excellent invalid aliment. Oysters can often be digested 
 earlier than meat in convalescence from fevers, and in many forms 
 of gastric disorder. 
 
 The " soft part " of shellfish is formed chiefly by the bulkier 
 liver, while the tough, harder portion is mainly the muscle which 
 attaches the animal to its shell. This muscle is coagulated and 
 rendered tougher by all forms of cooking; hence raw oysters are 
 more tender and digestible than if stewed or broiled. In oysters the 
 liver is relatively larger and more nutritious than in clams. In rec- 
 ommending oysters to invalids it is always best to allow only the 
 soft parts to be eaten, and when this rule is observed they may be 
 cooked in a variety of ways — by stewing, broiling, roasting, or " pan- 
 ning," and steaming — but they should never be fried for the sick. 
 
 Both oysters and clams have the advantage that they are very 
 generally liked, and they make a pleasant variety of food to relieve 
 restricted diets. They impart an agreeable flavour to milk and 
 broths. It is customary to forbid their use by diabetics, on the 
 ground that their livers contain glycogen. Clam juice or plain clam 
 broth is almost specific for some forms of vomiting, especially sea- 
 sickness. It may be tried in the vomiting of pregnancy, and may be 
 retained when beef juice and milk are not. It is mildly stimulating 
 to the gastric mucous membrane, and slightly nutritious and laxative. 
 It is best obtained fresh, but very good canned or bottled prepara- 
 tions of it are made which keep pure indefinitely. It may be taken 
 either hot or cold with a little Cayenne pepper half an hour before a 
 meal. It seems to have an invigorating effect upon the stomach, 
 and promotes the appetite. 
 
 Mussels are less commonly eaten in this country than in England 
 and some parts of Europe. They belong in the same category with 
 oysters and clams, and the remarks just made in regard to the latter 
 
VEGETABLE FOODS 127 
 
 apply to them as well. There is a form of poisoning by mussels 
 which is exceedingly dangerous and sometimes fatal. (See Poison- 
 ing by Shellfish.) 
 
 In some persons shellfish, like crustaceans, produce skin erup- 
 tions, such as urticaria, or aggravate existing eczema. 
 
 IV. VEGETABLE FOODS 
 
 Sugars 
 
 Sugars are crystallisable carbohydrates in which oxygen and 
 hydrogen exist in proportion to form water. There are many vari- 
 eties, of which the commoner contained in food or used as an adjunct 
 to diet are cane sugar, saccharose or sucrose, grape sugar, dextrose 
 or glucose, levulose or fruit sugar, and sugar of milk or lactose. 
 Inosite, mannite, dextrin, sugar of malt or maltose, honey, a sweet 
 nitrogenous substance called saccharin, and fruit sugar or levulose 
 (diabetin) are also used. Sugar may be derived from the stems of 
 plants, as in the case of the sugar cane, or the palm, from tubers like 
 the beet, from maple-tree sap, and from other vegetable growths. 
 
 The sugars present slight differences in their physical properties, 
 such as specific gravity, solubility, and effect upon polarised light. 
 They also differ in sweetness of taste and in digestibility. 
 
 As foods, sugars have essentially the same uses as starches (see 
 Farinaceous Foods, p. 134), for all starch must be converted into 
 dextrin or sugar before it can be assimilated. For this very reason, 
 sugars, although they form an excellent class of food, producing 
 force and heat and fattening the body, are not absolutely necessary 
 for the maintenance of health if starches or fats are eaten. Recent 
 experiments in the German, British, and other armies show that a 
 liberal allowance of sugars in the diet tends, during manoeuvres, to 
 maintain strength, lessen hunger and thirst, and lessen the liability to 
 heat exhaustion. 
 
 They possess additional properties, in that they have a more 
 agreeable flavour than starches, are more satisfying to the palate, 
 and they have antiseptic and preservative power. Hence sugars and 
 sirups are extensively employed to preserve fruits either in solution 
 or in dried form, like " candied " cherries, ginger, etc. 
 
 When taken for food, sugar is quickly soluble, and on this account 
 taxes the digestive organs but little. Cane sugar, however, needs to 
 be converted into grape sugar before it can be absorbed and assimi- 
 lated, and grape sugar, which needs no change, is therefore some- 
 times spoken of as a predigested carbohydrate. 
 
 Between seven and eight million tons of sugar are consumed each 
 year in the world at large. The English-speaking nations are the 
 largest consumers. In 1895 the per capita consumption in England 
 
128 FOODS AND FOOD PREPARATIONS 
 
 was 86 pounds as against 30 pounds in Germany, France, and Hol- 
 land, and 7 pounds in Italy, Greece, and Turkey (Mary Hinman 
 Abel). Cane sugar was originally used exclusively in preparation of 
 medicines, not as a food. 
 
 Many persons acquire an inordinate fondness for sugar, and con- 
 tinued overindulgence in this food is very sure to give rise to 
 flatulent dyspepsia, constipation, and disorders of assimilation and 
 nutrition. It may even cause functional glycosuria. (See Dia- 
 betes.) 
 
 Sugar is very fattening. In the West Indies the negroes always 
 grow fat in the sugar season, when they chew the cane in the 
 fields. 
 
 Sugars are emphatically force producers.* Chauveau and Kauf- 
 mann have demonstrated that during muscular activity the consump- 
 tion of sugar in the body is increased fourfold. If one pound of 
 sugar were burned so as to utilise all the heat, it would raise five 
 gallons of water from the freezing to the boiling point (A. C. 
 True). 
 
 Harley found experimentally that the muscle-energy producing 
 effect of sugar is so great that two hundred grammes (seven ounces) 
 added to a small meal increased the total amount of work done from 
 6 to 30 per cent, and that when sugar was added to a large meal it 
 increased this total from 8 to 16 per cent. 
 
 Sugars and the Urine. — Grape sugar and fruit sugar or levulose, 
 when eaten in large quantity in health, reappear unaltered in the 
 urine, but the latter sugar in diabetes is said by Moritz to be con- 
 sumed within the body. Sugar eaten in excess with other food 
 increases the quantity of urine and feces and the urea elimination 
 (W. G. Morgan). 
 
 Saccharose, eaten in excess, may reappear in the urine unaltered, 
 or more commonly as glucose. 
 
 Lactose is converted into glucose, and it produces functional gly- 
 cosuria more easily than the latter if eaten in bulk. 
 
 Alimentary glycosuria usually ceases in a few hours after discon- 
 tinuance of eating the food which has caused it. 
 
 There are some diseases in which sugar in all forms should be 
 strictly avoided, such as flatulent dyspepsia, acute and chronic gas- 
 tritis, gastric dilatation, gout, rheumatism, obesity, and the uric- 
 acid diathesis, and it should be absolutely forbidden in diabetes. 
 Temporary disturbances of digestion from eating too much sweet 
 food are very common, and can usually be rectified by simple reme- 
 dies, and by withholding or diminishing the customary allowance of 
 sugar. Sugar eaten constantly in excess spoils the teeth and de- 
 stroys the appetite for other food. It lessens the hydrochloric acid 
 of the gastric juice in cases of hyperchlorhydria, and is said to dis- 
 solve mucus. 
 
VEGETABLE FOODS 1 29 
 
 Cane Sugar. — Cane sugar, saccharose, or sucrose, as used in 
 the United States, is usually derived from the clarified and crys- 
 tallised juices of the sugar cane (saccharum ofhcinarum) , but it is also 
 made from beet root, as originally discovered by Marggraf, of Berlin, 
 in 1747. The latter form is somewhat less sweet than are the better 
 grades of cane sugar. The root contains 12 to 15 per cent of sugar. 
 One third the world's commercial sugar is derived from sugar cane, 
 and two thirds from beets. The annual per capita consumption of 
 sugar in the United States is 66 pounds. About one quarter of 
 a pound per diem may be eaten without harm. Much more than 
 this in a short time is liable to disorder digestion, just as do the 
 equally diffusible peptones eaten in excess. 
 
 Mary Hinman Abel, in an exhaustive study of the food value of 
 sugar, says : 
 
 " There is no proof that sugar is harmful to the teeth, although 
 doubtless sweet food, allow r ed to cling to the teeth after eating, 
 rapidly ferments, and acids will be formed that, according to Pro- 
 fessor Miller, of Berlin, may attack the teeth. This is equally true 
 of starchy foods. It is said, however, that the negroes of the 
 West Indies, who consume enormous quantities of sugar, have 
 the finest teeth in the world. It is also unproved that sugar pro- 
 duces gout." 
 
 Sugar is better digested in proportion to the amount of exercise 
 taken. 
 
 The maple tree yields from 2 to 10 per cent of sucrose. Maple 
 sugar is eaten chiefly as a luxury, on account of its unique and 
 agreeable flavour. It also makes an excellent sirup which is in 
 great demand. About 7,500,000 pounds of maple sugar are made 
 annually in the United States. Cane sugar can be obtained from 
 the sugar pea, from the flower buds of the coca palm, and from 
 other substances. It is soluble in half its weight of cold water and 
 in less hot water. 
 
 The sap which is drawn from the sugar cane as well as the juice 
 of compressed beet root is not a pure aqueous solution of sugar, but 
 is mingled with other materials, chiefly of a mucilaginous character. 
 An elaborate process of refining is applied in order to produce the 
 commercial white sugars of various grades. The principal steps in 
 this process are as follows: " 1, Melting of the sugar; 2, straining 
 through bag filters ; 3, filtering through charcoal ; 4, boiling or 
 evaporating the decolourised liquid in vacuum pans ; 5, separation 
 of crystallised sugar by centrifugals " (Clark). The process is so 
 cheap that cane sugar is practically never adulterated. 
 
 Cane sugar was formerly sold more extensively than at present 
 in the form of coarse brown sugar. This variety is somewhat im- 
 pure, and on this account has a slightly laxative action ; but the' 
 great improvements made of late years in the processes of refining 
 
130 FOODS AND FOOD PREPARATIONS 
 
 sugar, and the extreme cheapness of this commodity, place the 
 clarified forms of it within the reach of all, and even reduce to a 
 minimum the temptation for sophistication which was originally 
 much more extensively practised, especially in the adulteration of 
 confectionery, with chalk, plaster of Paris, etc. 
 
 The most highly refined cane sugars contain about 0.25 per cent 
 only of impurities and ash, but poorer grades hold 1 to 2.3 per cent, 
 with as much water (Konig). Cane sugar is about two and a half 
 times sweeter than glucose. Cane sugar is completely digested and 
 absorbed, leaving no fecal residue. 
 
 " Grocer's itch " is a form of irritation of the skin of the hands 
 sometimes acquired from contact with moist brown sugar, adulter- 
 ated with dirt or sand and mites. 
 
 Caramel. — By the application of heat, at 400 F., refined cane 
 sugar is melted, browned, and converted into a non-crystallisable 
 fluid substance called caramel, having a slightly bitter but agree- 
 able taste. Comparatively insipid farinaceous food, such as corn- 
 starch and farina, may be flavoured with it for invalid diet. Burned 
 flour may be used in the same manner, but its flavour is less agreea- 
 ble. Caramel is also useful for flavouring milk, custards, etc. 
 
 At 320 F. sugar melts to an amber fluid, which, on cooling, is 
 brittle and transparent. In this form it is called " barley sugar," and 
 is much used in confectionery. 
 
 When sugar is cooked with acid fruits it is partly converted by the 
 heat and acid to less sweet substances, hence to sweeten cooked 
 fruits the sugar should be added when the cooking is completed. 
 
 Sugar differs from starch by containing another molecule of 
 water. Starch, which forms fully three fourths by weight of the 
 solid ingredients of wheat flour, is altered into sugar by heating with 
 a little sulphuric acid, or even by prolonged heating alone or " torri- 
 fication." The latter process converts it into dextrin, sometimes 
 called " British gum," on account of its substitution in commerce 
 for gum arabic. With prolonged heat there is a further change in 
 the starch, which becomes of a brownish and finally black hue, pass- 
 ing through a stage analogous to the formation of caramel from 
 sugar, and with extreme heat forming a residue of black carbon, all 
 the water having been driven off. A hard, dried, thoroughly 
 browned bread crust or toast is therefore similar to caramel, and 
 every one is familiar with its gain in flavour. 
 
 Sugar candy is made by extremely slow crystallisation. 
 
 Sorghum is a variety of grass or cane from which sugar can be 
 extracted, but in this country it is used more for the manufacture of 
 molasses. 
 
 Candy and Confectionery. — Candy contains from 75 to 90 per cent 
 of sugar, to which may be variously added butter or other fats, nuts, 
 fruits, starch, glucose, flavouring extracts. Cheap varieties are 
 
VEGETABLE FOODS 131 
 
 coloured with aniline dyes, and are composed largely of glucose 
 and starch. Children assimilate candy better than adults because 
 they are less liable to dyspepsia, and because of their relatively 
 active muscular energy and relatively large body surface for losing 
 heat, in proportion to their size. They do not, as a rule, care for 
 fat meat, and prefer sweets as a natural substitute. 
 
 An infant taking two quarts of milk per diem consumes nearly 
 three ounces of sugar in the form of lactose. In later childhood the 
 ability to digest starches replaces to some extent the need for sugar. 
 It is, however, important that the taste for candy and sugar common 
 to all children should not be permitted to interfere with a wholesome 
 and natural appetite for other foods, especially fresh vegetables and 
 fruits. The value of sweets in the adult dietary has of late years 
 found recognition in armies. The British War Office shipped 
 1,500,000 pounds of jam to South Africa as a four months' supply for 
 116,000 troops, and one New York firm during the Spanish-Amer- 
 ican War shipped over fifty tons of confectionery to the troops in 
 Cuba, Porto Rico, and the Philippines. The confectionery consisted 
 of chocolate creams, cocoanut macaroons, lemon and other acid fruit 
 drops. 
 
 Molasses, Treacle, and Sirup. — Molasses and treacle are products 
 incidentally formed in the process of crystallising and purifying cane 
 sugar. Treacle is the waste drained from moulds used in the refin- 
 ing process, and it contains, besides sugar, acids, extractives, salts, 
 and more or less dirt. Like cane sugar, molasses constitutes a 
 very desirable food, and is highly nutritious. Its use, both for cook- 
 ing and to add to farinaceous food and enhance its flavour, is too 
 well known to require description. Molasses, according to Konig, 
 contains acetic and formic acids, which impart their feaction to it. 
 It also contains cane sugar and 30 per cent each of invert sugar and 
 of water. 
 
 Both treacle and molasses, owing to impurities, are more laxa- 
 tive than refined sirup, and the effect, as an aperient, of plain ginger- 
 bread made with good brown molasses is due to this property. For 
 young children from six to ten years of age molasses sometimes 
 operates very well in keeping the bowels open. 
 
 Plain molasses candy is a wholesome form in which to give sugar 
 to growing children, if they are not allowed to eat too much and 
 spoil their appetite for other foods. It is mildly laxative. Walker 
 says that " good candy is good food." Candies are often made too 
 rich with butter, chocolate, and other ingredients, when they dis- 
 agree. 
 
 Molasses, like sirup, is a good preservative. It has been used to 
 preserve potatoes in layers. An old-time custom among soldiers in 
 the field is to fill a canteen with two parts vinegar and one part 
 molasses as an emergency sustaining drink. 
 
I32 FOODS AND FOOD PREPARATIONS 
 
 G-lucose. — Grape sugar is present in almost all fruits, in the 
 sweeter varieties of which it exists in large quantity. In peaches, 
 pineapples, and strawberries it is found with cane sugar, and in 
 grapes, cherries, and honey it occurs in connection with other varie- 
 ties of sugars. . In dried fruits, such as raisins or figs, glucose is 
 present in a gummy form. It is commonly manufactured from 
 starch. 
 
 Although prepared for immediate absorption from the stomach 
 and intestine and assimilation, glucose is of little service for fla- 
 vouring other articles of food, for when so used it is apt to produce 
 flatulent dyspepsia with acid eructations. Moreover, it has less 
 strength of sweetness than cane sugar, and, as it is more difficult 
 to crystallise, it is much less convenient and desirable for gen- 
 eral use. 
 
 Sucrose and maltose can only be absorbed by alteration into glu- 
 cose. If glucose be eaten as a food, in form of candy or otherwise, 
 it overloads the system by being too promptly absorbed. Malt ex- 
 tracts, sirups, and preserves adulterated with glucose easily ferment, 
 for nothing ferments more promptly than such combinations with 
 the bacteria present in the stomach. 
 
 Lactose. — Lactose, or sugar of milk, is taken as a food in some 
 quantity with ordinary milk, and forms a very important ingredient 
 of the diet of the growing infant, who is unable to digest much 
 starch during the first year of life, and yet requires an easily 
 assimilable form of carbohydrate. Cow's as compared with human 
 milk is deficient in lactose, and the latter should therefore be added 
 in proper proportion to the milk of bottle-fed infants. (See Milk 
 Composition, p. 52.) It might be used for sweetening various arti- 
 cles of food, but it possesses no advantages over ordinary cane 
 sugar, and is in fact more expensive and less sweet. It is mildly 
 diuretic. 
 
 Mannite. — Mannite is obtained from the sweet juice of the stems 
 of the ash tree. It is also contained in beet roots and some other 
 vegetables. Like sucrose, it crystallises, and is white and free 
 from odour. It does not ferment with yeast. It is laxative, and 
 it may be used in diabetes, for it is not secreted in the urine as 
 glucose. 
 
 Levulose. — Fruit sugar, or levulose, is now sold under the name 
 of diabetin, in crystalline form, for use in diabetes, on the ground 
 that it is not known to reappear in the urine. It can be taken freely 
 and in considerable quantity without disordering digestion, as sac- 
 charin often does after continued use. Diabetin is sweeter than cane 
 sugar, and has a somewhat fruity taste. 
 
 Honey. — Honey is a form of sugar prepared from the cane sugar 
 of various flowering plants gathered by bees, which convert it by 
 hydrolysis chiefly into dextrose. They then store it in cells. Thus 
 
PLATE III. 
 
 '£®S 
 
 V- 
 
 K* 
 
 Q i 
 
 
 r "* 
 
 WHEAT 
 
 
 # fe 
 
 *fc> 
 
 "1 
 
 RYE 
 
 OATS 
 
 &^*; 
 
 CORN 
 
 #i#^^ 
 
 
 RICE 
 
 STARCH GRANULES, MAGNIFIED. 
 
 (From Bulletin .Vo. 13, Division of Chemistry, United States Agricultural Burma' 
 
 liltA \\ \ 1(1 liKO. MARX. 
 
VEGETABLE FOODS 1 33 
 
 it is really a vegetable product, although manufactured by an insect. 
 In addition to sugar, it holds several other ingredients, principally 
 wax, gum, pigment, and odorous materials. The sugar exists in 
 two forms — crystallisable and non-crystallisable. The former is 
 somewhat similar to glucose. 
 
 Honey contains, according to Konig: Water, 16.13; dextrose, 
 78.74; cane sugar, 2.69; nitrogenous matter, 1.29; ash, 0.12 per cent, 
 besides traces of other ingredients. 
 
 Honey was more in demand for sweetening before the discovery 
 of a method of making sugar from the sugar cane. It is a whole- 
 some food, and is fattening when eaten with bread. In some coun- 
 tries — as, for example, in the Black Forest of Baden — the peasants 
 consume it as a staple article of diet. Artificial honeycombs are 
 now made from paraffin, stamped into cells to imitate the original, 
 which enables the bees to devote more energy to the manufacture of 
 honey and bestow less on the combs. 
 
 In a few instances, fortunately very rare, honey has proved poi- 
 sonous owing to the bees having fed upon poisonous flowers. An 
 epidemic of gelsemin poisoning occurred in Branchville, S. C, from 
 this cause in which twenty persons were severely affected, three 
 of them fatally. 
 
 Saccharin. — Saccharin is a crystallisable organic-acid substance, 
 containing, in addition to the elements carbon, hydrogen, and 
 oxygen, a little sulphur and nitrogen. It was introduced a few years 
 ago as a substitute for sugar, and it is especially useful in cases of 
 obesity, rheumatism, gout, and diabetes, when the withdrawal of 
 sugar is followed by intense craving for it, or a refusal to eat those 
 foods which are customarily flavoured with it. It is antiseptic, and 
 has the property of acidifying the urine, being eliminated unaltered 
 by the kidneys, hence it can be used medicinally in cases of pyelitis 
 or cystitis. It may be given for months at a time without danger, 
 if the quantity prescribed does not exceed more than one or two 
 grains, three times a day. More than this dose may cause gastric 
 derangement. It may be added to food in cooking, or a one-quarter 
 grain tablet may be used to sweeten a cup of coffee. 
 
 Cereals and other Starchy Foods 
 
 Starchy Foods in General. — The cereals in commonest use as food 
 products are wheat, corn, rice, rye, barley, oats, buckwheat. From 
 these are manufactured a variety of flours and meals. 
 
 About 30 per cent of all cereals produced in the world are grown 
 in the United States, and at least one fourth of the total wheat pro- 
 duction is from this country ; on the other hand, 98 per cent of the 
 rye and 75 per cent of the barley and oats are grown in Europe. 
 The United States produces about 75 per cent of the corn of the 
 
134 
 
 FOODS AND FOOD PREPARATIONS 
 
 world. These estimates give a general idea of the relative use of 
 these cereals, and illustrate the great preponderance of wheat bread 
 and cornmeal and other preparations of corn eaten in the United 
 States. 
 
 Besides the cereals and vegetables which, like the potato, are 
 composed chiefly of starch, there is a large miscellaneous group of 
 starchy foods used as flours, which are therefore conveniently con- 
 sidered with the cereals. Such are arrowroot, tapioca, cassava, sago, 
 and peas. Peanuts, chestnuts, and plantains are also sometimes used 
 to furnish flour. 
 
 Starch is the term applied to the fecula or granular material 
 found in fruits, roots, and tubers and in the cellular tissue of plants. 
 The structure and form of the starch granules vary, and those from 
 different plants may be distinguished by microscopic examination. 
 
 Patients, as a rule, are ignorant as to the nature and limitations 
 of " starchy foods," and their conception of them is based upon such 
 foods as resemble powdered laundry starch in appearance, like ar- 
 rowroot, cornstarch, etc. After being told to eat no starchy foods, 
 they not infrequently will say they suppose that potatoes are not 
 starchy. The expression at best is not an accurate one ; for many 
 starch-holding foods contain a large proportion of other ingredients, 
 especially proteids, as will be seen from the following table furnished 
 by Riibner : 
 
 Wheat 
 
 Rye 
 
 Barley 
 
 Maize 
 
 Rice 
 
 Buckwheat 
 
 ONE HUNDRED PARTS OF 
 
 DRY MEAL 
 
 CONTAIN — 
 
 
 Albumin. 
 
 Starch. 
 
 16.52 
 
 
 56 25 
 
 II.g2 
 
 
 6O.9I 
 
 17.70 
 
 
 38.31 
 
 13-^5 
 
 
 77-74 
 
 7.40 
 
 
 86.21 
 
 6.8—IO.5 
 
 
 65-05 
 
 Farinaceous foods are composed of flour of different kinds, and 
 constitute a subdivision of starchy foods. The different starchy and 
 farinaceous foods are derived from a variety of plant structures, in- 
 cluding roots, tubers, bulbs, stems, pith, flowers, seeds, fleshy fruits, 
 etc. Some, like the banana and certain vegetables, are eaten raw, 
 but the majority require cooking, and the starches derived from 
 grain-bearing plants of the grass tribe or cerealia usually must be 
 prepared by grinding and milling before cooking. About one sixth 
 of the protein of the various grain flours passes through the ali- 
 mentary canal undigested. 
 
 The following table by Professor Atwater will be found useful in 
 giving at a glance the average percentage of starch contained in the 
 commonest vegetable foods : 
 
VEGETABLE FOODS I 35 
 
 Atwaters Table of the Percentage of Starch in Vegetable Foods 
 
 "Wheat bread 55-51 Potatoes 21.3 
 
 "Wheat flour 75-6 Sweet potatoes 21. 1 
 
 Graham flour 71.8 
 
 Rye flour 78 . 7 
 
 Buckwheat flour 77-6 
 
 Beans 57.4 
 
 Oatmeal 68.1 
 
 Cornmeal 71. o 
 
 Rice 79 . 4 
 
 Turnips 6.9 
 
 Carrots 10 . 1 
 
 Cabbage 6.2 
 
 Apples 14. 3 
 
 Pears 16.3 
 
 Bananas 23.3 
 
 In round numbers it may be stated that starch composes one fifth 
 of potatoes, one half of peas, beans, wheat, rye, and oats (their flours 
 contain more), and three fourths of rice and Indian corn. 
 
 In addition to the cooking which the cerealia require, they are 
 often predigested by diastase for invalid use. Strong heat converts 
 starch to dextrin ; but diastase, like the natural digestive ferments, 
 can convert it into maltose, and as such it is fitted for absorption. 
 
 Fortified gruels, as they are called by Roberts, are made of cereal 
 flours or dried legumes, with addition of milk, beef tea, or eggs. The 
 flours if used alone, in strength of 5 per cent, become pasty and taste 
 insipid, but if one eighth of their weight of ground malt be added 
 they remain fluid with 20 per cent of flour, and, as this starch is 
 largely dextrinised, they are highly nutritious. Thus made, Roberts 
 says they contain 2 per cent of proteid and 14 per cent of carbo- 
 hydrates. 
 
 Bread-making. — It has been well said that the quality of the 
 bread used by the inhabitants of any country is a fair measure of 
 their civilisation. Flour is prepared from various grains by crushing 
 and grinding processes. The grains consist of (1) an outer layer, 
 the husk or skin, which is woody, fibrous, and indigestible, and which, 
 in the milling process is separated into " bran " ; (2) the kernel 
 within the husk, which is composed of gluten, fats, and salts ; (3) the 
 starch. 
 
 To appreciate the important details of bread-making, it will be 
 necessary to first review the structure and composition of the grain 
 from which the bread is derived. 
 
 Structure of the Wheat Kernel. — The wheat kernel is subdivided 
 into four layers. The first or outermost layer (Fig. 1, H) consists of 
 two or three strata of elongated cells the long diameters of which 
 correspond with the long axis of the grain. From these cells slender 
 filaments or tapering, hair-like processes project outward. The cell 
 margins are irregular in outline, and appear somewhat beaded. 
 
 Immediately beneath the outer hairy layer lies the second layer 
 
 (Fig. 1, F), consisting of more or less quadrangular cells, with 
 
 rounded angles, which are more uniform in size than the others, and 
 
 grow at right angles to them. The third layer (Fig. 1, K) consists 
 
 11 
 
136 
 
 FOODS AND FOOD PREPARATIONS 
 
 Fig. i. 
 
 of a delicate, transparent membrane-like structure. The fourth or 
 internal layer (Fig. I, S) is composed of large, almost rectangular 
 cells arranged in one or two strata, and which contain a dark granular 
 
 material which may be easily separated 
 from the cell walls. 
 
 The grains of other cereals conform 
 in a general way to the structure of the 
 wheat grain, although they differ in the 
 thickness of the several layers, the num- 
 ber of their strata, and the size of the 
 individual cells. 
 
 Bran. — Bran (Fig. 2, a) contains car- 
 bohydrate material which is but little if 
 at all digested in the human alimentary 
 canal, although the lower animals derive 
 abundant nutrition from it. The nutritive 
 salts of wheat are chiefly contained in the 
 bran ; and for this reason, if bread con- 
 stitutes the principal food for a. time, it is 
 best to eat that which contains some bran. 
 But if too much is consumed it hastens 
 peristalsis, and nutrition suffers because 
 the food is hurried out of the alimen- 
 tary canal before absorption is complete. 
 When bread is eaten with other food con- 
 taining nitrogen and salts, white bread is preferable. 
 
 Gluten. — Gluten is separated in the process of making starch 
 from wheat and other grains. It is a valuable nitrogenous food 
 product, consisting of (a) 60 
 to 70 per cent gliadin and (b) 
 30 to 40 per cent glutenin. 
 The greater part of the glu- 
 ten is held in the central four 
 fifths of the grain. The glia- 
 din adheres to the glutenin, re- 
 tains the gas in dough, and in 
 excess it makes the flour soft 
 and sticky, hence soft wheat 
 yields a flour with high per- 
 centage of gliadin, but hard 
 wheat has a low percentage. 
 
 Gluten is capable of considerable expansion independently of the 
 development of C0 2 , and, as this power varies with different flours, 
 it affects the quality of lightness of the bread. Some glutens expand 
 four or five times as much as others (H. Snyder and L. A. Voor- 
 hees). 
 
 Section through wheat 
 kernel (from Rupp). H y hair- 
 like processes ; F, K, second 
 and third layers ; S, fourth 
 internal rectangular cell lay- 
 er ; a, b, c, d, successive lay- 
 ers represented as partially 
 stripped off. 
 
 Fig. 2. — Microscopic characters of wheat 
 ( 4- 200) (from Landois and Stirling), a, cells 
 of the bran ; b, cells of thin cuticle ; c, gluten 
 cells ; d, starch cells. 
 
I'LATK IV. 
 
 Maize Starch x 145 
 
 Wheat Starch x 145 
 {Prom Bulletin So. IS, Division of Chemistry , United States Agricultural Hurmi 
 
 HICIIAKDSUN. 
 
VEGETABLE FOODS I 37 
 
 Composition of Bread. — Bread is really a mixed food, in that it 
 contains so many classes of ingredients — fat, protein, salts, sugar, 
 and starch — and this is probably the explanation of the fact that its 
 daily use never cloys the appetite. Although it contains some fat, 
 it has not enough for a perfect food, and hence the almost universal 
 custom of using butter with it. Moreover, it forms a convenient 
 vehicle for taking fat in this manner, and the butter aids in the 
 mastication and deglutition of the bread. 
 
 Good bread contains, on the average, protein, 9.57 per cent ; fat, 
 1.5 to 2 per cent ; and carbohydrates, 55 per cent, the remainder being 
 largely water, with a trace of salts. In round numbers, bread con- 
 tains about two thirds nutrient material, or twice as much as beef, 
 although it is of different force value in the body. One hundred 
 grammes furnish 216 calories. A pound of bread is made from 
 about three quarters of a pound of flour by the addition of 25 per 
 cent of water. Some flours will take up 10 per cent more water 
 (Snyder and Voorhees). 
 
 Bread-baking. — Bread is made from a mixture of the flour of 
 any cereal with water, which is added in definite proportion, consti- 
 tuting a dough which is made uniform by kneading either by hand 
 or by machinery. A small quantity of the ferment yeast is also 
 worked uniformly into the dough and the mass is left to stand for a 
 number of hours, during which fermentation progresses, producing 
 from the starch alcohol, carbonic acid, and water. The best tem- 
 perature at which this leavening proceeds is from ioo° to no F. 
 After remaining for some hours at a uniform temperature, the bread 
 is baked in a hot oven the temperature of which is sufficient to kill 
 the yeast germs and check further fermentation. 
 
 Of all the cooking processes now in use by civilised man, the 
 baking of bread is, perhaps, the most important. The object of 
 cooking flour in this manner is to make it light and porous, so that 
 the digestive fluids may be easily incorporated with it. Flour eaten 
 alone forms a glutinous or sticky mass which is quite indigestible 
 and difficult to swallow, besides being comparatively tasteless. 
 There are many variations in the process of bread-making, but all 
 are based upon the same principle — the development of carbonic-acid 
 gas throughout the mass of dough, which bubbles up and causes it 
 to " rise " or forces it apart. In general, the process involves a loss 
 of about 1 per cent of C0 2 and 1 per cent of alcohol. The loss of 
 volatile products represents a loss of but 1.58 per cent of starch. 
 Of the remaining starch less than 8 per cent is converted into soluble 
 form (dextrin), but many of the starch granules are ruptured or dis- 
 integrated. A very small percentage of fat also disappears in the 
 process of baking. 
 
 Development of Carbonic-acid Gas. — Carbonic-acid gas may be 
 generated or introduced in four ways : I. Indirectly by natural fer- 
 
138 FOODS AND FOOD PREPARATIONS 
 
 mentation excited by the addition of the yeast fungus, Torula or 
 Saccharomycetes cerevisice. II. By the use of " leaven," a name given 
 to old dough in which fermentation has already occurred. III. By 
 the addition of baking powders. IV. Directly by " aeration." 
 
 I and II. Bread made by Yeast or Leaven. — When bread is made by 
 yeast or leaven the process, which may be divided into three stages, 
 is as follows : 
 
 (1) The wheat or other flour, finely ground, is mixed into a thick 
 paste with water, which may be either warm or cold, and to which 
 the ferment, together with a little salt, is added ; the mass is thick- 
 ened with flour to form a dough, and the dough is well worked by 
 hand or kneaded so that its several ingredients may become most 
 thoroughly incorporated. If this is not done properly the bread is 
 lumpy or of uneven porosity. The entire mass may be prepared at 
 once, or a small part of the flour is first allowed to ferment for a 
 short time, and then is kneaded into the remainder. 
 
 (2) The dough is next set aside for some hours in a warm place 
 to rise. This process consists of a fermentation which is produced 
 in the flour by the action of the yeast, resulting in the freeing of 
 carbon dioxide and water. The accumulating carbonic-acid gas en- 
 deavours to escape in bubbles, which become entangled in the more 
 or less tenacious gluten of the flour. Upon the size and number of 
 these bubbles depends the porosity of the bread, and this in turn is 
 modified somewhat by the kind of flour used, the quantity of the fer- 
 ment, and the rapidity with which the development of carbonic acid 
 is allowed to proceed. 
 
 (3) The final stage consists in the baking of the dough after it 
 has risen. The heat of the oven, by expanding the carbonic-acid 
 gas, makes the bread still more porous and " sets " the walls of the 
 little cavities which have formed so that the loaf maintains its shape. 
 The gas is finally driven off, together with a large quantity, but not 
 all, of the water. The baked bread is therefore considerably lighter 
 in weight than the dough, much drier, and porous. 
 
 The water added to make the dough escapes in part through 
 evaporation, and the external portion of the bread becomes drier and 
 browner than the interior or crumb, and constitutes the crust. The 
 thickness of the crust will depend upon the character of the flour 
 used, the temperature of the oven, and the duration of the process 
 of baking. Bauer claims that the crust contains less nitrogenous 
 material than the crumb, but this is contradicted by Dujardin-Beau- 
 metz, and there is no definite reason why it should. 
 
 With the exception of these changes, bread has practically the 
 same composition as its original flour. 
 
 Mixing meal or flour with fat tends to prevent the evaporation 
 of water from the bread. 
 
 The chief art in baking bread consists in arresting the yeast fer- 
 
VEGETABLE FOODS I 39 
 
 mentation of the dough by the heat of the oven (300 to 400 F.) at 
 exactly the right period. If fermentation has not proceeded far 
 enough the bread is tough, or sodden, or lumpy, whereas if it has 
 gone too far it acquires a sour taste by the development from the 
 carbohydrates or organic acids, such as acetic, butyric, and lactic, 
 which are both unpalatable and unwholesome. Fermentation pro- 
 duced by the use of leaven instead of yeast is much more difficult to 
 control, and these acids, therefore, are more likely to be formed. The 
 bread made with fresh brewers' yeast is by many esteemed to have 
 the best flavour. The process of bread-baking also causes the 
 starch granules to burst, if this has not already occurred from ab- 
 sorption of water in the dough, and results in the conversion of 
 some of the starch into dextrin, with the further formation of alco- 
 hol and sugar (glucose). About 6 to 8 per cent of the starch is thus 
 made soluble. There are several minor chemical changes, and the 
 entire action of yeast and heat upon the dough is thus summarised 
 by H. Snyder and L. A. Voorhees (U. S. Department of Agricul- 
 ture Bulletin No. 67, 1899) : 
 
 " (1) The fermentation of the carbohydrates and the production 
 of carbon dioxide and alcohol ; (2) the production of soluble carbo- 
 hydrates, as dextrin, from insoluble forms, as starch ; (3) the pro- 
 duction of lactic and other acids ; (4) the formation of other volatile 
 carbon compounds ; (5) a change in the solubility of the proteid com- 
 pounds ; (6) the formation of amid and ammonium compounds from 
 soluble proteids ; and (7) the partial oxidation of the fat." 
 
 About 2 per cent of the weight of the flour used is lost in volatil- 
 ising various organic products. With prolonged fermentation this 
 loss may amount to 8 per cent. 
 
 The soluble dextrin has the physical properties of a gum. It 
 is obtained by heating starch to 300 to 400 . In steam-cooked ce- 
 reals also, the starch is partially dextrinised. 
 
 III. Baking Powders. — Carbonic-acid gas may be developed in 
 bread by the action of baking powders. These powders are very 
 extensively employed, and " a conservative estimate of the quantity 
 of baking powder used in the United States each year places the 
 figure considerably above 50,000,000 pounds " (Clark). 
 
 There has, however, been much argument in regard to their 
 wholesomeness, and elaborate researches in chemistry and the physi- 
 ology of digestion have been conducted to determine whether or 
 not the continued use of these ingredients in bread is injurious. The 
 so-called baking powders are manufactured by the combination of 
 many different ingredients, such as sodium carbonate with tartaric 
 acid, the acid phosphate of lime with sodium carbonate and potas- 
 sium chloride (Liebig-Horsford), or a combination may be used of 
 ammonium carbonate with hydrochloric acid. It is claimed by the 
 advocates of the use of baking powders that they possess many ad- 
 
140 FOODS AND FOOD PREPARATIONS 
 
 vantages, such as the fact that the bread rises quicker, and that al- 
 though fermentation does not occur, the bread is more porous, and 
 hence more digestible, and that its taste is not impaired. On the 
 other hand, it is argued that such bread is practically less wholesome, 
 and that its continued use, from the introduction of so many chem- 
 icals, especially when ammonium carbonate is employed, proves irri- 
 tating to the stomach and may excite dyspepsia and gastric catarrh. 
 Even when not used for the making of bread these baking powders 
 are often employed in the preparation of various forms of cake 
 where lightness and quickness in making are important features. 
 
 Baking powder when pure should consist only of cream of tartar 
 (acid tartrate of potash, obtained as a precipitate in the casks in which 
 wine is made) and soda, with a little flour added, and should be free 
 from alum, ammonia, etc. Mixed with water and dough, the soda 
 is split by the acid tartrate, liberating carbonic-acid gas. Alum is 
 sometimes used in baking powders with soda. Its action is less reli- 
 able, and in large quantities it is astringent and injurious to digestion. 
 
 IV. Aerated Bread. — The process of aerating bread consists in 
 the forcing of carbonic-acid gas into the dough under pressure. The 
 gas is generated by the action of sulphuric acid upon lime, and while 
 there are several methods of its use, in general, about one cubic foot 
 of gas is applied to fourteen pounds of flour, although not over one 
 half of this quantity remains in the dough. It is claimed for this 
 process that the bread is exceptionally light, dry, and porous, that 
 there is no danger of malfermentation, with production of acidity, 
 and that it sooner hardens when exposed to the air as compared with 
 home-made bread prepared with yeast. 
 
 Aerated bread keeps fresh longer than other varieties. It has a 
 peculiar taste which, however, is preferred by some people. It is 
 claimed as a further advantage for its manufacture that the bread 
 requires less kneading by the sometimes dirty hands of the baker. 
 Some twenty or thirty varieties of germs are usually to be found 
 beneath the finger nails of persons who are ordinarily cleanly. If 
 special care is not taken by those who prepare bread it is possible 
 for disease germs to be introduced from beneath the nails into the 
 dough. It has been claimed that various infectious diseases might 
 be transmitted in this manner. The danger, aside from any aesthetic 
 consideration, is, however, grossly exaggerated, as the fermentative 
 processes, together with the prolonged heat used in baking, are 
 fatal to both germs and spores. In aerated bread salt is added as in 
 the other processes, with the result of making the bread firmer and 
 somewhat whiter. 
 
 There are many cereals, such, for example, as oatmeal and the 
 coarser whole meals, which are exceedingly wholesome when cooked 
 by some methods, but which cannot be baked into good bread be- 
 cause of the difficulty of making them porous, and their attempted 
 
VEGETABLE FOODS 141 
 
 use in this form usually results in dyspepsia, with heartburn and 
 acid fermentation. 
 
 It is pointed out by Sir Henry Thompson that when coarse meal 
 is necessarily used for bread-making, it, " being a bad conductor of 
 heat, will have a hard, flinty crust if baked sufficiently to cook the 
 interior ; or it will have a soft, dough-like interior if the baking is 
 checked when the crust is properly done." For this reason he ad- 
 vises baking the flour in the form of flat cakes, which can be uni- 
 formly heated throughout. Palatable cakes can be made in this 
 manner by a mixture of wheat meal and Scotch oatmeal. 
 
 The addition of boiled rice flour in bread-making causes the bread 
 to become more adhesive and to hold more water. Hence bakers 
 sometimes resort to this means to make their bread heavier. By 
 turning the fresh loaf over occasionally as it lies upon the shelf the 
 water is prevented from gravitating to the bottom and making it 
 sodden. While the primary object of bread manufacture is to ren- 
 der the starch more soluble, the gluten is also easier digested after 
 fermentation. Freshly baked bread is much less digestible than dry 
 bread for the reason that, being more moist, it tends to form a tena- 
 cious bolus in the mouth which is not readily mingled with the saliva 
 or other digestive secretions. Dry bread, on the other hand, crum- 
 bles into smaller particles, which are easily acted upon by the saliva 
 and pancreatic juice. For the same reason, the crust of bread is 
 more digestible than the interior part of the loaf. 
 
 Spoiled Bread. — Bread may be unfit for use from being made of 
 adulterated or too old flour, from turning sour from bad flour devel- 
 oping excess of lactic acid, from becoming bitter from yeast, from 
 becoming sodden from insufficient fermentation or aeration, and it 
 may grow mouldy from exposure to air when it is too moist. 
 
 " Most of the diseases of the War of 1812 were due to defective 
 food, and in 90 per cent of the cases the flour was at fault. In the 
 War of the Rebellion similar reports were often received " (Wood- 
 ruff). 
 
 VARIETIES OF BREADSTUFFS 
 
 Bread of different kinds constitutes the staple starchy food for 
 Americans, as the potato does for the Irish peasantry and macaroni 
 for the Italians. 
 
 The quantity of bread consumed varies somewhat with the ability 
 to obtain other articles of diet. For example, persons residing in 
 large cities are wont to eat a larger percentage of animal food and 
 less breadstuff than those in the country. The French labourer con- 
 sumes daily eight hundred grammes of bread in the country against 
 five hundred in the city. The most important bread used, both from 
 the standpoint of its nutritive value and the quantity consumed, is 
 •derived solely from wheat flour ; but, for economical or other reasons, 
 
142 
 
 FOODS AND FOOD PREPARATIONS 
 
 this flour is sometimes advantageously mixed with potatoes or bean 
 flour. The latter, added in the proportion of i part to 10 of wheat, 
 gives a white bread rich in nitrogen and highly nutritious. Corn 
 flour may be mixed in the same proportion. 
 
 Composition of Breads and Crackers of Various Kinds (Clark) 
 
 Water. Nutrients. Protein. 
 
 Fats. 
 
 Per cent. Per cent. Per cent. Per cent 
 
 Wheat bread 32.51 
 
 Graham bread (wheat; 34-2 
 
 Rye bread 
 
 Boston crackers 
 
 Soda crackers 
 
 Pilot crackers 
 
 Graham crackers 
 
 Oatmeal crackers 
 
 Oyster crackers 
 
 30.0 
 
 8.2 
 3.0 
 
 7-9 
 5-o 
 
 4-9 
 
 3.8 
 
 67.5 
 65.8 
 70.0 
 
 9i 
 92 
 92 
 95 
 
 95 
 96 
 
 8 
 
 8 
 
 1.9 
 
 55- 
 
 9 
 
 5 
 
 1.4 
 
 53- 
 
 8 
 
 4 
 
 0.5 
 
 59- 
 
 10 
 
 7 
 
 9.9 
 
 68. 
 
 10 
 
 3 
 
 9.4 
 
 70. 
 
 12 
 
 4 
 
 4 4 
 
 74- 
 
 9 
 
 8 
 
 13-5 
 
 69. 
 
 10 
 
 4 
 
 13-7 
 
 69. 
 
 11 
 
 3 
 
 4.8 
 
 77- 
 
 Carbo- 
 hydrates. 
 
 Per cent. 
 
 Mineral 
 waters. 
 
 Per cent. 
 I.O 
 1.6 
 1.4 
 2. 
 I, 
 I . 
 2. 
 I, 
 2. 
 
 Wheaten Flour and Bread. — In the average composition of 
 wheaten bread nitrogen exists in the proportion of 1 part to 21 of 
 carbon (Yeo). Besides the deficiency in nitrogen, there is but a trace 
 of fat in refined flour, a trace of acid, and little mineral matter. 
 
 The following table from the U. S. Department of Agriculture 
 Bulletin No. 67, 1899, gives the percentage of 
 
 Proteids in Wheat Flour 
 
 Albumin 0.3 per cent. 
 
 Globulin 9 
 
 Proteose body 2 
 
 Gliadin 6.8 
 
 Glutenin 4.5 
 
 Total 12.7 
 
 The best wheaten flour for wholesome bread should be of a slight 
 yellowish-white tinge, and not too fine. The colour fades as the 
 flour becomes dry. 
 
 Yellow flour is sweeter and more nutritious than white pastry 
 flour, although it makes a darker bread. The flour contains 10 to 11 
 per cent of gluten. Such flour when mixed with water should form 
 a dough which is both coherent and ductile. These properties are 
 due to the gluten which it contains. 
 
 Bread made from good flour should be porous, but not filled with 
 large holes, and should have the proper consistence and firmness to 
 cut well in thin slices. Wheaten flour contains much less crude 
 gluten after thorough baking, for in the process of strongly heating 
 flours containing nitrogenous material, the proteid as well as the 
 starch becomes more soluble in water (Leeds). 
 
 Heavv, sodden bread has been insufficiently fermented. 
 
VEGETABLE FOODS I43 
 
 Tough, moist, imperfectly baked, or hot bread is liable to ex- 
 cite further fermentation in the stomach, causing heartburn and other 
 symptoms of dyspepsia. The digestibility of such bread is promoted 
 by heating it to drive off the moisture, and by spreading it well with 
 butter to prevent it from agglutinating in the stomach. 
 
 Water continues to evaporate from hot fresh bread, and such 
 bread should not be covered tightly, or else it becomes sodden. 
 
 Stale bread and dry toast are both more digestible than fresh 
 bread. In stale bread water is evaporated to a great extent, so that 
 the bread becomes friable and is more readily masticated and mingled 
 with digestive fluids. The fact that stale bread on being warmed 
 over becomes softer is accounted for on the hypothesis that in dry- 
 ing the water has not all been evaporated, but that some of it has 
 combined with the flour, forming a new compound, which is disso- 
 ciated by the further application of heat (Yeo). 
 
 In toasting, the digestibility of bread is still further promoted by 
 additional heat, and the superficial layers are browned and altered in 
 flavour, acquiring a taste somewhat similar to caramel. Water is 
 evaporated, and a slice, if sufficiently thin, bakes dry and crisp 
 throughout, but if thick, the outer layers are scorched while the mass 
 within may become even softer than before toasting. 
 
 Buttered dry toast is a digestible form of invalid food, for if the 
 butter be spread thin while the toast is quite hot it penetrates to the 
 interior, and both fat droplets and starch crumbs mutually protect 
 each other from cohering in large masses. The butter, moreover, 
 enables one to eat more bread in this form. The same is true of 
 milk toast, and this furnishes in addition a means of giving consid- 
 erable milk to patients who are unwilling to drink it. 
 
 Whole-meal Bread. — For some flours the whole of the wheat is 
 used, the gluten nitrates and phosphates being all retained. They 
 are more delicate than oatmeal, and more digestible. 
 
 Wheat yields soluble matter, such as albumin and dextrin, 
 amounting together to about 10 per cent, besides various salts. The 
 insoluble matter of the grain is chiefly starch and gluten, which con- 
 stitute from 72 to 75 per cent. Wheaten bread contains about 25 
 per cent of carbon and 1.2 per cent of nitrogen (or about 8 per cent 
 of protein material). The proportion which these elements bear to 
 each other and which is needed for maintenance of life is carbon 
 fifteen to nitrogen one ; hence it appears that wheaten bread alone 
 is not an economical food. If man is to live upon it alone for any 
 length of time, brown bread or Graham bread is better than the vari- 
 eties made from fine flour, from which latter the nitrogenous ele- 
 ments have been largely removed by milling. A " bread-and-water 
 diet " is proverbially a reducing diet, and as such it is given to in- 
 subordinate prisoners (see Diet in Prisons), but they cannot subsist 
 upon it for longer than two or three weeks at most. 
 
144 FOODS AND FOOD PREPARATIONS 
 
 Bread made of whole meal is usually not so light as that made 
 with refined white flour. The explanation of this is said to be the 
 fact that the silicious envelope of the grain contains a ferment resem- 
 bling diastase, which is called cerealin. While the dough is rising, 
 this ferment acts upon a good portion of the starch, forming viscid 
 compounds of dextrin and sugar, which by agglutination prevent the 
 carbonic-acid gas from purring up the bread as much as it should. 
 On the other hand, too much attrition in the mill ruptures the indi- 
 vidual starch granules, and without the use of artificial baking 
 powders the bread will not be light and wholesome. " Seconds " is 
 a medium ground flour which makes a digestible bread. 
 
 The British Commissioners of Prisons recommended the use of 
 whole-meal bread for convicts at hard labour on account of its greater 
 cheapness and nutritive value, but advised a modification in the pro- 
 cess of its manufacture. The dough is made of flour from which the 
 sharps, etc., have been removed. The latter are then added and 
 mixed thoroughly with the dough just before it is ready for baking, 
 and it is claimed for this process that there is not time for the cerea- 
 lin to act, and consequently the bread is much lighter. 
 
 Pumpernickel is a German black bread made with unbolted meal 
 and sour dough. It is somewhat laxative. 
 
 Zwieback is a thoroughly dry form of bread, which is very whole- 
 some for invalids. 
 
 Graham bread — so called after Sylvester Graham, who advocated 
 its use — differs from white wheat bread by containing the outer coat- 
 ings of the wheat kernel, called bran, which contain a larger percent- 
 age of albuminous material and of phosphate. The bran, however, 
 while containing serviceable food products, is so difficult of digestion 
 that it tends to irritate the mucous membrane of the intestine and 
 increase peristaltic action. For this reason it is more laxative than 
 white wheat bread, but also less nutritious. 
 
 It is a popular idea that coarse bread, black bread, whole-meal 
 bread, etc., are more nutritious than the bread made from refined 
 white wheaten flour or delicate French breads. This is not neces- 
 sarily true, and much depends upon the digestive organs of the in- 
 dividual. In a report on the digestibility and nutritive value of 
 bread (Bulletin No. 85, U. S. Department of Agriculture, 1900) by 
 Charles D. Woods and L. H. Merrill, they show the coefficient of 
 digestibility of white bread averages 93.37 per cent (in some samples 
 it is as high as 97.06 per cent), whereas that of whole-wheat bread is 
 91.50 per cent, and that of Graham bread is but 86.94 per cent. They 
 also found that bread was rendered more digestible when eaten with 
 milk than if eaten alone, the increase in digestibility amounting to 
 15 per cent. There are peasants in Europe who can thrive upon the 
 coarsest forms of sour, black bread, and there are others who can 
 use different forms of fermenting foods and beverages which to those 
 
VEGETABLE FOODS I45 
 
 unaccustomed to them would prove most injurious. Thus gener- 
 alisations cannot be made, for much depends upon the condition of 
 life of the individual and the general habit of his digestive organs. 
 Wheat bran contains about 15 per cent of nitrogenous material, 3.5 
 per cent of fatty matter, and 6 to 7 per cent of mineral substance, main- 
 ly phosphates (Yeo), all of which materials, from a purely theoretical 
 standpoint, should be nutritious, but, practically, little bran is ab- 
 sorbed, and it is often irritating, especially where feebleness of the di- 
 gestive organs exist. As proved by the researches of Professor Sny- 
 der, this is the reason why bread made from patent flours is so much 
 more digestible than that made from Graham or whole wheat flour. 
 
 According to Bauer, " with wheaten bread, rice, macaroni, etc., 
 the carbohydrates are utilised to within 0.8 or 1.6 per cent, whereas 
 of black bread, potatoes, and the like, 8 to 18 per cent of the carbo- 
 hydrates are passed with the feces." 
 
 Decorticated flour is prepared by special methods of grinding with 
 the object of removing two or three of the outermost and toughest 
 coverings of the grain, but not the inner envelope. Yeo says of 
 bread made from such flour, that while it may be suitable " for 
 young and growing persons with sound and active digestion," it may 
 " prove very indigestible to adults leading sedentary lives. It makes 
 a bread which is usually heavier, moister, and of closer texture than 
 that made from the finest wheat flour." 
 
 When digestion is not vigorous, it is better to obtain the neces- 
 sary nitrogenous material from animal sources. The special uses of 
 coarse forms of bread will be pointed out under the treatment of 
 constipation. 
 
 The portion of grain which is useless in the diet of man is whole- 
 some for some of the lower animals, who can convert it into flesh, to 
 be eventually eaten by man. 
 
 Gluten Bread. — Bread made from gluten flour is useful where 
 there is a tendency to obesity, and is given to diabetics. It may be 
 toasted like ordinary bread. The best bread of this kind is made in 
 Paris, and contains from 40 to 50 per cent of gluten. Another good 
 gluten biscuit is made by the Battle Creek (Mich.) Sanitarium Health 
 Food Company, but there are many so-called gluten breads in mar- 
 ket which do not contain above 16 per cent of gluten, the remainder 
 being starch. 
 
 Poluboskos is a gluten food which is said by those interested in its 
 manufacture to contain only 0.4 per cent of starch. The name indi- 
 cates " much nourishment." It is given to diabetics in doses of one 
 or two teaspoonfuls in milk. 
 
 Rye Bread. — Next to wheat, rye is the most important bread- 
 making flour, although it is less digestible for invalids, and it may be 
 mixed with wheat flour in the proportion of two parts of the former 
 to one of the latter. 
 
146 FOODS AND FOOD PREPARATIONS 
 
 It has the advantage of keeping fresh longer than pure wheaten 
 bread, and if well made it is wholesome and somewhat more laxative, 
 but contains much less gluten than white bread from wheat. It 
 should be baked in a hotter oven to insure its digestibility. 
 
 Biscuits, Pastry, Puddings, etc. — In addition to bread an almost 
 innumerable variety of biscuits, cakes, pastry, tarts, pies, etc., are 
 prepared by the addition, in various proportions, of flour, milk, 
 cream, butter, or other fat, sugar, eggs, flavouring extracts, and 
 fruit, such as raisins. 
 
 For making pastry, cake, and puddings of different kinds, the 
 finer grades of wheat flour are usually employed, although corn and 
 Indian meal are sometimes used. 
 
 The dough is raised in such preparations by the help of yeast, 
 alcohol, fat, baking powders, or whipped white of egg. A hot fire 
 is used in the cooking, and the puddings are either baked, boiled, or 
 steamed, so that the flour is altered by the heat in much the same 
 manner as in the manufacture of bread. 
 
 These foods vary so much in richness and digestibility that it is 
 difficult to formulate any definite rules for their use. In general, 
 they must be avoided by all persons having indigestion, dyspepsia, 
 or, in fact, any severe illness ; but farinaceous puddings, simply made 
 and thoroughly cooked, with the addition of eggs and milk, play an 
 important part in hospital dietaries, and are very good foods for 
 convalescents. 
 
 Boiled or steamed puddings, being unfermented and surrounded 
 with abundant water, are very likely to be sodden or stringy, and 
 therefore wholly indigestible. 
 
 Pastry, even when light, is apt to be too rich, and if not well 
 cooked it is sodden or tough and almost certain to disagree, mainly 
 because of the changes which the high grade of heat produces in the 
 butter or other fats used in its preparation. 
 
 PREPARED FARINACEOUS FOODS 
 {Often called " Infant Foods'" or " Prepared Baby Foods'') 
 
 Prepared farinaceous foods are made by the following methods : 
 1. Application of heat alone. 2. Digestion with malt or diastase 
 combined with heat. 3. After dextrinisation, the food is evaporated 
 with milk or cream. 
 
 The prepared farinaceous foods may be eaten alone or diluted 
 with water, but they are usually given to invalids in a cup of broth 
 or beef tea, which disguises their sweetness. The sweeter varieties 
 are best combined with milk. 
 
 1. Farinaceous Foods prepared by Heat alone. — Flour ball, Ridge's 
 Food, Blair's Wheat Food, Schumacher's Food, Imperial Granum,. 
 and Robinson's Patent Barley are examples of this class. 
 
VEGETABLE FOODS I47 
 
 Wheat and oats are sometimes prepared by roasting (not steam- 
 ing), a process which removes all moisture besides producing some 
 chemical changes in the fats and starches. Cereals treated in this 
 manner will keep from moulding in any climate, and are both diges- 
 tible and nutritious. 
 
 Imperial Granum is a type of a large class of prepared foods, 
 the basis of which is starch, modified, it is claimed, so as to render 
 it easily digestible. Such foods are often fed to newborn infants 
 to the exclusion of milk, but no greater mistake can be made, for their 
 digestive apparatus is wholly unfit to deal with starch in any form. 
 The human infant is designed to be nursed at the breast for the 
 first year of life, and Nature has furnished ample food for it which 
 is wholly devoid of starch. The saliva and pancreatic secretion 
 upon which the digestion of starches depends are not fitted for this 
 work at all during the first eight or nine months of life, and then 
 only partially, hence starchy foods, " farinaceous baby foods," should 
 never be given at all before that age as foods, and should only be 
 used very sparingly, if at all, as mechanical diluents of milk. More- 
 over, in such simple starchy foods as arrowroot the proportion of 
 tissue-building to heat-producing foods is one to twenty, whereas in 
 human milk it is one to five (Starr). Even when the starch of in- 
 fant foods is rendered soluble or dextrinised or converted into sugar, 
 the absorption of too much of such material diverts energy which 
 can be better employed in controlling metabolism in other ways or 
 removing waste. 
 
 Granum is composed of over three fourths starch, made into a 
 fine flour. One teaspoonful of it should go to each three ounces of 
 water, in which it is boiled for ten minutes. An equal quantity of 
 milk is then to be added, and the mixture must be again boiled for 
 five minutes. 
 
 The mixture may sometimes be fed to infants after the eighth or 
 ninth month, but only once or twice in twenty-four hours. It is a 
 useful temporary food for adults with irritable stomachs. 
 
 Flour ball is prepared by boiling wheat flour tied in a bag, with 
 the supposed purpose of converting it into dextrin, and it is a popular 
 belief that this conversion is quite complete ; but it requires a tem- 
 perature of 250 F. to dextrinise starch, and this degree cannot be at- 
 tained by the process. Leeds has shown by recent analyses that even 
 after seventy-five hours of continuous boiling the percentage of solu- 
 ble carbohydrates is increased by only 0.05 of 1 per cent, whereas 
 some of the prepared foods contain from two to six times as much 
 soluble carbohydrate as wheat flour. Flour ball tastes flat and in- 
 sipid, owing to the long boiling dissolving out fat, soluble albumi- 
 noids, and salts (Leeds). 
 
 Starr gives the following rule for the making of flour 
 ball: 
 
I48 FOODS AND FOOD PREPARATIONS 
 
 Tie one pound of unbolted wheat flour firmly in a pudding bag 
 and boil for ten hours. At the end of this time it will be found, on 
 opening the bag, that the outer layer of the ball is doughy, while the 
 interior is hard and dry, it having been baked by the long-continued 
 heat. This hard mass may be used for infant feeding in the latter 
 part of the first year, but it should not be given more than twice a 
 day. The flour ball is grated fine, and it may then be prepared, 
 according to Starr's rule, as follows : " Rub one teaspoonful of the 
 powder with a tablespoonful of milk into a smooth paste, then add a 
 second tablespoonful of milk, constantly rubbing until a cream-like 
 mixture is obtained. Pour this into eight ounces of hot milk, stirring 
 well, and it is then ready for use. The flour ball thus prepared is 
 quite digestible, and it prevents the formation of large curds of 
 milk. 
 
 As a diluent of milk it is much cheaper for the poor than the pre- 
 pared amylaceous foods which are on sale. 
 
 2. Farinaceous foods digested with malt or diastase with heat are 
 often called " Liebig's Foods." 
 
 Liebig's foods are made of equal quantities of wheat flour and 
 barley malt, with bran, and 1 per cent of bicarbonate of potassium. 
 These ingredients are mixed into a paste with water and digested 
 for several hours at fixed temperatures, until the starch is trans- 
 formed into soluble carbohydrates, maltose, and dextrin. The food 
 is strained, pressed, and extracted with warm water, evaporated, 
 dried, and pulverised, when it is ready for use. 
 
 Examples of Liebig's type of dextrinised foods are : Mellin's 
 Food, Horlick's Food, Savory & Moore's Infant Food. 
 
 According to Leeds's analysis, the best samples of Mellin's* and 
 Horlick's foods contain no starch, but a large percentage (Mellin's 
 68.18 per cent, Horlick's 76.83) of soluble carbohydrates, and about 
 10 per cent each of albuminoids — if the process is complete. Savory 
 & Moore's food he finds contains considerable starch. 
 
 Mellin's Food consists of brown sweetish granules, easily soluble 
 in both hot and cold water, milk, etc. It is made of coarsely ground 
 wheaten flour with the addition of malt and potash. It is then 
 digested with water at a moderate temperature to form dextrin and 
 sugar. Afterwards it is strained through sieves and evaporated in a 
 vacuum pan. 
 
 Mellin's Food is often fed to infants, but it contains too much 
 sugar without fat for a wholesome baby's food for continued use in 
 quantity. It may be resorted to temporarily when good cow's milk 
 cannot be obtained. The food may be prepared for use as follows : 
 
 For an Infant One Month Old 
 
 Mellin's Food 5 level teaspoonfuls. 
 
 Fresh milk 10 tablespoonfuls. 
 
 Hot water 22 
 
VEGETABLE FOODS I 49 
 
 For an Infant of Three Months and for Delicate Children 
 
 Mellin's Food 8 level teaspoonfuls (equal to 1 heaping tablespoonful). 
 
 Fresh milk 16 tablespoonfuls (equal to \ pint). 
 
 Hot water 16 tablespoonfuls (equal to \ pint). 
 
 For Infants of Six Months and Over 
 
 Mellin's Food 2 heaping tablespoonfuls. 
 
 Fresh milk 24 tablespoonfuls (equal to £ pint). 
 
 Hot water 8 tablespoonfuls (equal to \ pint). 
 
 Mix the Mellin's Food with a little hot water into a smooth paste, add the 
 remainder of the water and the milk, and mix thoroughly. Keep this mixture on the 
 ice or in a cool place. 
 
 Bengers Food is a preparation of wheateil flour to which, after 
 cooking, pancreatic extract is added. When mixed with warm milk 
 both milk and flour are newly digested. A tablespoonful of the food 
 is dissolved in two ounces of cold milk. Then half a pint of boiling 
 milk or milk and water is slowly stirred in. Further pancreatinisa- 
 tion is then arrested by boiling for twenty to thirty minutes. The 
 preparation has no bad taste and is a nutritious and digestible food 
 in cases of gastric ulcer, phthisis, dyspepsia, etc. 
 
 3. Foods which are Dextrinised and then Evaporated with Milk or 
 Cream. — These are sometimes called " milk foods." Such are Lac- 
 tated Food, Malted Milk, Loeflund's Cream Emulsion, Nestle's 
 Food, Gerber's Food. 
 
 The general process by which foods of this class are made is as 
 follows : 
 
 Wheaten or other flour is first made into dough, baked, ground, 
 mixed with more or less condensed milk or cream, and then dried at 
 a moderate temperature. By addition of malt or diastase the starch 
 is partially converted into dextrin and maltose, and the albuminoids 
 are rendered slightly more soluble, the casein is dried, and the lact- 
 albumin is precipitated. 
 
 One form of " cereal milk " is made from a mixture of wheat and 
 barley meal with milk. 
 
 It is claimed for some of the malted foods prepared for infant 
 and invalid use that the artificial digestion is not wholly completed, 
 and this is said to be an advantage in stimulating the digestive organs. 
 
 Malted milk is a powdered sterilised preparation of pure cow's 
 milk and extracts of malted barley and wheat, the starch of which 
 has been converted into dextrin. The mixture is dried in vacuo. 
 
 The casein of the milk is predigested by a vegetable ferment. 
 The preparation keeps well while hermetically sealed, and when re- 
 quired for use for an infant, from one to four teaspoonfuls are dis- 
 solved in from eight tablespoonfuls to a half pint of water. For 
 adults, two tablespoonfuls of the powder in a half pint of water make 
 the strength of cow's milk. The idea of this preparation is to furnish 
 
150 FOODS AND FOOD PREPARATIONS 
 
 a substitute for human milk which will keep well, be always ready 
 for use, and in which dextrin takes the place of additional fat. 
 
 It resembles Mellin's Food, except that it contains some, though 
 not enough fat. It is used in about the same proportion. It makes 
 a better invalid food for adults than for infants, and patients with 
 enteric fever and severe gastro-intestinal disorder take it with benefit. 
 
 Nestle' 's Food is prepared in Switzerland, at Vevay, from sterilised 
 fresh cow's milk to which wheaten bread crust is added after dex- 
 trinisation by additional heat. Cane sugar is mixed in, and the mass 
 is dried, pulverised, and hermetically sealed in tins. For use it re- 
 quires dilution with water. 
 
 Carnrick's Food is composed of evaporated or desiccated milk 
 partly peptonised and thoroughly sterilised by heat, 45 parts ; dextrin 
 and soluble starch, 45 parts ; milk sugar, 10 parts. 
 
 Eskay's albuminised food consists of the prepared cereals — oats, 
 barley, maize, and wheat together with lactose and Qgg albumin. It 
 contains 11.33 P er cent °f tota ^ solids. 
 
 Bread Jelly. — A bread jelly may be made to add to milk for 
 invalids and for use while weaning infants who are old enough to 
 digest a little starch — i. e., over one year of age. The crumb of 
 stale bread is broken into small fragments and covered with boiling 
 water, in which it is allowed to soak until well macerated. The 
 water is then strained off, fresh water is added, and the mass is boiled 
 until quite soft. On cooling, a jelly forms which may be mixed with 
 milk in any desired proportion. 
 
 Farina is a general name meaning flour, and is defined by Web- 
 ster as " the flour of any species of corn or starchy root " ; but in 
 England the term corn is used as a general name for any grain grow- 
 ing in ears. Farina as sold by grocers in this country is often made 
 from wheat, but much of the gluten and bran has been separated, 
 rendering it less nutritious than whole wheat. In cases of diarrhoea 
 it is more bland and less irritating than whole wheat. The name 
 farina is also applied to fine white potato starch, which forms a jelly 
 when cooked, like arrowroot. 
 
 Wheatena is a nutritious food containing all the wheat berry ex- 
 cepting the husk, and thereby differing from finer preparations in 
 which the layer of gluten cells is removed with the bran. The starch 
 granules, moreover, have been ruptured by heat. It is commonly 
 eaten as a thin mush or porridge. 
 
 Cracked or rolled wheat has similar advantages. 
 
 Shredded wheat and pulled bread are modified breadstuff's which 
 have lately become deservedly popular for dyspeptics on account of 
 their easy digestibility. 
 
 Shredded wheat biscuit is made of wheat which is thoroughly 
 cleaned, washed, cooked, and treated by machinery which draws out 
 the wheat kernels into long, continuous filaments, thus breaking 
 
VEGETABLE FOODS 151 
 
 •down their structure without separation of the component parts. 
 Eighty such filaments are obtained within a space four inches wide ; 
 they are porous and, unlike dough, are capable of absorbing the 
 digestive fluids, thus no leavening or baking powder is required. 
 The shreds are folded by mashing into oblong biscuits, which are 
 recooked at successive temperatures until all moisture is driven off 
 and they are ready for use. They may be eaten soaked in milk, 
 cream, or broth, or moistened with hot water and buttered. 
 
 Crackers. — All kinds of crackers enter more into the dietary in 
 America and England (where they are called " biscuits ") than in 
 any other country. The lighter forms of sugar wafers are nutritious 
 and very easily digested by invalids having mild gastric disorder, 
 for the starch has been well torrefied. 
 
 Crackers vary much in hardness and flavour, but, generally speak- 
 ing, they are quite as digestible as good bread. The simplest forms, 
 such as water crackers or milk crackers, are made with flour and 
 water or milk, to which a little salt is added, after which they are 
 baked in flat shapes so as to become hard and more or less brittle. 
 Soda is sometimes added. If it is desirable to have them less friable, 
 butter may be added in small quantity. The hard unleavened prepa- 
 rations known as " ship biscuits," " hard-tack," and " pilot biscuits," 
 which form an important article of diet for sailors at sea, are manu- 
 factured upon these principles. 
 
 Ship biscuits are so dry and firm that they are much less bulky 
 than bread, and it is estimated that three fourths of a pound of such 
 biscuits is equivalent to one pound of bread in actual nutritive value. 
 
 Most biscuits, if kept long exposed to the air, become exceed- 
 ingly dry and tasteless, although they do not readily mould. Owing 
 to their hardness and unpalatableness when long kept, it is found in- 
 expedient to give them to soldiers or sailors to the exclusion of fresh 
 bread whenever the latter can be obtained. The biscuits known as 
 " hard-tack " are usually made five inches square and are perforated 
 with small holes. They have the advantage of keeping well for a 
 very long time and remaining edible, although they are not very 
 palatable even when fresh. They are extremely tough, and require 
 soaking in milk or water before they can be eaten. 
 
 Granose is a flaky form of entire wheat biscuit prepared by the 
 Battle Creek (Mich.) Sanitarium Health Food Company. It may be 
 eaten with cream or hot milk, and is palatable and nutritious. Gran- 
 ola is a similar preparation. 
 
 Semolino is a name having two applications. In France it de- 
 notes the hard central substance of the wheat grains which are 
 retained in the bolting machine after separation of the finer por- 
 tion which has passed through ; but in Italy the word is used to 
 ■denote the finer portion itself, consisting of fine hard granules 
 rounded by grinding. The larger sizes contain much gluten, and 
 
152 FOODS AND FOOD PREPARATIONS 
 
 may be used to thicken soups. The granules swell in water. When 
 the grinding and sifting process is carried still further the starch 
 granules are obtained in the fine powder which constitutes flour. 
 
 Semolino is used extensively in the manufacture of what are 
 called " alimentary pastes," such as macaroni. 
 
 Macaroni is made by mixing semolino made from hard flinty 
 wheat into a paste which is kneaded and put into a cylinder, the 
 bottom of which is pierced with holes. A piston descends in the 
 cylinder, and the paste issues from the perforations in the form of 
 long thin tubes, which are cooled by a current of air, cut in lengths, 
 and dried on screens. As much as twenty million pounds of maca- 
 roni are manufactured annually in Lyons alone. It contains 16 to 18 
 per cent of gluten, whereas bread holds 10 to 11 per cent. 
 
 Sir Henry Thompson says, in speaking of macaroni, that, 
 " weight for weight, it may be regarded as not less valuable for 
 flesh-making purposes in the animal economy than beef or mutton. 
 Most people can digest it more easily and rapidly than meat ; it 
 offers, therefore, an admirable substitute for meat, particularly for 
 lunch or midday meals." 
 
 After thorough soaking and when well cooked by boiling or 
 stewing in milk or stock it is very nutritious, and it is often agree- 
 ably combined with cheese, although this is not advised for persons 
 with feeble digestive power. Cooked alone with boiling water, 
 macaroni is by many regarded as tasteless ; and as the art of cooking 
 it properly is less understood in this country than in Italy, it is not so 
 favourite an article of diet as it might be. 
 
 The use of Italian pastes, such as spaghetti and vermicelli, in this 
 country is extensive, but by no means as much so as their intrinsic 
 value deserves. They are manufactured from flour from which the 
 starch has been in part removed, and hence contain a relatively 
 large proportion of nitrogenous matter. Although very whole- 
 some they are tough, and require prolonged cooking. The vermi- 
 celli which is sold in the form of letters, to use in soups, cannot be 
 boiled sufficiently to be thoroughly digestible unless the letters lose 
 their shape. 
 
 Buckwheat. — Buckwheat, or blackwheat as it is sometimes called, 
 is indigenous to temperate climates, and in some parts of the world, 
 notably in Russia, Siberia, and Brittany, it constitutes a staple of diet, 
 but in the United States it is the least imporant of the cereals, and 
 is used rather as a luxury for making griddle cakes. The buckwheat 
 produced in the United States is mainly raised in New York, Penn- 
 sylvania, and some of the New England States. Buckwheat bread 
 is nutritious, but it crumbles and does not keep well. 
 
 Soya bread is made from an oily pea which grows in China and 
 Japan, and is used sometimes by diabetics, for it contains over one 
 third part of gluten and but 1.17 per cent of glucose. 
 
VEGETABLE EOODS I 53 
 
 Millet and sorghum are grown in the warmest parts of Asia and 
 Africa, and to some extent in southern Europe. In Russia millet is 
 sold as a white meal. White sorghum, which is a grass or cane, is 
 converted into flour called doura, and in Africa, mingled with barley, 
 it is distilled into beer. A fine quality of alcohol may be made from 
 it. In the United States it is mainly grown for molasses and sirup ; 
 sugar is also made from it. Bread made from either millet or sor- 
 ghum meal is fairly palatable and nutritious when warm, but when 
 it becomes cold it grows dark and crumbles. The grains are hulled 
 like barley and are ground into flour, which is either eaten pure or 
 mixed with bread. Millet is a grass raised largely in India, China, 
 Egypt, along the west coast of Africa, in Italy, Spain, and Portugal. 
 There are many sub-varieties. It contains, on an average, over 7 
 per cent of fat, nearly 10 per cent each of proteid and dextrin, 60 
 per cent of starch, and 2 of sugar (Parkes). 
 
 Eye. — Rye may be said to stand very close to wheat in impor- 
 tance as a food. In Europe it is more in use for bread-making than 
 in this country, where it is mainly eaten by the Germans. In Ger- 
 many the rye production is double that of wheat, and in Russia it 
 is three times greater. Former generations lived almost entirely 
 upon rye in France, as they did upon oats in Scotland and parts of 
 England, wheat being an almost unobtainable luxury. 
 
 Rye yields a coarser, darker bread than w r heat, but is about 
 equally nutritious, although not always so digestible, and it is some- 
 what laxative. In general, the statements made in the preceding 
 pages (pp. 1 37-141) in regard to bread-making, etc., with wheaten 
 flour, may be applied to rye flour. 
 
 Rye bread contains less gluten than wheaten bread, and it takes 
 less time to raise and bake it, provided the oven is very hot. If prop- 
 erly made it is easily assimilated, and many like its taste. 
 
 Rye is often combined with wheat in France, under the name 
 of meteil, and in Spain and Greece a mixture of the same name is 
 made with barley instead of wheat. 
 
 Corn. — Maize, or Indian corn, is very extensively grown in tem- 
 perate and warm climates all over the world. It may be dried, 
 parched, and roasted whole, or ground into meal of various degrees 
 of fineness. 
 
 There are some 300 varieties of corn, but the common kinds 
 are known simply as white, yellow, and red. 
 
 The chief preparations of corn are hominy, samp, cornmeal, 
 cracked corn, cerealine, and maizena (a South American cornmeal, 
 used in the manufacture of a drink called 4l chicca "). 
 
 Aside from its use as a food, corn furnishes alcohol and liquor, 
 as well as glucose and laundry starch. 
 
 Chittenden and Osborn have made an elaborate research into the 
 chemical composition of the " proteids of the corn or maize kernel " 
 
154 FOODS AND FOOD PREPARATIONS 
 
 (American Chemical Journal, vol. xiii, Nos. 7 and 8, and vol. xiv, 
 No. 1). These consist of " three globulins, one or more albumins, 
 and an alcohol-soluble proteid " called maize fibrin or zein. 
 
 Corn is a wholesome cereal, for it contains considerable fat and 
 proteid as well as starch, and it furnishes abundant energy, produc- 
 ing heat. It is very fattening for both the lower animals and man. 
 In the Southern States and in France it is largely fed to horses. 
 
 As a vegetable, corn is less used in Europe than in America, 
 perhaps on account of the prevalent idea that it is a hog's food, 
 although cornmeal is employed for baking into cakes and to mix 
 with flour in bread-making. Eaten as a vegetable, unless very young 
 and tender, corn is one of the least digestible foods, and canned corn 
 is notoriously so. This is chiefly on account of the toughness of the 
 husk of the kernel, which often is found in the feces practically 
 unaltered by its transit through the body. Hence it may cause 
 flatulency, indigestion, and diarrhoea. 
 
 Cornmeal, on the other hand, is quite digestible, and, like oat- 
 meal, is somewhat laxative. As compared with wheaten flour, it 
 contains more fat, having about 9 per cent, but it is deficient in salts. 
 It makes a dry, friable bread. 
 
 Samp is a very digestible form of corn when well boiled. 
 
 When maize becomes mouldy it causes the disease known as 
 pellagra. (See Diet in Pellagra.) 
 
 Polenta is a maize meal extensively used in Italy. 
 
 Cornstarch is very white and soft. It contains 53 per cent of 
 starch. The best grades are used as a substitute for arrowroot, and 
 make a wholesome invalid food, being very white and soft. 
 
 Indian meal is yellow, granular, and coarser than cornstarch. 
 
 Mush is made of well-ground cornmeal or Indian meal. The 
 cereal is boiled in salted water, and when cooked is not pasty, but 
 mixes well with cream, and is very digestible and nutritious. 
 
 Rice. — Although less eaten in this country than wheat, corn, and 
 rye, except in the Southern States, rice constitutes the staple food 
 of a majority of the world's inhabitants. Asia produces most of the 
 rice consumed, but a little is grown in Spain, Italy, and Portugal. 
 According to Clark, " in Asia a large part of the population con- 
 sume 275 pounds per head a year," and nearly two billion pounds 
 are used per year in Europe. In the United States, where rice 
 was first introduced in 1694, it is chiefly grown in South Carolina. 
 There are several hundred varieties of rice, the two principal classes 
 being the dry or mountain rice, and the wet rice, which grows in 
 flat marshland, periodically inundated. Both the Chinese and Japa- 
 nese make a wine from rice, and a vinegar can also be obtained. 
 
 The native Oriental method of treating rice is to beat the ker- 
 nels of grain out of their husks in wooden mortars, and for European 
 markets they are glazed by shaking in a sheepskin-lined drum 
 
PLATK V 
 
 wjmaSB^ir*j-s 
 
 
 "£ A A&* •■■•* 
 
 
 
 Rice Starch x 150 
 
 
 
 
 **M « 
 
 
 & m t*+ 
 
 
 Rice Starch x 450 
 From Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau 
 
 BY 1 1,11 -Till; it UM'IIARltSiiN. 
 
VEGETABLE FOODS I 55 
 
 (Clark). They are also bleached, and may be broken after decorti- 
 cation and ground into a flour. 
 
 Rice contains more starch than any other cereal — from 75 to 85 
 per cent — and is an exceedingly digestible form of starch for in- 
 valids when properly cooked, so that the individual grains are 
 swollen or softened. This object is best attained by the process 
 of steaming. The digestibility of plain boiled rice is improved by 
 eating it with a little fresh butter, which coats the kernels and pre- 
 vents their agglutination into a pasty mass. If the rice tastes in- 
 sipid it may be spiced or flavoured with raisins. Rice pudding, 
 milk and rice, and rice with beefsteak juice constitute excellent foods 
 for young, growing children, and for use in convalescence from 
 typhoid fever, diarrhoeas, and many other diseases. It is also advan- 
 tageous to eat rice with fruit, such as apples or prunes. 
 
 Rice should not be depended upon without some form of animal 
 food, for it contains too little nitrogen to satisfy the needs of the 
 system. 
 
 Bread cannot be made economically from rice, on account of the 
 small amount of nitrogen which this cereal contains, and the con- 
 sequent lack of stability in the shape of the loaf, and unless wheat 
 be added in large proportions, such bread is indigestible and watery. 
 
 Barley. — Barley ranks very close to wheat in nutritive power, and 
 cooked barley meal, like wheaten flour, contains gum, albuminoids, 
 starch, and dextrin. As compared with wheat, barley contains more 
 fat, salts, and indigestible cellulose, less protein, and less digestible 
 carbohydrate. 
 
 The employment of barley bread for food is of very ancient 
 date, reaching back to the early days of the Greeks and Hebrews, 
 but with the spread of the use of potatoes and the cheapening of 
 w r heaten flour, it has fallen into comparative disuse, and in the 
 United States barley is mainly used to thicken soups and in the 
 manufacture of beer. In some of the Pacific States it is fed to 
 horses. Pearl barley is made by depriving barley corns of their 
 outer shells or covering, and then subjecting them to rubbing be- 
 tween a single millstone and a sheet of rasped iron or wire cloth, a 
 process which polishes the kernels and rounds them off. 
 
 Barley water makes an excellent diluent of milk and a demulcent 
 drink for infants and invalids. For the latter it may be flavoured 
 with lemon juice. It may be made as follows : Grind half an ounce 
 of pearl barley in a coffee mill, add six ounces of water, boil twenty 
 minutes, add salt, and strain. It should be made fresh daily and 
 kept in a cool place. It is better than oatmeal water whenever the 
 bowels are loose. The latter, made in a similar manner, is to be 
 preferred when constipation exists. 
 
 Oatmeal. — Oats contain considerable fat, protein, salts, and indi- 
 gestible cellulose, in addition to a large percentage of starch. They 
 
156 FOODS AND FOOD PREPARATIONS 
 
 have been eaten in Germany for over a thousand years, and consti- 
 tuted the original grain food for all Europe. 
 
 Oatmeal is much less used than other cereals for bread because 
 it lacks gluten, although it is still so employed to a limited extent 
 among the poorer classes in France. It makes a dark, bitter bread, 
 but forms a better porridge than can be obtained from rice or 
 barley. The use of oatmeal porridge by all classes is very exten- 
 sive throughout the United States. This is largely attributable to 
 the improved methods of its preparation by high milling, rolling, 
 etc. Scotch groats are prepared by removing the outer husk, leav- 
 ing the grain almost whole. The grain is then reground between 
 closer set millstones. It forms two grades of meal, the coarser of 
 which is used for porridge and the finer to make bannocks or oat- 
 meal cakes. A good deal of the oatmeal sold in America is identical 
 with Scotch groats. True Scotch groats are heated by the miller 
 over perforated iron plates and slightly parched for three or four 
 hours before being ground. For those who can digest oatmeal well, 
 it ranks among the cheapest and most satisfying of foods. 
 
 The nutritious value of oatmeal is great, but it depends very 
 largely upon the skill with which it is cooked. It is not infre- 
 quently cooked in such a manner that the individual grains are left 
 whole, but in this form the flavour is less well developed than it is 
 by prolonged cooking ; the oatmeal granules are much more diffi- 
 cult of digestion, and are capable of exciting gastro-intestinal irri- 
 tation in feeble persons. But for many people oatmeal thus cooked 
 possesses a decided advantage from the fact that it is less completely 
 absorbed, leaving a considerable residue which adds to the bulk 
 of fecal matter, excites peristaltic action, and reduces the liability 
 to constipation. For most persons, however, and especially for all 
 those with limited digestive power, oatmeal should be so thor- 
 oughly cooked as to acquire the consistence which enables it to 
 be easily poured, and on cooling it should form a tender, gelat- 
 inous mass. 
 
 Oatmeal is a very hearty food, and those who eat much of it 
 should live a vigorous outdoor life. If ill-cooked and if given to 
 very young children, it occasions colic, flatulence, and rashes. 
 
 It is best when of recent crop and freshly ground. If it is kept 
 long it absorbs moisture, and, losing its delicate flavour, becomes 
 mouldy and sour. 
 
 The following analysis of oatmeal is given by Letheby : 
 
 Nitrogenous matter 12.6 per cent. 
 
 Carbohydrates, starch, etc 63.8 " 
 
 Fatty matter 5.6 " 
 
 Mineral matter 3.0 " 
 
 Water 15.0 
 
 Total 100. o 
 
VEGETABLE FOODS I 57 
 
 Oatmeal, like cornmeal, has more protein and fat than the flours 
 and meals derived from other cerealia, and hence, like bread, it may 
 be eaten daily without impairing the appetite. 
 
 Revalenta, or revalenta Arabica, is a farinaceous food much eaten 
 in some parts of Europe, which is a mixture of several meals, princi- 
 pally ground peas, beans, corn, and lentils, but barley and oatmeal 
 may be included. 
 
 Arrowroot. — Arrowroot is derived from the rhizomata or root 
 stocks of several kinds of tropical plants grown in both the East and 
 West Indies. The roots are washed, reduced to a pulp, strained, 
 dried, and pulverised into a very fine starchy flour. The best flour 
 is made from the Maranta aruridinacea. It is obtainable in market in 
 the form of a fine white powder, and consists of exceptionally pure 
 starch, the granules of which are small and friable. It has a very 
 bland, insipid taste, and it is as digestible or more so when cooked 
 than any other starch which is used in making gruel or jellies for 
 invalids. In the form of a jelly it keeps longer without souring than 
 do many other forms of starchy food, such as the potato ; and in bad 
 cases of dyspepsia, when much gastric irritation exists, it often con- 
 stitutes a serviceable article of diet. Arrowroot is sometimes fed to 
 young infants, but it is unwholesome for them, and ferments in the 
 stomach. 
 
 Tous-les-mois. — Tous-les-mois is a starch derived from a West 
 Indian tuber by maceration, straining, washing, and drying. It is 
 used for the same purpose as arrowroot. Its granules are the larg- 
 est of any of the food starches, but they are quite digestible and 
 nutritious for invalids. 
 
 Salep. — Salep is a starchy food which is obtained from the tuber- 
 cles of certain Oriental orchids. It is a mixture of starch and mu- 
 cilage which makes a useful demulcent drink. 
 
 Tapioca, Cassava. — Tapioca and cassava are made from the 
 rhizomata of the Manioc utilissima or Manihot, a common plant in 
 temperate and tropical regions. It is extensively grown in South 
 and Central America, Africa, and the West Indies. Manioc flour 
 forms the basis of food of the natives, and when made into bread 
 and cakes it replaces the wheaten bread of Europe and North Amer- 
 ica. Cassava contains a poisonous juice that must be first drained off. 
 
 Tapioca, which is purified cassava, is made, like sago, by drying 
 on hot plates, the clarified starch being first heated into a paste in 
 large metal pans. It is an almost pure starch. The granules are 
 not tough, and are very easily digested, so that they form one of 
 the most useful of the amylaceous foods for persons with feeble 
 digestion. Tapioca may be eaten alone in the form of puddings 
 with cream or flavoured with lemon juice, wine, nutmeg, or other 
 spice or aromatic, or may be used to thicken broths or soups. 
 " Pearl tapioca " is a spurious article made from potato starch. 
 
158 FOODS AND FOOD PREPARATIONS 
 
 Air-dry tapioca contains 11.97 per cent of water. Water-free 
 tapioca consists of: protein 0.79, carbohydrates 98.90, and ash 0.31 
 (C. D. Woods and L. H. Merrill). 
 
 Sago. — Sago is an easily digestible form of starch derived from 
 the pith found in the stem of different varieties of palm from 
 Sumatra, Java, and Borneo. It is commonly sold in market in a 
 granular form, and is known as " pearl sago." This is prepared by 
 adding water to sago flour so as to form a paste which is run through 
 sieves to granulate it. The spherical form of the granules is ac- 
 quired by allowing them to fall into a shallow iron pan held over a 
 fire. Sago is made with milk, cream, and eggs into nutritious pud- 
 dings, and it may be used to thicken broths and soups of various 
 kinds. It has an agreeable flavour, somewhat more delicate than 
 tapioca, and is an invaluable adjunct to the invalid dietary. 
 
 Iceland Moss (Cetraria Islandica) is a lichen sometimes employed 
 as food after purifying it by washing. It contains at first various 
 bitter principles, which "must be eliminated. It can be made into 
 bread or used as an ingredient of blancmange, etc. It has been 
 recommended by Senator and others for use by diabetics to replace 
 ordinary bread, and it makes a convenient vehicle for the adminis- 
 tration of fats, such as bone marrow (Walker). It also forms a good 
 demulcent decoction. 
 
 Several forms of seaweeds are used as food by the Japanese,. 
 Siamese, and Polvnesians. 
 
 Starchy Foods for Children 
 
 The best cereals and other starches for children are rice, hominy,. 
 Indian meal, barley, oatmeal, cracked wheat or wheaten grits, farina, 
 cornstarch, and sago. 
 
 When the cereal grains are used instead of flour, they should be 
 soaked in cold water for five or six hours and then cooked for two 
 or three hours in a double boiler. If fed to infants less than two 
 years of age or to children with any gastro-intestinal disorder, they 
 must be thoroughly strained. They should be salted and served 
 with cream, but without much sugar. The steamed preparations 
 of oats, wheat, etc., which are sold in market, may be boiled one 
 hour, and otherwise treated as the grains. 
 
 Bread and crackers may be allowed to infants after the first 
 year, but only with their meals. The bread should always be porous, 
 well baked, and stale. It may be toasted, or given dry in milk, or 
 moderately buttered. Zwieback and plain rusk are also good foods 
 for young children. 
 
 Crackers are made in great variety for children who have passed 
 the second year. They should not be too dry or hard. They may 
 be eaten in milk or with beef juice, or separately, with meals only. 
 
ATE VI 
 
 "':} 
 
 MARUNTA 
 
 POTATO 
 
 
 i" 
 
 9 
 
 \ 
 
 L..i>^ 
 
 GINGER 
 
 rtfe 
 
 € 
 
 it 
 
 
 
 SAGO 
 
 ^fip 
 
 B 
 
 PEAS BEANS 
 
 STARCH GRANULES, MAGNIFIED. 
 
 (From- Bulletin No. 13, Division of Chemistry, United States Agricultural Bureau . 
 
 DRAW N Rl iiK(i. MARX. 
 
VEGETABLE FOODS I 59 
 
 The best are those made of wheaten or Graham flour, oatmeal, or 
 gluten. The latter are the least palatable. 
 
 A large variety of prepared cereal foods are sold and recom- 
 mended especially for children's use. These foods have been con- 
 verted by heat or malt to dextrin and glucose or maltose, but they 
 often contain a deficiency of flesh formers, and should never be long 
 relied upon for feeding young infants to the exclusion of more natu- 
 ral food. (See Prepared Farinaceous Foods, p. 146.) 
 
 Diastase, Malt Extracts, etc. 
 
 Diastase is a vegetable ferment which has the property of con- 
 verting starchy foods into a soluble material called maltose. It is 
 soluble in water and weak alcohol, insoluble in stronger alcohol. Its 
 advantage, as compared with similar ferments in the saliva and pan- 
 creatic juice, is considerable, and its strength enables it to dissolve 
 starches when present in the proportion of only 1 to 2,000. Like the 
 above-named ferments, it acts in alkaline solution, but, unlike them, 
 it continues to operate in acid media ; hence its action is not dis- 
 turbed by the gastric juice. Diastase is the peculiar substance which 
 causes the ripening during germination of fruits and vegetables by 
 converting their starches into dextrins and sugars. Hence fruit 
 becomes more and more digestible as it ripens. 
 
 In prescribing diastase or malt extract it should be remembered 
 that the ferment is precipitated and destroyed by alcohol of even 
 moderate strength, and also by salicylic acid, which is antagonistic 
 to it. 
 
 When malt is added to a pease pudding or other mashed vege- 
 table, it separates the mass into a paste of cellulose and vegetable 
 casein, with a supernatant solution of dextrin. 
 
 Williams recommends the use of malt flour with cereal foods to 
 render them more digestible. Malt flour alone is too sweet, but, 
 added in the proportion of one part to four or eight of oatmeal, it 
 makes an excellent light, thin porridge for invalids. 
 
 A variety of malt extracts and malted foods are prepared for in- 
 valids, and many of them possess intrinsic value for nutrition and 
 tonic action. They are especially useful in chronic and subacute ail- 
 ments and convalescence from protracted fevers. They are benefi- 
 cial in tuberculosis, caries, chronic abscess, neurasthenia, the scrofu- 
 lous diathesis, typhoid fever, and to some extent they can be used 
 as beverages to replace the stronger malt liquors, ale, beer, etc., for, 
 according to Leeds, they always contain above 3 per cent of alcohol. 
 
 All malted foods are deficient in fats and protein. Farinaceous 
 meal of any kind mixed with one eighth of its weight of ground 
 malt forms a highly digestible combination. Even 20 per cent of 
 meal can be used, and the preparation still keeps fluid (Roberts). 
 
l6o FOODS AND FOOD PREPARATIONS 
 
 Kepler s Extract of Malt is given in the dose of a teaspoonful 
 after meals in milk or soda water, or it may be spread upon any form 
 ■of starchy food. 
 
 Loeflund's Malt Extract is given in doses of a dessertspoonful 
 after meals in a gobletful of milk. 
 
 Maltine is made from three cereals — barley, wheat, and oats. It 
 is rich in diastase. It may be added in equal part to wheat or barley 
 flour which has been previously boiled in water, and the mixture 
 may be used as a diluent of milk. Maltine may be taken after meals, 
 either plain or added to cod-liver oil, coca wine, pancreatin, hypo- 
 phosphites, etc., for use in tuberculosis and other diseases. 
 
 HofF's Malt Extract is given in doses of a wineglassful or more 
 with meals for adults, and one or two tablespoonfuls for children. 
 It contains considerable diastase, a minimum of alcohol (about 2 
 per cent), and is said to be free from noxious ingredients. It may be 
 drunk warmed, with a lump of sugar added, as a soothing draught 
 to allay cough. If desirable for feeble stomachs, it may be diluted 
 with water or soda water. 
 
 Trommers Diastatic Extract of Malt is composed of the soluble 
 ingredients of Canada barley malt. It is of a sirupy consistence 
 and has a sweetish taste, which some patients object to, while many 
 prefer it. The sweetness may be lessened or disguised by dilution 
 with water, hot milk, brandy, whisky, or rum. It is advisable, if the 
 stomach is feeble, to give teaspoonful doses at first, to be increased 
 to a tablespoonful three times a day after meals. 
 
 Pancreatic extract or three to five grains of pancreatin with five 
 grains of sodium bicarbonate may be added to a cupful of thick, well- 
 boiled farinaceous gruel of any sort — oatmeal, cornstarch, etc. — 
 and if kept at ioo° F. for a few minutes, the mass is soon liquefied 
 and made digestible. The hydrated starch has been converted into 
 dextrin and sugar. There is little or no alteration produced in taste, 
 and if starch is to be given to an infant under a year old for any 
 purpose, it may be prepared in this manner. 
 
 Vegetable Food 
 
 Nearly all the great divisions of the vegetable kingdom afford 
 wholesome food for man. 
 
 Vegetable food eaten in large quantity increases the elimination 
 of carbon dioxide from the lungs. It also makes the urine alkaline 
 and intensifies the alkalinity of other secretions. The urine of her- 
 bivorous animals is normally alkaline when they are well fed, but 
 during prolonged fasting it becomes acid. The nursing calf when 
 taking only animal food from the mother passes acid urine, but after 
 weaning, when the animal changes to a vegetable diet, the reaction 
 becomes alkaline. 
 
VEGETABLE FOODS l6l 
 
 The chief vegetable proteids are vegetable albumin, vegetable 
 casein or legumin, and gluten. The latter predominates in the cerea- 
 lia, and the legumin is principally found in pulses. These proteids 
 are less rich in nitrogen than the corresponding animal albuminates. 
 
 Many vegetables contain tough cellulose, and at best not over 50 
 per cent of this material is digested and assimilated in man, although 
 the lower animals derive much more nutriment from it. 
 
 A purely vegetable diet is not economical for a labouring man, 
 for the reason that to derive sufficient nitrogenous substance from it 
 he must either obtain the very best and most expensive cereals or 
 legumes, or he must eat a very large quantity of vegetables. (See 
 Vegetarianism, p. 35.) By the addition of albuminous food or fat 
 to his diet he saves both expense and wear and tear of his digestive 
 organs. If unable to obtain fresh meat, he may employ for this 
 purpose milk, bacon, lard, dried fish, such as herring or cod. Among 
 vegetable foods oatmeal and beans will furnish him with the largest 
 available proportion of nitrogenous material. Vegetables, except 
 those which are really seeds, such as those of the leguminosse or 
 pulse tribe, contain but little fat. 
 
 A strict classification of vegetables is impossible in these pages. 
 Green corn is certainly a vegetable, but it is more conveniently 
 described in connection with cornmeal, samp, etc., among the cereals. 
 (See Maize, p. 153.) 
 
 Certain vegetables are classed as " green vegetables," meaning 
 the lighter kinds of vegetables which contain considerable earthy 
 salts and comparatively little starch, like spinach and lettuce, in dis- 
 tinction from heavy vegetables which contain much starch, like pota- 
 toes, beans, etc. The former term is used to describe fresh garden 
 vegetables of all kinds in distinction from those which, like potatoes 
 or onions, may be kept for some days or weeks without spoiling. 
 The name is, however, too vague for accurate description. 
 
 " Greens " is the common name given to such vegetables as 
 spinach, lettuce, beet tops, etc., which contain much chlorophyll and 
 little starch or sugar, and which are eaten soon after being taken 
 from the garden. 
 
 A simple division of vegetables for patients is (a) those the edible 
 portions of which grow above ground and (b) those which grow 
 below ground. With few exceptions, like the legumes, corn, and 
 cabbage, the heavier vegetables — i. e., those which require more 
 digestive power, and which contain abundant starch or sugar — grow 
 below ground, or are tubers. Those which grow above ground are 
 more digestible when fresh and young. 
 
 Celery, however, is not a tuber, is not especially " starchy," and 
 yet grows, in part, at least, beneath the earth ; so it is best in all im- 
 portant cases to specify by name the individual vegetables which can 
 be partaken of rather than to describe them in general classes. 
 
l62 FOODS AND FOOD PREPARATIONS 
 
 Many vegetables, in themselves difficult of digestion, may be 
 made less so by conversion into well-cooked purees, or their extracts 
 can be used for flavouring broths and soups for invalid use. Gener- 
 ally speaking, dried vegetables are much less digestible than when 
 fresh. They become hard, stringy, and tasteless. 
 
 The following-named vegetables are those in common use which 
 contain the largest percentage of both starches and sugars : Pota- 
 toes (both white and sweet), yams, beans, lentils, corn, peas, carrots, 
 parsnips, beets, turnips. 
 
 Vegetable foods which are somewhat stimulant or pungent in 
 their action are leeks, onions, garlic, herbs in general, mustard, 
 cresses, mints, asparagus, and radishes. They increase the secretion 
 of the saliva and gastric juice, and several are somewhat diuretic. 
 
 Some vegetables are laxative on account of their special chemical 
 composition. Such, for example, are spinach, tomatoes, and most 
 green vegetables when fresh and well cooked. Some, like cucum- 
 bers, are laxative from the seeds, or, like old corn, from the indigesti- 
 ble residue which they contain. The heavier vegetables, such as 
 peas, beans, turnips, potatoes, etc., are liable to be constipating, al- 
 though they aid normal peristalsis in that class of cases in w T hich the 
 diet has been previously mainly nitrogenous. (See Dietetic Treat- 
 ment of Constipation.) 
 
 Vegetables which have a special antiscorbutic reputation are cab- 
 bage, tomatoes, and all those used for fresh salads. These also fur- 
 nish calcium oxalate in the urine. 
 
 All vegetables which are eaten raw should be thoroughly washed 
 beforehand ; otherwise they may be contaminated with manure and 
 other impurities, or the excrement of domestic animals which have 
 been roaming in the garden. The larvae of both tapeworms and 
 roundworms have been transmitted to man in this manner. Water 
 from foul wells is sometimes used for sprinkling gardens, and it is 
 possible for typhoid, cholera, or other noxious germs to be spread 
 by this means when the vegetables are eaten raw. 
 
 Legumes 
 
 Peas, Beans, Lentils, Peanuts. — Legumes rank next to cereals in 
 importance as vegetable food. In middle and northern Europe 
 among legumes peas are preferred, but in Mediterranean countries 
 the use of beans and lentils predominates. In this country both peas 
 and beans are extensively eaten, the lentil very little. Owing to the 
 exceedingly leathery external envelope which they possess when old, 
 legumes are very indigestible unless cooked for a long time, and if 
 dried they require previous prolonged soaking in cold water, for 
 drying diminishes their size and makes them extremely tough. 
 Fresh legumes contain much water, and in percentage composition 
 
PLATE VII. 
 
 Bean Starch x 145 
 
 Pea Starch x 145 
 [From Bulletin No. 13, Division of Chemistry, United States Agricultural Buretu 
 
 IH'Tn i:\ ' 1.1 KKiHMl It 1 ( II A RPSIIN . 
 
VEGETABLE FOODS : 1 63 
 
 resemble the cabbage. They also contain much protein, carbo- 
 hydrates, and a little fat. The proteid substance v. Liebig called 
 " plant casein," from its resemblance to milk casein. It differs from 
 the proteid gluten of grains and pea and bean flour and will not form 
 dough or make bread. The percentage of protein in legumes ex- 
 ceeds that of the best beef (M. H. Abel). Although the legumes 
 contain so large a percentage of protein, it is by no means all assimi- 
 lated. Hoffman found that nearly one half of the protein of lentils 
 passed off in the feces, being unabsorbed. Striimpell found that 
 40 per cent of the protein of whole beans — i. e., with the skins in- 
 tact — is undigested ; but when made into flour only 8.2 per cent of 
 protein was unabsorbed, the latter corresponding with the digesti- 
 bility of meat protein. 
 
 Legumes are liable to induce intestinal fermentation, with exces- 
 sive and often annoying production of gas (methan), hence they are 
 not available as the sole article of diet. If eaten as an exclusive 
 food, eighteen ounces of dried peas or beans, making six pints of 
 thick soup, would have to be consumed daily (M. H. Abel). 
 
 Dried or " split " peas have had the external envelope removed, 
 and they may be made into nutritious purees. The tough external 
 coats of old peas may often be found wholly unaltered in the feces. 
 
 According to Parkes, a pound of peas contains 168 grains of 
 starch, and about 6.5 per cent of this food is wasted in the alimentary 
 canal. 
 
 Fresh very young green peas, petit pois, are easily digested, and 
 may occasionally be allowed in a convalescent dietary, but old and 
 tough legumes require more mastication even than meat. 
 
 The legumes are often cooked with pork, which raises the per- 
 centage of fat in this form of food and adds to their nutritive value. 
 Baked beans are cooked in this way, and also pea soup ; the swelling 
 starch granules mingle with the melting fat of the pork and make 
 the dish more palatable as well as much more digestible than when 
 this fat is added to meat in the form of croquettes or mince, when it 
 merely smears the outside of the larger particles of food. 
 
 Erbswurst, or pea sausage, was introduced some years ago in the 
 German army. It was invented in 1870 by a cook named Griinberg, 
 and the German Government bought the secret of its preparation. 
 It is a cooked food composed of pea meal mixed with fat pork and 
 salt, so treated as to prevent the decay of legumin. It is highly nu- 
 tritious, for the peas contain a large proportion of nitrogenous as 
 well as starchy material, and the fat furnishes energy, but as a diet 
 it soon becomes monotonous, and not infrequently produces flatu- 
 lence and diarrhoea, for which the legumes are noted. The flatu- 
 lence is caused by liberation of sulphuretted hydrogen from a sub- 
 stance called legumin. 
 
 Erbswurst may be quickly made into soups. It figured largely 
 
164 
 
 FOODS AND FOOD PREPARATIONS 
 
 in the Franco-Prussian War, and was known as the " iron ration." 
 A powdered " pea soup " may now be obtained which is composed of 
 powdered peas and extracts of beef with salts and herb extracts for 
 flavouring. A three-and-a-half-ounce package contains in grammes : 
 proteids, 21 ; fats, 17.25 ; carbohydrates, 46.5. It is excellent for 
 army service in the field. 
 
 Composition of some Prepared Military Pea Foods (Woodruff) 
 
 
 Water. 
 12.09 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Wood 
 fibre. 
 
 Ash. 
 6.15 
 
 n-73 
 13-53 
 
 6.03 
 
 Authority. 
 
 
 3I.I8 
 16.OO 
 I5-70 
 16.93 
 15.81 
 
 21.09 
 
 3.08 
 
 35- 00 
 
 23.00 
 
 8.98 
 
 24.41 
 
 17.25 
 
 47-50 
 27.OO 
 
 53-44 
 36.78 
 
 46.45 
 
 1-34 
 1.69 
 
 4.40 
 
 Blythe. 
 Parkes. 
 
 as first used. . 
 1887 
 
 Dried pea soup (1) 
 
 " " " (2) 
 
 Kopf's " " (used by 
 the English army). . . . 
 
 7.58 
 8.08 
 
 4.78 
 
 Konig. 
 
 S. P. Sharpless. 
 
 Penzoldt has succeeded in obtaining predigested vegetable albu- 
 min by the following receipt : 
 
 Finest pea meal 250.0 grammes. 
 
 Pepsin 0.5 gramme. 
 
 Salicylic acid 1 . o " 
 
 Mix and let stand at ioo° F. for twenty-four hours ; strain. 
 
 The fluid retains the taste of pea soup, and is quite free from 
 starch. It may be added to meat extracts or eggs, and may be fla- 
 voured with salt, pepper, and spices. 
 
 Haricots or kidney beans constitute a very serviceable article of 
 diet, being one of the cheapest and best of all the pulses. These 
 beans must be thoroughly soaked until swollen and soft before boil- 
 ing, and should be only eaten when wholly tender. Their flavour 
 is heightened by the addition of a little onion, parsley, or other 
 aromatic vegetable, and their nutritive value is increased by cooking 
 them with pork. 
 
 Fresh, young, and tender string beans are very digestible. 
 
 Young, fresh Lima beans are wholesome and very nutritious, but 
 if old they are indigestible. 
 
 The red bean of the tropics, which is largely used in the Mexican 
 army ration, is less prone to cause diarrhoea than the dry domestic 
 white bean ; but it has a more tender skin, is therefore less easily 
 transported, and it absorbs moisture so rapidly that it is liable to 
 ferment. 
 
 The frijole is a small, flat, reddish-brown bean much eaten in 
 Mexico and neighbouring portions of the United States. 
 
 The soy bean is the chief legume of China and Japan, where it 
 furnishes the necessary protein to add to a rice diet. From its vege- 
 table casein several varieties of bean cheese are made. 
 
PLATE VIII 
 
 Potato Starch x 43 
 
 Potato Starch 
 (trom Bulletin So. IS, Division of Chemistry, United States Agricultural Bureau) 
 
 'HMTO l!Y 1 1.1 1 Hi 'K 1> RICHARDSON. 
 
VEGETABLE FOODS 165, 
 
 Lentils. — Lentils are much cultivated in the south of France, and 
 also near Paris. They are usually dried and split, in which condition 
 they make a nutritious soup. They are used more on the Continent 
 of Europe than in this country, and they are eaten in England, 
 usually in the form of puree. Lentil flour contains twice as much 
 protein as that of oats or wheat, and nearly twice as much lime 
 (Roberts). The Hindoos rely upon the lentil for its staying power 
 when undertaking arduous journeys. 
 
 Lentils are sold under the name of " rcvalenta Arabica " of which 
 they form an ingredient (p. 157). Their taste is somewhat bitter, 
 and on that account, unless disguised by some vegetable flavour, they 
 may be disliked. Like the other legumes, they contain protein and 
 fat, and are nutritious. 
 
 Peanuts. — The peanut is not a nut at all, but a legume growing 
 under ground. It resembles nuts, however, in its large content of 
 fat — 50 per cent. 
 
 Peanuts are nutritious, but indigestible when roasted whole. 
 Peanut flour is made from the ground and bolted nuts, and it is 
 claimed that a pound of it contains as much nutritive material as 
 three pounds of beef or two of peas. The peanut grits may be 
 boiled like oatmeal or made into biscuits. Experiments have been 
 made with the view of possible introduction of this food into the 
 German army to be used like the Erbswurst of fame in the Franco- 
 Prussian War. Peanuts contain considerable oil, which is extracted 
 and sold largely as spurious olive oil. It is also sometimes used in 
 the preparation of oleomargarine, and the roasted nuts themselves 
 make a sort of imitation coffee. A form of peanut meal is prepared 
 for diabetics which is said to contain little or no carbohydrate. 
 Pancakes may be made from it. The meal contains 52 per cent of 
 protein, 27 per cent of carbohydrates, and 8 per cent of fat. Four 
 million bushels of peanuts are raised annually in the Southern States 
 of this country. 
 
 Roots and Tubers 
 
 Roots and tubers constitute a very important class of vegetable 
 foods. They contain both starch and sugar as well as a little pectin 
 and potash salts. They have much less albuminous material than is 
 to be found in any other forms of starchy food, and they also hold 
 a large percentage of water. Many of them are very nutritious 
 and even fattening, but in proportion to their bulk they afford less 
 actual nutriment than either the legumes or cereals. 
 
 Potatoes. — The potato ranks first in importance among the class 
 of tubers which serve man for food, both on account of its easy cul- 
 tivation in a great variety of soils and on account of its digesti- 
 bility when properly cooked. As an exclusive article of diet the 
 potato is too largely composed of starch to be of much nutritive 
 
1 66 FOODS AND FOOD PREPARATIONS 
 
 value, and enormous quantities have to be eaten (several pounds a 
 day) in order to supply enough nitrogen for the energy of the body. 
 The potato, however, has less starch than rice, peas, or lentils. It 
 also has less woody fibre than most underground vegetables. In 
 Ireland this vegetable constitutes a greater proportion of the daily 
 food than in almost any other country, and in periods of famine 
 has been known to form four fifths of the entire food for a time, 
 but of late years it has been largely supplemented by the culti- 
 vation of Indian corn and other products. The flavour and quality 
 of the potato is influenced very much by the soil and climate in 
 which it grows, a sandy soil being best. 
 
 Konig gives the percentage composition of the potato as water, 
 75.77; nitrogenous materials, 1.79 (others give 2.10); fat, 1.60; 
 starch, 20.56 ; cellulose, 0.75 ; ash, 0.97. It is thus seen to contain 
 about one fourth solid matter. 
 
 The potato becomes a much more strengthening food when 
 eaten, as it usually is, with meat gravy, fat, or butter and salt. 
 
 Potato juice has a faintly acid reaction, and its vegetable acids 
 are mainly combined with salts of potassium, but also with sodium 
 arid calcium. It also contains traces of iron, phosphoric and sul- 
 phuric acids, chlorine, silica, and magnesia. Owing to the large 
 proportion — from 12 to 24 per cent — of nearly pure starch which 
 is found in the potato, it is very extensively used in this country and 
 elsewhere for the manufacture of laundry starch. Old potatoes, and 
 those which have been long kept, show some alteration in the quan- 
 tity of their starch, and a part is converted into sugar and gum. 
 
 Potato starch, as compared with other starches, is thoroughly 
 digestible, but much depends upon the cooking. The starchy gran- 
 ules are tough and absorb water from the acid juices which surround 
 them and from water added in cooking, and when properly prepared 
 the potato becomes soft and mealy. When this is not the case, how- 
 ever, it remains hard and soggy, and is thoroughly indigestible. 
 
 The following statement in regard to the potato is made in a re- 
 cent report of the British Commissioners of Prisons : 
 
 " Within and surrounding the cells is a fluid or juice the albumi- 
 nous constituents of which are coagulated during the process of 
 cooking. The watery part of this juice is absorbed by the starch 
 granules, which swell up and distend the cells in which they are con- 
 tained, so that they no longer adhere together, and the result is the 
 loose flocculent mass which is described as a floury or mealy potato. 
 Unless the potato be properly cooked, the fluid referred to is only 
 partially absorbed, the cells do not become sufficiently distended and 
 separated, and the potato is then described as ' waxy ' and ' dense.' 
 In this condition it is not digested, and consequently does not fur- 
 nish to the system the antiscorbutic principle in which resides its 
 chief value as an article of diet." 
 
VEGETABLE FOODS I 67 
 
 When potatoes are cooked in water, it is desirable not to remove 
 their skins, for the latter prevent to a great extent the passage of 
 the salts out into the fluid. The fact that potatoes will not decay if 
 kept dry for a length of time makes them very useful vegetables 
 upon sea voyages, when their antiscorbutic properties are especially 
 serviceable. 
 
 Potatoes are more digestible when cooked by baking in their 
 skins than by any other process. They then become mealy and their 
 starch is digested with comparative ease by invalids. They are also 
 quite digestible if steamed, or if boiled and mashed through a 
 colander. 
 
 Potatoes must be avoided in all cases of feeble digestion unless 
 they are perfectly mealy and crumble readily, and this quality de- 
 pends not alone upon the method of cooking, but upon the nature of 
 the potato itself, which varies according to the soil or the season of 
 the year in which it has been grown. Very young potatoes are not 
 mealy. They require more cooking and are less digestible than 
 those of medium age. If too old, on the other hand, potatoes be- 
 come waxy and equally undesirable. If they have been exposed to 
 frost or have been cultivated in a damp, boggy soil, their digestibility 
 is much impaired. 
 
 Sweet Potatoes. — The variety known as the sw r eet potato contains 
 somewhat less starch than the white potato, having but 16 per cent, 
 but it has more water, and a larger proportion of sugar — 10 per cent. 
 It forms a valuable and decidedly nutritious food which is eaten ex- 
 tensively throughout the United States, but it is not so digestible as 
 the white potato, for it cannot always be obtained in a mealy form, 
 and is sometimes stringy and sodden. A flour or meal can be pre- 
 pared from it by drying. Its use in Europe antedates that of the 
 white potato, which has to a great extent superseded it. These po- 
 tatoes vary much more in flavour than do the white. In general, 
 they should not be given to invalids. 
 
 The yam, another form of tuber, is eaten in the tropics and in 
 some parts of Europe. It is mealy, but not very sweet, and it con- 
 stitutes a wholesome and thoroughly digestible food. 
 
 The Jerusalem artichoke, or ground pear, is a tuber belonging to 
 the sunflower family, which was originally introduced from Brazil. 
 It is used more commonly in England than elsewhere, but is also 
 sometimes cultivated in the United States. It is sweet and watery, 
 for it contains little starch, and it is not " mealy " when cooked. It 
 contains more sugar than the sweet potato, having 14 per cent of 
 sugar, 3 per cent of nitrogenous material, and 2 per cent of inulin 
 (Yeo). Its nutritive value is comparatively slight, but it is easily 
 digested. 
 
 The Beet contains among its solid ingredients between 85 and 
 90 per cent of starches and sugars, a trace of salts, and somewhat 
 13 
 
l68 FOODS AND FOOD PREPARATIONS 
 
 over i per cent of proteid matter. It is a common source of sugar, 
 which when refined is sometimes less sweet than cane sugar, but is 
 otherwise as good. On account of the sugar which they contain, 
 beets have the reputation of contributing to the formation of fat 
 in the body. Young, tender beets are very nourishing, and they 
 are often eaten in the form of salads or with vinegar and oil, and 
 thus contribute a useful variety to the diet. 
 
 Succulent Tubers. — There is a group of succulent roots which 
 contain considerable watery juice, and on this account are usually 
 eaten fresh, for if kept long they become dry and less palatable, or 
 are apt to decay ; with care, however, they may be preserved in their 
 natural state for a considerable period. They are very digestible, 
 and when thoroughly boiled are nutritious. They are carrots, pars- 
 nips, turnips, salsify, and radishes. 
 
 Carrots consist of upward of 85 per cent of water, with a small 
 proportion of salts, 8 per cent of carbohydrates with some sugar, and 
 about 1 per cent of protein. The outer layers of the carrot contain 
 a material called pectin that can be obtained as a jelly and mixed 
 with fruit or meat jelly for flavouring invalid diet. 
 
 Young carrots, when soft and friable, if boiled are very tender 
 and highly flavoured, and constitute a nutritious food. In France 
 and Germany they are more popular than in this country and are 
 cooked w T ith other vegetables, although somewhat at the expense of 
 the flavour of the latter. At the baths of Vichy they form a part of 
 the daily breakfast. 
 
 Parsnips contain the sugar of starch with a large percentage of 
 water, and they are sometimes fermented into an alcoholic beverage. 
 They are a wholesome although less used food than carrots. The 
 parsnip contains over 90 per cent of water and only 6 per cent of 
 starch and sugar, with 1 per cent of protein, besides other materials. 
 It is a rather strongly flavoured vegetable, and bulky in proportion 
 to its nutritive value. It is extensively used for feeding cattle, and 
 when young and properly cooked by prolonged boiling and season- 
 ing it is a good food. It should be particularly avoided by those 
 persons in whom there is any tendency to flatulency, which, like the 
 legumes, it is apt to produce. 
 
 Turnips are less nutritive than either carrots or parsnips. They 
 should never be eaten by the sick. 
 
 Kohl rabi, or turnip-root cabbage, yields an overground turnip, 
 which is somewhat astringent. 
 
 Salsify, or oyster plant, is a root which has a mild sweet flavour 
 somewhat similar to the parsnip, and is an excellent food of easy 
 digestibility. 
 
 Radishes, which are not unlike turnips in composition, contain a 
 large percentage of water and a comparatively small amount of 
 starch. This vegetable is of no special value for nutrition, and serves 
 
VEGETABLE FOODS 169 
 
 chiefly as a relish. Being usually eaten raw, it is difficult of digestion, 
 and is apt to produce eructations. It is rendered more digestible by 
 cooking. It has some reputation as an antiscorbutic. 
 
 Green Vegetables 
 
 Composition. — Green vegetables do not contain much nutriment 
 in comparison with the cereals and tubers, and they are mainly useful 
 for furnishing a pleasing variation in diet and for supplying a large 
 proportion of salts and some acids which are believed to be service- 
 able in the prevention of scurvy. The various uses of the salts have 
 been elsewhere described (see p. 45). These vegetables often con- 
 tain 90 per cent or more of water, which in itself is useful to the 
 system in many ways. They furnish only a small quantity of nitro- 
 genous material, which varies from 1.5 up to 4 per cent. In addition, 
 they contain cellulose, chlorophyll, sugars, gum, pectin, and some- 
 times a little fat. Their variety of taste depends upon the presence 
 of flavouring materials, chiefly essential oils. As a rule, they have a 
 better flavour, and are more digestible when young than old, when 
 they become tough and " stringy " from a relatively large percentage 
 of cellulose or woody fibre. Since the green vegetables afford so 
 little nutriment in proportion to their bulk, they are not of much 
 service for persons with feeble digestion, and, unless they are young 
 and tender, they are positively harmful by overtaxing the digestive 
 system and irritating the alimentary canal. On the other hand, they 
 are very useful in overcoming constipation by their bulky waste 
 matter, which acts as a mechanical stimulus to peristaltic action and 
 promotes movement of the bowels. 
 
 The digestibility of these vegetables is rendered much greater by 
 careful cultivation in suitable soils. Owing to the large quantity of 
 water which they hold (which readily evaporates), they soon wilt or 
 become dry in market. For the most part they should be eaten when 
 quite fresh, although celery and winter cabbage form an exception 
 to this, as they may be kept for weeks. 
 
 Fresh green vegetables as well as roots or tubers are always made 
 more digestible by cooking, which softens them. Their most diges- 
 tible form for invalids is that of purees. 
 
 Cabbages. — The cabbage family, which belongs to the natural 
 order Crucifercu, furnishes many examples of green vegetables, some 
 of which are of value for their leaves, and others for their modified 
 flowers. There are about seventy varieties of cabbages. They con- 
 tain considerable sulphur, which, if malfermentation exists in the 
 alimentary canal, produces sulphuretted hydrogen, causing flatulence 
 and unpleasant odour. They may also give rise to calcium oxalate 
 in the urine, by causing indigestion, and they should be avoided by 
 the rheumatic or gouty, and, in fact, by all classes of invalids. Cab- 
 
170 FOODS AND FOOD PREPARATIONS 
 
 bages and other vegetables of this order impart a strong taste and 
 odour to the water used for boiling them. When soft and crisp, 
 cabbage is a wholesome food for those with strong digestion, and 
 it has decided antiscorbutic properties when fresh, which are less- 
 ened by fermentation. 
 
 The principal edible representatives and preparations of the cab- 
 bage family are the following : 
 
 1. Sauerkraut is made by placing salt between layers of cabbage 
 leaves and subjecting them to pressure, which bruises them and 
 squeezes out their juices. The mass then ferments with the forma- 
 tion of organic acids. 
 
 2. Cauliflower and broccoli are the flowers of plants which are 
 grown large and tender by cultivation. When boiled and served 
 with a milk sauce they are much esteemed for their flavour and easy 
 digestibility in healthy stomachs, but they cause flatulence if eaten 
 by dyspeptics. These vegetables may be dressed with olive oil and 
 eaten as a salad. 
 
 3. Cole is a plant of the cabbage family which does not " head." 
 
 4. Seakale is grown in the dark, so that it has no chlorophyll. It 
 is equally digestible with cauliflower if well bleached. It is more 
 often cultivated in England than in this country. 
 
 Spinach, beet tops or " greens," dandelion tops, and turnip tops 
 are all useful green vegetables, and of these spinach, which is slightly 
 acid, is the most common and desirable. These substances afford 
 almost no nutriment, and are valuable chiefly for their laxative action. 
 The mineral salts which they contain, especially those of spinach, 
 have been shown by Luff, of London, to be of positive value in gout 
 in increasing the solubility of sodium biurate and retarding the con- 
 version of quadriurates into biurates. (See Goutr) If the leaves 
 are young and tender, and if they are cooked until they become 
 quite soft and are then chopped into a fine pulp, they are very whole- 
 some articles of food for the relief of chronic constipation. The 
 dandelion leaves have a less delicate flavour than spinach, and are 
 said to possess a slight diuretic action. Unless bleached they are 
 bitter. The dandelion root is laxative, like the leaves, and it forms 
 an ingredient of root-beer. 
 
 Lettuce, etc. — There is a group of vegetables of which lettuce is 
 the chief type, the leaves of which are eaten raw. They are useful 
 for their flavour and for the variety which they furnish in the course 
 of a meal. They cannot be said to possess any nutrient value, but 
 they are usually taken with vinegar and oil, and the latter is very 
 nourishing. Since they contain little starch and practically no sugar, 
 they may be allowed in the diabetic regimen. 
 
 Sorrel and cress, or peppergrass, are used in the making of salads, 
 but less in this country than in Europe. Sorrel has a somewhat pun- 
 gent or acid flavour, which is due to acid oxalates, and this fact ren- 
 
VEGETABLE FOODS 171 
 
 ders it unfit for use by patients who are subject to attacks of gout 
 and rheumatism or who have the uric-acid diathesis. A fatal case of 
 sorrel-poisoning in a boy five years of age has been reported. To 
 quench thirst, excited by eating a quantity of sorrel, he swallowed 
 some soapy water, the alkali of which produced a soluble oxalate. 
 A quantity of oxalic acid was found in the stomach. 
 
 Many other substances are mentioned in works on dietetics which 
 are used in the making of salads or pickles and as relishes. They are 
 antiscorbutic and serve to stimulate the digestive secretions and give 
 a fillip to the appetite. Such are green peppers, capers, mint, tarragon 
 (an aromatic Siberian plant), parsley, chervil, endive, chicory, okra. 
 
 Celery is a wholesome vegetable when cooked in milk until it is 
 quite soft ; but eaten raw it is stringy, and, as it has but little nutri- 
 tive value, its use in that form should be discarded by invalids. Its 
 aromatic flavour makes it very popular, and it furnishes a useful 
 addition to a light luncheon with bread and cheese. It has acquired 
 an undeserved reputation for use in rheumatism. " Celery salt " is 
 an agreeable flavouring substance for soups and salads. Various 
 preparations are made from the plant, which are sold by druggists as 
 hypnotics. They are of no value. 
 
 Artichokes are a variety of thistle. They contain tannin and mu- 
 cilaginous materials, but nothing of true nutrient power, although, 
 according to Moleschott, they hold 17.75 P er cent °f organic matter. 
 
 Green artichokes when tender and thoroughly cooked are easily 
 digested, but their cost in this country prevents them from being 
 consumed except as an article of luxury. They may be given to 
 some diabetic patients among the few vegetables which they can eat 
 with impunity. Eaten raw, as they sometimes are in France, they are 
 very indigestible. 
 
 Tomatoes. — The tomato is a vegetable which was introduced into 
 this country about sixty years ago, the value of which is becoming 
 more and more appreciated. In Germany it is still sold as a fruit of 
 luxury rather than as a common vegetable. It is wholesome when 
 eaten raw as a salad with vinegar and oil, and it forms a popular in- 
 gredient of strong condiments, such as tomato catsup. It is refresh- 
 ing, slightly acid, and easily digested. The oxalic acid which it con- 
 tains makes it injurious in cases of gout or the uric-acid diathesis. 
 The tomato is much prized as a canned vegetable on account of the 
 fact that it retains more of its original flavour than do most vege- 
 tables preserved by this process. 
 
 The eggplant is related to the tomato, and like it contains many 
 seeds when full grown, but it is much less digestible, especially when 
 fried, and is not a suitable food for invalids. 
 
 Cucumbers are mainly eaten raw, and they should be young. Like 
 celery, they contain too much woody fibre to be consumed in bulk. 
 They are valuable for pickling in vinegar or in the making of chow- 
 
172 FOODS AND FOOD PREPARATIONS 
 
 chow, but they are always indigestible ; this is due in great part 
 to the large size of the seeds which the vegetable contains, and it 
 should never be eaten by any one excepting those having vigorous 
 stomachs. Eaten raw, even in small quantities, it may produce vio- 
 lent colic and diarrhoea. 
 
 Asparagus is a vegetable possessing a very delicate flavour, and 
 from the fact that it is among the first of the fresh vegetables to ap- 
 pear in the early spring it is highly esteemed. When young and 
 tender it is very digestible, even for invalids. The green asparagus 
 contains more bitter and resinous principles than the white. It has 
 been claimed that it possesses some influence as a cardiac sedative 
 as well as aphrodisiac action, but these properties are imaginary. It 
 is, however, slightly diuretic, and it owes this influence to a substance 
 called asparagin, which may be obtained in crystalline form. Aspara- 
 gus imparts a very strong and disagreeable odour to the urine which 
 I have known to appear within an hour after it has been eaten, and 
 which persists from twelve to twenty hours. It is caused by a vola- 
 tile sulphur product, a methyl mercaptan, which has been proved to 
 originate in the intestine during digestion, from whence it is absorbed. 
 
 Rhubarb, or " pieplant," the stems of the leaves of which are 
 eaten stewed, is an excellent vegetable. The flavour is quite tart, 
 and the fibre is stringy, but thorough cooking renders it soft and 
 digestible. It is laxative, and is therefore useful in cases of chronic 
 constipation. This wholesome vegetable has not received the atten- 
 tion it deserves. In Germany, for instance, it is still grown merely 
 as an ornamental garden plant on account of its large showy leaves. 
 It produces calcium oxalate in the urine if eaten in excess, and must 
 therefore be avoided in oxaluria, gout, and rheumatism. 
 
 Pumpkins and squash contain much water and a good deal of 
 coarse fibre. Tender and young summer squash is fairly digestible, 
 but presents no special dietetic advantages. The pumpkin is one of 
 the oldest vegetables on this continent, for it was grown extensively 
 together with maize by the early Indian tribes. 
 
 Onions, garlic, shallots, and leeks, which are edible both as fresh 
 vegetables, and after long keeping, are useful as condiments for fla- 
 vouring salads, meat stews, and other foods. They are also eaten 
 independently for their nutritive properties, which are somewhat 
 greater than those of the four or five vegetables last considered. 
 Tender young leeks and white onions boiled and served with milk or 
 cream are very wholesome and of delicate flavour. They possess, in 
 common with the other green vegetables, a moderate laxative action, 
 and are antiscorbutic. They impart a strong typical odour to the 
 breath, which appears within two or three hours, and if constipa- 
 tion exists, persists for twenty-four hours or more. This is due 
 to volatile substances which are absorbed by the blood from the ali- 
 mentary canal and carried to the lungs, where they are liberated. 
 
VEGETABLE FOODS 
 
 173 
 
 Vegetable marrow is a highly succulent vegetable, somewhat re- 
 sembling the pumpkin. It possesses an agreeable flavour, but con- 
 sists so largely of water that it is of scarcely any use as food. 
 
 Cranberries are really more of a fruit than a vegetable, but they 
 are usually eaten with meat as a vegetable. They are serviceable 
 for their agreeable acidity and flavour, but unless very thoroughly 
 cooked and made into a jelly with much sugar, they are indigestible, 
 for their outer coatings are extremely tough. They should never be 
 given to invalids. 
 
 The composition of some common vegetables is thus tabulated 
 ■by Moss : 
 
 Composition of Vegetables 
 
 Constituents. 
 
 Potato 
 
 (Payen). 
 
 Potato 
 (Lethe- 
 
 by). 
 
 Sweet 
 
 potato 
 
 (Payen). 
 
 Jerusa- 
 lem ar- 
 tichoke. 
 
 Carrots 
 (Lethe- 
 
 by). 
 
 Parsnips 
 
 (Lethe- 
 
 by). 
 
 Turnips 
 
 (Lethe- 
 
 by). 
 
 Cab- 
 bage. 
 
 Nitrogenous matter 
 
 2.50 
 20.00 
 I.04 
 I.09 
 O.II 
 1.26 
 
 2.1 
 
 18.8 
 
 3-2 
 0.2 
 O.7 
 
 75-o 
 
 I.50 
 16.05 
 
 0.45 
 I0.20 
 O.30 
 2.60 
 l.IO 
 
 67.50 
 
 3-1 
 
 1-5 
 
 14.7 
 
 0.2 
 
 i-3 
 
 O.q 
 
 0.4 
 
 1.9 
 
 76.0 
 
 I 
 8 
 
 
 
 83 
 
 3 
 4 
 
 2 
 
 
 
 
 I.I 
 9.6 
 
 5*8 
 
 o-5 
 1,0 
 
 82.0 
 
 1.2 
 5-1 
 
 2.1 
 
 o!o 
 
 9I.O 
 
 2.0 
 
 
 (m 
 
 0.5 
 0.7 
 
 Sugar and gummy matter 
 Fatty matter 
 
 
 
 Pectic acid 
 
 Pectin 
 
 Inulin 
 
 Water 
 
 74.^0 
 
 91 .0 
 
 
 Total 
 
 IOO.OO 
 
 100. 
 
 IOO.OO 
 
 100. 
 
 100 
 
 
 
 100. 
 
 IOO. O 
 
 100.0 
 
 
 
 
 
 The following analyses of common vegetables have been made 
 by Konig: 
 
 Water 
 
 Nitrogenous matters 
 
 Fat 
 
 Sugar 
 
 Other non-nitrogenous ex 
 
 tractives 
 
 Cellulose 
 
 Ash 
 
 Carrots. 
 
 Turnips. 
 
 Beet root. 
 
 Celery. 
 
 Onions. 
 
 88.32 
 
 9I.24 
 
 87.07 
 
 84.09 
 
 85.99 
 
 I.04 
 
 O.96 
 
 1-37 
 
 I.48 
 
 1.86 
 
 0.2I 
 
 O.I6 
 
 0.03 
 
 0.39 
 
 0.10 
 
 I.90 
 
 4.08 
 
 o.54 
 
 O.77 
 
 2.78 
 
 7.17 
 
 I.90 
 
 9.02 
 
 II.03 
 
 8.04 
 
 0.95 
 
 O.9I 
 
 1.05 
 
 I.40 
 
 0.71 
 
 0.7I 
 
 0.75 
 
 0.92 
 
 O.84 
 
 0.70 
 
 Cabbage. 
 
 89.97 
 I.89 
 0.20 
 2.29 
 
 2.58 
 I.84 
 I.23 
 
 Water 
 
 Nitrogenous matters 
 
 Fat 
 
 Sugar 
 
 Other non-nitrogenous ex 
 
 tractives. , 
 
 Cellulose 
 
 Ash 
 
 Cauli- 
 flower. 
 
 Brussels 
 sprouts. 
 
 Spinach. 
 
 Lettuce. 
 
 Asparagus. 
 
 90-39 
 
 85.63 
 
 90.26 
 
 94-33 
 
 93.32 
 
 2-53 
 
 4.83 
 
 3-15 
 
 1. 41 
 
 I.98 
 
 O.38 
 
 O.46 
 
 o.54 
 
 0.3I 
 
 O.28 
 
 1.27 
 
 
 0.08 
 
 
 0.40 
 
 3-74 
 
 6.22 
 
 3.26 
 
 2.I9 
 
 2-34 
 
 0.87 
 
 1-57 
 
 0.77 
 
 0.73 
 
 I. 14 
 
 0.82 
 
 1 .29 
 
 1.94 
 
 I.03 
 
 0.54 
 
 French 
 beans. 
 
 36 
 
 77 
 14 
 
 20 
 
 82 
 
 14 
 
 57 
 
174 FOODS AND FOOD PREPARATIONS 
 
 The two preceding tables differ slightly in detail, but no more 
 than the average variation in percentage composition of the vege- 
 tables when not grown under identical conditions. They agree as 
 nearly as can be expected. 
 
 Fruits 
 
 Composition. — The varieties of fruits which are consumed in 
 all countries are innumerable, and their uses are various. Sweet 
 fruits no doubt largely composed the diet of primordial man, as they 
 do of every savage tribe to-day living outside of the Arctic Zone. 
 
 Speaking generally, fruits are composed largely of water with 
 starches, sugars, a vegetable jelly called pectin, cellulose, and organic 
 acids. 
 
 Pectin is a carbohydrate substance found in ripe pulpy fruits. It 
 enables fruit to gelatinise when boiled. Its properties and com- 
 position are not thoroughly understood. 
 
 The organic acids exist mainly in union with alkalies, forming 
 compounds which are readily split up in the system, leaving the al- 
 kalies free to combine as carbonates or phosphates. 
 
 The most important acids are citric, malic, and tartaric, which 
 exist in various quantities and combinations. 
 
 Citric acid predominates in lemons, limes, and oranges ; tartaric 
 acid in grapes ; malic acid in apples, pears, peaches, apricots, goose- 
 berries, and currants. 
 
 Among the least acid of the common fruits are peaches, sweet 
 pears, sweet apples, bananas, and prunes ; moderately acid are straw- 
 berries. The most acid of all are currants and lemons. 
 
 Fruits contain a smaller proportion of earthy -salts than other 
 foods. 
 
 Certain fruits also hold a little nitrogenous material, chiefly as 
 albumins, but, as a rule, the starches and sugars predominate, and 
 the nutritive value of any fruit depends upon them chiefly. Most 
 fruits contain too much water to constitute an economic diet if eaten 
 alone. Some also contain a small quantity of fat and waxy matter, 
 and most of them have more or less pigment. 
 
 Fruits which are especially rich in flavour, and which exhale a 
 pleasant aroma, owe these conditions to the various essential oils 
 and compound ethers which they possess in considerable amount. 
 
 Many fruits are only partially edible owing to the fact that they 
 are composed of a pulp contained within an indigestible structure of 
 cellulose or woody fibre. 
 
 Fruits are commonly classified into stone-bearing fruits, pomes, 
 berries, capsules, and pepos. Some, such as the date, the plantain 
 and its variety, the banana, afford sufficient nutriment to amply sup- 
 port life for a long time ; others, like the apple, are wholesome, but 
 slightly nutritious ; while others again are of little value for nutri- 
 
VEGETABLE FOODS 
 
 i/5 
 
 tive purposes, and are mainly serviceable for their agreeable flavour 
 to furnish variety in the diet. 
 
 Composition of 
 
 Fruits 
 
 (Bauer) 
 
 
 
 
 
 Apple. 
 
 Pear. 
 
 Peach. 
 
 Grape. 
 
 Straw- 
 berry. 
 
 Currant. 
 
 Orange, 
 o P „t 
 
 Water 
 
 83.58 
 0.39 
 O.84 
 
 7-73 
 
 5-17 
 1.98 
 0.31 
 
 83-03 
 O.36 
 0.20 
 8.26 
 
 3-54 
 4-3o 
 0.31 
 
 83-03 
 O.65 
 O.92 
 
 4.48 
 
 7.17 
 6.06 
 O.69 
 
 78.18 
 
 o-59 
 0.79 
 
 24.36 
 
 1.96 
 3.60 
 
 o.53 
 
 87.66 
 I.07 
 0.93 
 6.28 
 
 O.48 
 2.32 
 O.81 
 
 84.77 
 O.5I 
 2.15 
 
 6.38 
 
 O.9O 
 
 4-57 
 0.72 
 
 89.01 
 
 0.73 
 2.44 
 
 4-59 
 
 o.95 
 1.79 
 
 0.49 
 
 Nitrogenous matters 
 
 Free acids 
 
 Sugar 
 
 Other non - nitrogenous 
 matters 
 
 Cellulose and kernel 
 
 Ash 
 
 Co7nposition of Fruits (Yeo) 
 
 
 Apple. 
 
 Cherry. 
 
 Raisin. 
 
 Fig. 
 
 Water 
 
 27-95 
 1.28 
 0.82 
 3.60 
 42.83 
 17.00 
 4-95 
 i-57 
 
 49.88 
 2.07 
 O.30 
 
 32.22 
 
 14.29 
 
 O.61 
 
 I.63 
 
 32.02 
 2.42 
 0.49 
 
 54-26 
 
 7.48 
 1.72 
 1. 21 
 
 31.20 
 4.OI 
 I.44 
 I. 21 
 
 Nitrogenous matters 
 
 Fat 
 
 
 Sugar 
 
 49-79 
 4-5i 
 4.98 
 2.86 
 
 Other non-nitrogenous matters 
 
 Ash 
 
 
 
 Fruits arranged According to the Proportions between Acid, Sugar, Pectin, 
 Gum, etc. {Average). (Fresenius) 
 
 Fruits. 
 
 Plums 
 
 Apricots 
 
 Peaches 
 
 Raspberries . . . 
 Currants. . . . 
 Blackberries . . 
 Whortleberries 
 Strawberries.. . 
 Gooseberries . . 
 
 Prunes 
 
 Apples 
 
 Sweet cherries. 
 
 Grapes 
 
 Red pears 
 
 Acid. 
 
 Sugar. 
 
 I. 
 I 
 
 2. 
 2. 
 
 3- 
 3- 
 4- 
 4- 
 4- 
 7.0 
 11 .2 
 
 17-3 
 20.2 
 94.6 
 
 Pectin, gum, etc. 
 
 3-i 
 6.4 
 
 11. 9 
 1 
 o 
 1 
 o 
 o 
 o 
 
 4-4 
 5-6 
 2.8 
 2.0 
 
 44.4 
 
 Fruits arranged in the Order of their Conte?it of Sugar {Average). 
 
 (Moss) 
 
 Peaches 1.6 per cent. 
 
 Apricots 1-8 
 
 Plums 2.1 " " 
 
 Reineclaudes 3- 1 " 
 
176 FOODS AND FOOD PREPARATIONS 
 
 Mirabelles 3 ■ 6 per cent. 
 
 Raspberries 4-0 
 
 Blackberries 4-4 
 
 Strawberries 5-7 
 
 Whortleberries 5-8 
 
 Currants 6.1 
 
 Prunes 6.3 
 
 Gooseberries. 7 • 2 
 
 Red pears 7-5 
 
 Apples. - - 8.4 
 
 Sour cherries 8.8 
 
 Mulberries 9-2 
 
 Sweet cherries 10 . 8 
 
 Grapes 14 • 9 
 
 Uses and Properties. — The uses of the different fruits may be 
 summed up as follows : 
 
 1. To furnish nutriment. 
 
 2. To convey water to the system and relieve thirst. 
 
 3. To introduce various salts and organic acids which improve 
 the quality of the blood and react favourably upon the secretions. 
 
 4. As antiscorbutics. 
 
 5. As diuretics, and to lessen the acidity of the urine. 
 
 6. As laxatives and cathartics. 
 
 7. To stimulate the appetite, improve digestion, and give variety 
 in the diet. 
 
 8. As special " cures " for certain diseases, like the grape cure, 
 although their specific action is very doubtful. 
 
 In a study of the diet of women students at Lake Erie College in 
 Ohio, made in 1900 by Isabel Bevier and Elizabeth C. Sprague, it 
 was found that an increase in fresh fruit consumption, especially at 
 breakfast, showed that more breakfast was eaten and it materially 
 lessened the craving for sweets. 
 
 Fruits which afford the most nutriment are the banana, date, fig, 
 prune, and grape. This is due to the large proportion of sugar which 
 they contain. 
 
 Fruits which contain the most water are muskmelons, water- 
 melons, oranges, lemons, limes, shaddocks, and grapes. 
 
 The antiscorbutic value of fruits is illustrated particularly by cer- 
 tain varieties which furnish abundant potash salts, as well as lime 
 and magnesia. Among these are to be mentioned apples, lemons, 
 limes, and oranges. 
 
 The diuretic influence of fruits is in part due to their water, but 
 chiefly to their organic acids and salts, which stimulate the circula- 
 tion and probably also the activity of the renal epithelium. 
 
 Fruit-eating lessens the acid of the urine or even makes it alka- 
 line owing to decomposition of various alkaline salts in the blood or 
 tissues, which are reformed into alkaline carbonate and, as such, are 
 
VEGETABLE FOODS I 77 
 
 excreted. For this reason fruit is sometimes beneficial in lithgemia 
 and allied conditions to prevent accumulation of acid urates. 
 
 The laxative action of fruits is partially derived from indigestible 
 substances, cellulose, seeds, etc., and also, no doubt, from the special 
 influence of their organic ingredients, which in some instances is very 
 striking. 
 
 The best fruits to offset constipation are fresh apples, figs, 
 prunes, peaches, and berries. Dyspeptics must be careful to avoid 
 eating all hard skins, seeds, or coarse-fibred fruits. 
 
 Fruit Ripening. — As fruit ripens it absorbs more and more 
 oxygen, and the tannin and vegetable acids which it originally con- 
 tained are altered, so that it becomes less astringent and acid. The 
 starch is more or less completely turned into levulose or glucose, 
 and soluble pectin is formed. The aroma and taste of ripe fruits 
 depend upon the relative quantity of these different substances, 
 together with various volatile ethers and oils. The sour fruits have 
 either more acid or less sugar, and in the sweet fruits there is a 
 preponderance of sugar which masks the acid taste. The more 
 luscious the fruit, the more soluble sugars and special flavouring 
 substances does it contain. 
 
 The employment of fruits as a common article of daily diet is 
 highly beneficial, and the improvements which have been made of 
 late years in methods of culture and means of rapid transportation 
 make some varieties of fresh ripe fruits, such as the orange and the 
 banana, available in almost every climate in all seasons, while their 
 increasing cheapness places them within reach of the poor. 
 
 Fruit Poisoning. — While fruits eaten daily and in proper modera- 
 tion are very wholesome, if they are eaten too freely, or if they are 
 either insufficiently ripe or overripe, soft, and decomposing, they 
 undergo malfermentation in the alimentary canal, and are almost 
 certain to cause diarrhoea with colicky pains, cramps, and sometimes 
 nausea and vomiting. Severe attacks of gastritis may, especially 
 in children, be produced by indulgence in unripe apples, pears, cher- 
 ries, berries, etc., and even fatal choleraic diarrhoea has been occa- 
 sioned by the indiscriminate consumption of fruits which have 
 strongly laxative action. After such fruit poisoning, emesis should 
 be excited if the patient is seen in time, and otherwise, if free purga- 
 tion has not occurred, it is advisable to give a dose of castor oil or 
 other cathartic, to remove the irritating substances as soon as pos- 
 sible from the alimentary canal. In bad cases, prolonged gastric 
 fever may ensue. Some tropical fruits possess specific poisonous 
 properties. 
 
 When to Eat Fruit. — Cooked fruits may be eaten with any meal, 
 but usually when fruit is eaten for special dietetic purposes its effect 
 is always more pronounced if taken alone, either at the commence- 
 ment of meals or, better, between them. One often observes 
 
178 FOODS AND FOOD PREPARATIONS 
 
 patients who can obtain no laxative effect from apples, figs and 
 other fruit eaten as dessert, but which taken at night into an empty 
 stomach or an hour before breakfast, with a glass or two of cold 
 water, has a very pronounced favourable influence upon the bowels. 
 
 The poorest time for eating fruit is at the conclusion of a very 
 hearty dinner at which considerable variety of food has already been 
 consumed. Fruit in general is less wholesome when eaten out of 
 its natural season. All fruits, such as berries, the seeds of which 
 are eaten, are much less liable to produce intestinal irritation if taken 
 with bread or other bulky starchy food. Raw fruit unless eaten at 
 once after picking should be well washed. The skin and seeds of the 
 larger fruits and of grapes are quite indigestible. 
 
 Fruit Soups. — In Germany fruit soups are more in vogue for 
 general use than in this country, and they are often prescribed in 
 fevers when diarrhoea does not exist. Uffelmann directs that for 
 making a fruit soup one part of fruit to four or five of water may be 
 used, and Bauer recommends soups " made by boiling fresh or dried 
 fruits with water, with or without the addition of sugar, lemon peel, 
 etc., and freed from the solid residue by pressure." 
 
 Dried Fruits can be eaten less abundantly than fresh fruits. Some 
 of the dried fruits are wholly indigestible ; such are currants and 
 citrons. Others, like figs or prunes, are wholesome, and raisins, 
 sultanas, dates, etc., contain considerable nourishment. All these 
 dried fruits are preserved in their own sugar (glucose), which forms 
 a sticky, gummy, non-crystallised mass. Dried apples, peaches, 
 prunelles, etc., are preserved simply by the evaporation of the excess 
 of water which they contain. 
 
 Dried " currants " are the berries of a vine cultivated in the 
 Ionian Islands. The word currant is a corruption of Corinth. The 
 fruit in its dried state is wholly indigestible. 
 
 When dried fruits, such as figs or dates, have become too hard 
 they may be softened and made more palatable by pouring boiling 
 water over them and allowing them to soak for a few hours, or the 
 fruit may be put into cold milk and brought to the boiling point 
 over the fire. This method will soften them in a quarter of an hour. 
 
 A simple fruit diet which has been advocated for the cure of 
 obesity and other ailments is the following : Three meals a day are 
 eaten, consisting of half a pint to a pint of milk, with from two to 
 six ounces of whole-meal bread and a similar quantity of figs or 
 dates, prepared in milk as above described. Obviously this diet is 
 not sufficiently sustaining to be long endured. 
 
 Digestibility. — Among the commoner fruits of easy digestion are 
 grapes, oranges, grape fruit, lemons, cooked apples, figs, peaches, 
 strawberries, and raspberries. 
 
 Somewhat less digestible are melons, prunes, raw apples, pears, 
 apricots, bananas, and fresh currants. 
 
VEGETABLE FOODS 1 79 
 
 Of course the digestibility depends very much upon ripeness and 
 freshness of the fruit as well as personal idiosyncrasy, and any classi- 
 fication can only be approximate. 
 
 Fruits most Useful for Invalids. — The most useful fruits for the 
 sick are lemons, oranges, baked apples, stewed prunes, grapes, 
 banana meal (not the fruit pulp). 
 
 Varieties of Fruits. — Lemons, limes, and shaddocks may be con- 
 sidered together as possessing the same general properties. Owing 
 to the potash and other salts and abundant vegetable acids which 
 they contain, they are the most serviceable of the antiscorbutic fruits, 
 and also afford an agreeable acid and pungent flavour to articles of 
 diet which might become monotonous in taste. For many persons 
 the addition of a little lemon juice to some articles of food, such as 
 cooked cereals and porridge or broiled fish, renders them more im- 
 mediately digestible, and it can be regarded as having almost a 
 specific action in promoting gastric digestion, although it is difficult 
 to say in just what manner this comes about. Lemons are therefore 
 a most desirable addition to the diet kitchen. 
 
 Lemon juice is a well-known mild remedy for seasickness, and 
 holding a thin slice of freshly cut lemon in the mouth often removes 
 the disagreeable taste from a coated tongue, cleanses the mouth, and 
 may even counteract nausea. Sour lemonade taken in moderation, 
 and made quite strong by squeezing the juice of one or two lemons 
 in a small tumblerful of water, with the addition of only one or two 
 lumps of sugar, is a cooling and refreshing drink in fevers, and does 
 more to diminish the craving of thirst than almost any other form of 
 beverage. 
 
 For those who fancy effervescing drinks, the lemonade may be 
 improved by using one of the aerated waters — such as Apollinaris, 
 Vichy, or carbonic-acid water — instead of plain water, or efferves- 
 cence may be produced by the addition of five or ten grains of sodi- 
 um bicarbonate. In many cases this mild remedy is beneficial to the 
 stomach. 
 
 Henry claims that pure lemon juice poured into the nose will 
 often control epistaxis. Fresh lemon juice has a popular reputation 
 for warding off rheumatism, but it has been shown to have very little 
 influence over nitrogen elimination, although it increases the phos- 
 phates of the urine (K. Dauber). 
 
 Limes. — The lime is a thin-skinned acid fruit, but there is also a 
 sweet variety. Although less extensively eaten throughout this 
 country than the lemon, which it resembles in effect, it is equally 
 serviceable, and nearly ten thousand gallons of condensed lime juice 
 are imported annually into this country from Jamaica. To make 
 this juice the fresh limes are pressed by machinery, and the seeds 
 and pulp are removed by straining and filtering. The juice is then 
 boiled down to a high degree of concentration. It is carried on 
 
180 FOODS AND FOOD PREPARATIONS 
 
 
 sailing vessels to prevent scurvy, and used in almshouses and pris- 
 ons, where the diet is monotonous. 
 
 The shaddock, pomelo, or Citrus pomclanus, is a very large, globular 
 pulpy fruit, which may attain to a weight of fifteen pounds. The 
 rind is thick and acid, and the very juicy pulp is bitter. The fruit 
 keeps fresh for a long time. A smaller variety, known as the grape 
 fruit, has come into general use of late, although it is still a relatively 
 expensive fruit in most parts of the country. It grows in pendant 
 clusters. Many persons find that half a grape fruit taken at the com- 
 mencement of breakfast has both a laxative and diuretic action, and 
 it is always cooling and agreeable to those who do not dislike a bitter 
 taste. The objection to its use is that it requires a large quantity of 
 sugar to make it really palatable and diminish its astringency. This 
 is disadvantageous in cases of flatulent dyspepsia, but for invalids 
 who are convalescing from prolonged fevers, suppurating disease, 
 etc., an excellent tonic may be given by cutting a grape fruit in two 
 and pouring half an ounce or more of good rum into the fruit, with 
 the addition of a little sugar. The bitterness is entirely disguised 
 and the combination is agreeable and appetising. 
 
 Oranges. — Oranges are an exceedingly useful article of invalid 
 diet. The juice of ripe oranges allays thirst, and it is well borne in 
 cases where there is considerable gastric irritation and tendency to 
 vomiting. It is only in the worst forms of gastric disorders that 
 orange juice disagrees, and there is no fruit which is so generally 
 available in the sick-room, for it is agreeable to almost every one, 
 and is refreshing in fevers. I often give it in typhoid fever. 
 Orange juice is laxative, particularly for infants, and is the best 
 remedy for infantile scurvy. It may be given undiluted or made 
 into orangeade with one of the effervescing waters. In renal and 
 other diseases in which it is desirable for the patient to drink large 
 quantities of fluid for its diluent and diuretic effect, the addition of 
 orange juice to beverages will encourage their consumption. 
 
 Orange marmalade is a wholesome relish, having an appetising, 
 bitter flavour. 
 
 Orange water ice, as well as lemon ice, well frozen, if not made 
 too sweet, may be allowed in the milder forms of fever, inflammations 
 of the throat, etc., especially in children. It is soothing, refreshing, 
 and cooling, and is less likely to disagree than the richer ice cream. 
 
 Apples, when ripe and properly selected, are extremely whole- 
 some and very digestible. They contain abundant potassium and 
 sodium salts, as well as those of lime, magnesium, and a trace of iron. 
 Their nutritive value is not high, depending mainly upon a little 
 sugar, for they are largely composed of water, having over 83.5 per 
 cent (Bauer). In dried apples the percentage of water is reduced 
 to one third, while that of sugar is proportionately increased. 
 
 Apples contain free organic acids (malic and gallic) as well as 
 
VEGETABLE FOODS l8l 
 
 salts, such as malates, citrates, and tartrates. They also contain lime, 
 phosphates, plant albumin, gum, and chlorophyll. They are good 
 antiscorbutic remedies, and are laxative, especially when taken into 
 an empty stomach. There are many dyspeptics who thrive upon 
 apples, even if eaten raw, and who can regulate the action of the 
 bowels with them effectually. They should be given to most in- 
 valids only when cooked. They are most digestible when baked and 
 eaten with cream, or they may be beaten with white of egg to add 
 to their nutritive power. They are both palatable and very digesti- 
 ble for convalescents if stewed as apple sauce, when there is no 
 objection to the addition of the greater quantity of sugar which is 
 required in this method of cooking. They should be avoided in all 
 cases of diarrhcea, gastro-intestinal irritation, and diabetes. 
 
 Pears are similar to apples in their effect, but are less laxative. 
 If fully ripe and soft they are even more digestible raw than apples. 
 They have the advantage of keeping their flavour when well pre- 
 served in sirups, but they possess no special food value, and are 
 mainly used for their choice flavour, aroma, and appearance, which 
 stimulate the appetite. 
 
 Quinces are indigestible unless very thoroughly cooked. 
 
 Peaches, nectarines, and apricots are of comparatively little nutrient 
 value, but their flavour and appearance make them tempting articles 
 for the table. They do not contain as much sugar as apples and 
 other fruits. When thoroughly ripe they are wholesome if not 
 eaten in excess. They agree well with some gouty persons, and are 
 even allowed to diabetics in cases of moderate severity. Peach and 
 apricot juices are laxative. 
 
 Pineapples (Ananassa sativa), as usually obtained in this country, 
 have been picked green in Cuba, and if eaten raw are indigestible. 
 Their ripe juice is, however, very wholesome, and they contain a 
 ferment capable of digesting proteid material, which is used to some 
 extent in the preparation of predigested invalid foods, such as Mos- 
 quera's beef meal. Prof. R. H. Chittenden has isolated this ferment, 
 which has a rapid softening, disintegrating, and digesting effect upon 
 such proteids as blood fibrin and muscle tissue. It is an acid fluid 
 which acts best in a neutral medium, but, like trypsin, it also digests 
 in both acid and alkaline solution. Three ounces of the juice will 
 dissolve ten to fifteen grains of dried albumin in four hours. He 
 also found a milk-curdling ferment in the juice. 
 
 Tamarinds are cooling and laxative. When added to milk they 
 cause curdling, and form a whey which may be used as a beverage in 
 fevers when constipation is to be overcome. 
 
 The mango is a sweet and somewhat acid fruit, with moderately 
 laxative action. 
 
 The pomegranate is a pulpy fruit, wholesome when fresh, but it is 
 expensive and little used in this country. It has a thick, tough rind, 
 
1 82 FOODS AND FOOD PREPARATIONS 
 
 which is astringent, with a bitter-sweetish taste. A tseniacide for 
 the tapeworm is made from an infusion of the rind, but it is so 
 nauseous and disgusting to the taste that patients can seldom retain 
 it unless it is put into the stomach with a tube. 
 
 Bananas. — The banana is really a variety of the plantain, or Plan- 
 tago musa, but the fruit is not so large or so hard as that commonly 
 called plantain, and the flavour is far more delicate. The botanical 
 name of the banana, Musa sapientum, was given because it constituted 
 the principal food of the Brahmin caste of India. There are many 
 score of varieties of the banana, ranging from the most delicate 
 examples of the Musa sapientum family to the heaviest of the plan- 
 tains, and they vary in digestibility as they do in flavour. Casati 
 (Equatorial Province, 1891) names some fourteen varieties, having 
 different characteristics and existing in the Equatorial Province of 
 Africa alone. He noted that, curiously, only the women and chil- 
 dren ate the natural fruit, the warriors feeding on the fruits dried and 
 prepared in oil — probably from an intuition that they were more 
 highly nourished by the concentrated food. 
 
 In the West Indies, in the islands of the Pacific, along the Congo, 
 and throughout Central Africa many natives eat bananas as their 
 staple article of food, and maintain good physical development. The 
 fact that a diet consisting solely of this fruit will sustain life for long 
 periods is owing to the relatively high percentage of nitrogen which 
 it contains compared with sago, arrowroot, and similar carbohy- 
 drates. This percentage amounts to nearly five parts per hundred 
 of the entire fruit, or one fifth of the total solids (Corenwinder). 
 
 Grown on a given acreage, bananas will support a larger number 
 of persons than wheat. 
 
 The banana has of late years assumed a very -important position 
 among fruits sold in this country. Improvements in cultivation and 
 means of transportation, and the length of time through which the 
 fruit will keep without spoiling, are accountable for this, and up- 
 wards of one hundred thousand bunches of bananas are sold per 
 month for distribution" in New York city and vicinity alone. It 
 ranks equally with the orange in extent of consumption, and during 
 the winter months it is often the only fresh fruit which is universally 
 obtainable in remote country districts, while its cheapness places it 
 within the reach of almost every one. 
 
 In British Guiana the banana is employed especially as a nourish- 
 ing food for young children and invalids. 
 
 Many persons find that they cannot easily digest bananas as we 
 obtain them in this country ; but this no doubt depends upon the fact 
 that the fruit shipped to the United States is picked very green, and 
 is often quite immature and irregularly ripened when eaten. Imper- 
 fectly ripened bananas are composed chiefly of starch, but, as the 
 natural ripening proceeds, the saccharine material is converted 
 
VEGETABLE FOODS I 83 
 
 into a mucilaginous substance, which in turn forms dextrin and 
 glucose. 
 
 The flour, which is made by drying carefully selected and well- 
 ripened bananas, is, however, remarkably easy to digest, and highly 
 nutritious. 
 
 Surgeon Parke ("My Personal Experience in Equatorial Africa," 
 (p. 416), in an instructive and interesting account of his experience 
 with the sick of the Emin Pasha Relief Expedition, refers to Mr. 
 Stanley, who was in the midst of a severe attack of acute gastritis, 
 as follows : " He eats porridge made with banana flour and milk. It 
 is very light and digestible, and has more flavour than arrowroot ; it 
 is also very nutritious. We whites have very good reason to know 
 this fact now, as we have mostly lived on banana flour for the past 
 two years." 
 
 During most of this period, it should be observed, the members 
 of the expedition were taking very long marches and were suffering 
 from frequent attacks of malarial fever, which were a severe test of 
 the nutritive qualities of any dietary. 
 
 Farinaceous food is so prone to undergo malfermentation in the 
 stomach when the normal digestion is disordered that it becomes 
 very important to seek some variety of starchy food which can be 
 easily assimilated without the production of" acid eructations, flatu- 
 lence, or heartburn. The starchy foods which have heretofore been 
 obtainable in this country for this purpose have been all derived 
 from tubers or cereals which have been rendered more assimilable by 
 predigestion or " malting." 
 
 It is difficult to make a good fruit flour, for many fruits, when 
 dried, form a mucilaginous mass like the fig, or a sticky material like 
 the raisin, or shrivel to a stringy substance like the apple and the 
 apricot. But the banana, in some varieties and conditions, consti- 
 tutes an important exception, and when carefully selected and thor- 
 oughly dried it can be ground into a meal or even into a flour, mak- 
 ing as fine a powder as arrowroot, having a white or pale greyish or 
 yellowish colour, and an agreeable faintly aromatic odour and taste. 
 
 This meal possesses decided intrinsic advantages as an invalid 
 food. I have tested these preparations, both experimentally in the 
 laboratory and clinically, and found that an unboiled, saturated 
 aqueous solution of banana flour contains a very large percentage of 
 sugar — from one half to three fourths as much as certain of the best 
 known prepared saccharine foods for infants to which sugar had 
 been artificially added. The finest banana flour, called " bananose," 
 at the end of one and a half hour of pancreatic digestion was capa- 
 ble of developing twice as much sugar as the same quantity of oat- 
 meal or farina, and approximately one and a half time as much sugar 
 as cornstarch. Saliva, when substituted for pancreatic extract, pro- 
 duces a similar effect. 
 14 
 
1 84 FOODS AND FOOD PREPARATIONS 
 
 The banana flour, when prepared from the best quality of bananas,, 
 is made into a thin gruel or porridge by the addition of either water 
 or milk, and eaten with cream it constitutes a delicious and highly 
 nutritious article of diet suitable in cases of gastric irritability and 
 acute gastritis, etc. It is particularly serviceable for children be- 
 tween five and ten years of age. For those craving an acid flavour, 
 lemon juice with powdered sugar upon the banana porridge is found 
 to be very acceptable. The records of some fifty patients in the New 
 York and Presbyterian Hospitals to whom I gave gruel or porridge 
 made with banana flour show that it was exceptionally well borne by 
 irritable stomachs, almost never vomited, having no tendency to pro- 
 duce acidity from flatulence, nor did it cause diarrhoea or any ap- 
 parent laxative effect. It proved very useful in several cases of sim- 
 ple gastritis and acute gastritis complicating chronic indigestion and 
 in the early convalescent stage of typhoid fever. It was used with 
 advantage even during the fever itself whenever a change from an 
 exclusive milk diet seemed indicated either by the patient's dislike 
 for milk or by its causing dyspepsia. 
 
 The taste of banana flour is peculiar, and is not always agreeable 
 at first ; but it may be so modified by different processes of cooking 
 that the majority of patients find it much more palatable than the 
 conventional arrowroot, cornstarch, or farina. It is a decided gain 
 to be able to enlarge the list of starchy foods adapted to feeble 
 digestions by a fruit flour which presents the following advantages : 
 An agreeable variety of taste ; a high percentage of nitrogen, dex- 
 trin, and glucose ; ready digestibility ; high nutritive value ; the prop- 
 erty of keeping definitely in a concentrated dry state, ready for im- 
 mediate use. 
 
 Grapes. — Grapes are universally grown and enjoyed on account 
 of their delicious flavour and aroma as well as their general whole- 
 someness, and they constitute an important article of diet. Per- 
 fectly ripe and seedless grapes, such as the Black Hamburg and 
 other varieties, have long been recognised as an excellent food for 
 invalids. Grapes contain so large a proportion of water that they 
 possess but little nutrient property, although they hold considerable 
 sugar, but the salts which they furnish to the system are useful. 
 These salts are the sulphates, phosphates, and chlorides of sodium, 
 potassium, calcium, magnesium, and iron. 
 
 The habit which some people have of swallowing the pulp whole 
 with the seeds, however small the latter may be, cannot be too 
 strongly condemned. The seeds under no circumstances are di- 
 gested, being too hard and tough to be affected by any of the juices 
 of the digestive tract, and they therefore act as irritants or foreign 
 bodies. It was originally believed that inflammation of the appendix 
 vermiformis was often caused by the entrance of one or two sharp- 
 pointed grape seeds into this small division of the alimentary canal, 
 
VEGETABLE FOODS I 85 
 
 but this has been proved to be an exceedingly rare occurrence. The 
 main disadvantage of swallowing seeds consists in their interference 
 with normal digestive processes, while they are liable at any time to 
 cause more serious disturbance of the nature of diarrhcea, enteritis, 
 or intestinal obstruction. Swallowing the skins of grapes is equally 
 harmful. 
 
 Grapes, on account of their sugar, must be excluded in cases of 
 diabetes and gout. A special " grape cure " has been established for 
 some diseases. It is discussed under that heading. Unfermented 
 California grape juice constitutes an agreeable, wholesome, and 
 slightly laxative, non-alcoholic beverage, which may be prescribed 
 during mild fevers and in convalescence. Prof. Albert R. Leeds has 
 recently sent me the analysis of a new grape food which he says li is 
 entirely different from the grape juice, inasmuch as it contains, both 
 in amount and condition, the constituents of the grape to a point of 
 practical completeness which the manufactured juices have failed to 
 attain. I have verified by most exhaustive tests the absence of all 
 germs of fermentation, and this sirup will certainly keep indefinitely, 
 even in the absence of alcohol or antiseptic." This " liquid grape 
 food " contains protein and 64 per cent of grape sugar, with no alco- 
 hol and no starch. 
 
 Raisins, prepared by sun-drying from certain species of grapes 
 which are particularly rich in sugar, form a useful food, chiefly on 
 account of the agreeable flavour which they impart to more insipid 
 substances. (See also Raisin Wine.) 
 
 Raisins are usually made from white grapes, but they turn dark 
 purple or brown from oxidation of the tannic acid of their skins 
 (Leoser). Muscatel raisins are dried on the vine by incising the 
 stems to cause withering of the grapes. 
 
 Raisins cannot be eaten very abundantly without disordering 
 digestion unless they have been cooked. Added to some forms of 
 farinaceous food — such as rice pudding, sweetened breads, buns, 
 cakes, pemmican, and the like — they increase the appetite. If given 
 to children, as they too often are, they should be stoned carefully 
 beforehand, and the tough skins must not be swallowed. The latter 
 contain a whitish waxy material which keeps the grapes waterproof. 
 
 Plums. — Plums and greengages are wholesome fruits when they 
 are wholly ripe ; but they remain fresh for only a short time, and are 
 often on that account picked and sent to market in an unripe condi- 
 tion, in which they are very indigestible, and are prone to excite 
 diarrhcea and intestinal colic. 
 
 Prunes. — Prunes or dried plums are obtainable in various forms 
 and sold in large masses like dates, or preserved individually in jars, 
 in which form they have the advantage of keeping well for a long 
 period. They contain a large percentage of sugar. They have a dis- 
 tinctly laxative effect, eaten raw or, preferably, stewed, and they are 
 
86 
 
 FOODS AND FOOD PREPARATIONS 
 
 very wholesome and useful in cases of chronic constipation. They 
 are comparatively inexpensive, and by some patients may be taken 
 two or three times a day. They have a good effect in regulating the 
 bowels in children, and three or four prunes given once or twice a 
 day between meals will sometimes prove quite sufficient for this 
 purpose. 
 
 Pranelles are sold in masses dried like dates. They have a pleas- 
 ant acid flavour, but are not very digestible. 
 
 Olives are eaten for their agreeable flavour and their nutrient 
 value, which is due to the oil they contain. (See Olive Oil.) They 
 are much eaten as a relish, either plain or stuffed with peppers, and 
 are used for garnishing salads, sauces, etc. About seventy varieties 
 are now grown in California. They may be eaten fresh with bread 
 in the warm countries where they grow, but they are too bitter for 
 most palates, and are usually preserved by soaking respectively in 
 (a) strong lye, (b) fresh water, and (c) salt solution, and are left in 
 the latter for preservation. The lye neutralises their bitter taste. 
 In Greece dried olives are much eaten. The composition of the ash 
 of California olives presents, among other ingredients, 60 per cent of 
 potash, 16 per cent of lime, and 8.3 per cent of phosphoric acid. 
 
 Composition of Pickled Ripe and Green Olives 
 (C. B. Smith and F. Langworthy) 
 
 
 Water. 
 
 Fats (oil). 
 
 Carbohy- 
 drates. 
 
 Protein, 
 ash, etc. 
 
 Pickled ripe olives 
 
 Per cent. 
 65.08 
 78.41 
 
 Per cent. 
 25.52- 
 12.90 
 
 Per cent. 
 
 3-75 
 
 1.78 
 
 Per cent. 
 5.65 
 6.9I 
 
 Pickled green olives. 
 
 Berries. — The strawberry, on account of its exceptionally agree- 
 able flavour, and also from the fact that it is one of the first fruits of 
 the spring season in the eastern part of this country, is enjoyed by 
 almost very one. There are, however, a few persons who have a 
 striking idiosyncrasy against it, and in whom urticaria or more or 
 less violent gastro-enteritis with sore throat (Osier) is promptly 
 developed by taking even a few berries. The reason for this is not 
 fully explained, for analysis of the strawberry fails to show any 
 product which is peculiar to itself. There must consequently be 
 some combination of organic acids or other materials existing in 
 this berry which is exceptionally irritating to some persons. 
 
 The strawberry is usually a very wholesome food. It contains 
 abundant salts of potash, lime, and soda, which give it a moderate 
 diuretic action ; it is also slightly laxative, partly from the seeds 
 which it contains. There are many modes of eating, cooking, and 
 preserving the strawberry which are too familiar to require comment 
 here. Some persons learn that eating the berry with pepper or lemon 
 
VEGETABLE FOODS 187 
 
 juice enables them to digest it better, and those who suffer from 
 flatulent dyspepsia, if they can digest the berry at all, do well to take 
 it without sugar. 
 
 Currants, bilberries, mulberries, blueberries, huckleberries, rasp- 
 berries, blackberries, and gooseberries all contain considerable free acid, 
 and are moderately laxative, partly on account of their seeds, but 
 their expressed juices sometimes have the same effect. Not all ber- 
 ries are laxative, however. Huckleberries and blueberries may be 
 laxative when eaten with their seeds and skins, but Winternitz has 
 recently shown that a decoction made from these berries is a good 
 astringent for use in chronic diarrhoea. Blackberries have a similar 
 action. 
 
 The expressed juice of red currants, raspberries, or blackberries 
 makes a cooling and refreshing beverage or " shrub " when added to 
 some effervescing water, such as Apollinaris or carbonic-acid water, 
 and may sometimes be used in fevers, although lemon juice is usually 
 preferable. 
 
 Currants are preserved in various ways, the chief one being in 
 the form of jelly. Prepared in this manner, they constitute an appe- 
 tising and wholesome flavouring material, which may be taken with 
 meats and other foods to excite the appetite of invalids and con- 
 valescents whose chief difficulty is lack of desire for sufficient food. 
 
 Currants, raspberries, blackberries, etc., are frequently made into 
 jams. These, on account of the large quantity of sugar which is 
 added in their preparation, are quite nutritious, and their numerous 
 seeds have a laxative action. For this purpose they are sometimes 
 beneficially given to children to be eaten with bread and butter. 
 They aid in satisfying the natural craving of children for sweets, 
 and, if taken in moderation, they are very wholesome, and their 
 flavour may encourage the eating of more nutritious but less agree- 
 ably flavoured food, such as rice, cornstarch, or farina. 
 
 The gooseberry is much more popular in England than in the 
 United States. It contains citric and malic acids as well as sugar. 
 It is rendered more wholesome by cooking, and is sometimes made 
 into wine. 
 
 The elderberry furnishes an astringent wine, which is also some- 
 what diuretic and sudorific. 
 
 Melons. — Melons are of little service for nutrition, but they are 
 so agreeable to the palate that they are in very general use. The 
 varieties commonly obtainable in this country are the cantaloupe, or 
 muskmelon, and watermelon, and of these, the former is less likely to 
 produce gastro-intestinal disorder when not eaten too freely. 
 
 These fruits contain so large a proportion of water — upward of 
 95 per cent — that they are not satisfying to the appetite ; and since 
 in hot weather they are cool and refreshing, overindulgence in them 
 is a common fault, and most of the ill repute of watermelons has 
 
1 88 FOODS AND FOOD PREPARATIONS 
 
 arisen in this way rather than from any specific injurious effect which 
 they produce. If eaten with other food, they dilute the gastric 
 juice. Well-ripened muskmelons may often be eaten by invalids in 
 moderation to promote the appetite, served at the commencement of 
 a meal, at which time it is best that most fruit should be eaten when 
 taken with other food. 
 
 Citrons are very indigestible. 
 
 Figs and Dates. — Figs and dates are chiefly eaten in the United 
 States in the dry form, although m California and elsewhere they 
 may be obtained fresh. These fruits hold large quantities of sugar, 
 especially in their dry state, in which this ingredient is not only con- 
 centrated, but changed in the drying process. They also contain a 
 little nitrogenous material, so that they have more nutritive value 
 than many fruits ; in fact, in some Eastern countries they consti- 
 tute a staple article of diet, as illustrated by the use of the date in 
 Arabia. 
 
 Figs have a decided aperient action, which is chiefly, but not 
 solely, owing to their seeds. Three or four dried figs taken with a 
 glassful of water at night before retiring, and again half an hour be- 
 fore breakfast, will sometimes cure mild constipation. The dried 
 figs, like prunes, may be stewed if preferred. They contain a large 
 percentage of glucose. The best figs, called Turkey figs, are raised 
 in Smyrna, and when dried will keep for a long time. 
 
 Fungi 
 
 There are many species of fungi, some of which are available for 
 food, while others are irritating, and still others produce violent 
 gastro-intestinal disorder, and by their absorption give rise to symp- 
 toms of collapse, and may cause death. 
 
 Konig gives the following percentage composition : 
 
 Water 
 
 Non-nitrogenous substances 
 
 Fat 
 
 Grape sugar, mannite 
 
 Other non-nitrogenous substances, 
 
 Woody fibre 
 
 Ash 
 
 Fresh mushroom. 
 
 91 
 
 . 11 
 
 2 
 
 •57 
 
 O 
 
 13 
 
 I 
 
 05 
 
 3 
 
 71 
 
 
 
 67 
 
 
 
 76 
 
 Fresh truffle. 
 
 72.08 
 8.9I 
 O.62 
 
 7-54 
 7.92 
 2.21 
 
 Fresh common 
 morel. 
 
 9O.OO 
 3-48 
 O.24 
 O.72 
 
 3-95 
 0.67 
 0.94 
 
 Mushrooms. — Mushrooms, on account of their nitrogenous mat- 
 ter, are of some slight use as food ; but if eaten in sufficient quantity 
 to yield much nutriment, they always disagree. Bauer says : " Judg- 
 ing from their chemical composition, they ought to have no small 
 
VEGETABLE FOODS 1 89 
 
 value as foods, but it is doubtful how far they are really utilised in 
 the alimentary canal." 
 
 Mushrooms have a tempting flavour, which is developed on cook- 
 ing, and while they agree with most persons in health and form an 
 acceptable article of diet, there are some persons who can never 
 eat even the simplest varieties without suffering more or less from 
 acute gastro-intestinal irritation. They should never be eaten raw. 
 They are usually served alone, broiled upon toast or as a dressing 
 for beef, fillet, steak, etc., or they may be preserved in olive oil or 
 by drying. Their digestion requires fully three hours. The com- 
 mon mushroom consists of 91 per cent water, besides 3J per cent 
 of carbohydrates, and 4 per cent of proteid, with salts and other sub- 
 stances. 
 
 Truffles. — The truffle is a subterranean vegetable of the order of 
 Thecaphore. It is an expensive luxury, and is used to add flavour in 
 cooking and as an ingredient of rich meat sauces, pates, etc. It con- 
 tains no sugar. Eaten in quantity by itself it is a highly indigestible 
 substance. It easily decomposes with a very offensive nauseous 
 odour. There are several varieties, of which the black is the chief, 
 and it is obtained from beneath the trees of oak forests of Perigord 
 in Southern France, where it is hunted by trained Spanish poodles or 
 sows, whose sense of smell enables them to detect the fungus beneath 
 the ground. There is a special hereditary race of trufrling swine, 
 broken for the purpose. 
 
 The morel is a friable, greyish-black, cone-shaped mushroom, 
 which grows extensively in a variety of dry soils, but, like the cepe, is 
 obtained principally in France. It may be cultivated artificially. It 
 is used for flavouring, like the trufBe. 
 
 Cepe is a name given to several mushrooms belonging to the 
 Boletus family, which are globular in shape, and coloured orange or 
 white. 
 
 Poisonous Fungi. — Most poisonous fungi are distinguished from 
 the non-poisonous by a warty cap. They are often viscid and have 
 other peculiarities of structure, colour, etc. They are acrid or 
 astringent, and have a pungent, disagreeable odour (Christison). 
 Poisonous mushrooms may either produce violent gastro-intestinal 
 symptoms, which are seldom fatal, owing to the prompt evacua- 
 tion of the poison from the system, or these symptoms are fol- 
 lowed by a condition of narcosis ending in fatal collapse. The 
 pupils are contracted, the urine is suppressed, the face is livid, 
 and there is general vasomotor paralysis. The conjunctivae are 
 congested. 
 
 Muscarin is a substance isolated from poisonous fungi, which is a 
 violent cardiac poison and constrictor of the pulmonary blood ves- 
 sels, producing dyspnoea, prostration, and death. Its effects are 
 antagonised by belladonna. 
 
i90 foods and food preparations 
 
 Lichen 
 
 Iceland moss is used extensively as a food by dwellers in the 
 arctic regions. 
 
 Konig gives the percentage composition of the dried moss as fol- 
 lows : Water, 15.96; nitrogenous matter, 2.19; fat, 1.41 ; non-nitro- 
 genous matter, 76.12. 
 
 A bread is made from it after carefully washing out two bitter 
 organic acids which it contains. Senator has recommended this 
 bread for use by diabetics. 
 
 Nuts 
 
 Nuts contain protein, with some starch and more or less fat, and 
 very little water. From 50 to 65 per cent of the common nuts is shell. 
 With the exception of the cocoanut, chestnut, almond, and English 
 walnut, the varieties eaten in this country furnish but little nutri- 
 ment. Their chief value is to stimulate the appetite and afford 
 variety in the diet. Excepting chestnuts and cocoanuts, they are 
 usually eaten raw, as dessert, but they are much used in confectionery. 
 A few nuts are used in salads and as dressing for fowl. As a rule, 
 they are to be proscribed from invalid dietaries, but, with the excep- 
 tion of chestnuts and peanuts, they may be allowed to diabetics. A 
 preparation of malted nuts which may be obtained in market is both 
 nutritious and digestible. It contains emulsified nut fat, maltose, and 
 vegetable protein. 
 
 Almonds contain a ferment called emulsin and much fat, and sweet 
 almonds have 3 to 5 per cent of sugar, but no starch (Bauer). This 
 low percentage of sugar makes them of service in the treatment 
 of diabetes, in which disease they are sometimes used as a sub- 
 stitute for bread after being ground into meal. (See Diabetic 
 Breads.) 
 
 Macaroons are a digestible form of cake for convalescents and 
 children composed chiefly of almonds and sugar. 
 
 Almonds are wholesome and nutritious. They should not be 
 eaten in cases of gastric irritability, but occasionally dyspeptics 
 in whom gastric digestion is slow derive benefit from eating a 
 few salted almonds with meals. They should be soaked and 
 peeled or " blanched," otherwise their skins may set up gastric 
 irritation. 
 
 The bitter almond contains hydrocyanic acid, sugar, and oil, and 
 is not used except for flavouring cough mixtures. Almonds are 
 imported chiefly from Italy, France, and Spain, but of recent years 
 they have been extensively grown in California. 
 
 English walnuts eaten liberally between meals may assist in over- 
 coming constipation through the bulk of insoluble residue which 
 they leave, and possibly also from the oil which they contain. 
 
VEGETABLE FOODS 
 
 191 
 
 Cocoanuts are very indigestible even when thoroughly desiccated 
 and grated. The cocoanut contains a proteolytic ferment which con- 
 verts meat into albumoses with considerable activity. The cocoa- 
 nut has been successfully grown in Florida. 
 
 Brazil nuts, pecan nuts, beechnuts, butternuts, filberts, etc., all hold 
 much oil, and are difficult of digestion. Butternuts easily become 
 rancid after being shelled. 
 
 Chestnuts contain 15 per cent of sugar with so much starch that 
 they are very nutritious, and in some parts of Italy they are made 
 into cakes and eaten by the peasants as a substitute for potatoes. 
 Raw chestnuts are wholly indigestible, but if thoroughly roasted or, 
 better still, if long boiled, they become much less so. They should, 
 however, not be given to invalids. 
 
 The pistachio, a native nut of Syria, has a greenish, almond-like 
 kernel. It is chiefly used in confectionery and ices for both its colour 
 and delicate flavour. 
 
 Peanuts are described under Legumes, p. 165. 
 
 Composition of Nuts and some Other Food Materials (C. F. Langworthy) 
 
 Almonds 
 
 Brazil nuts 
 
 Filberts 
 
 Hickory nuts 
 
 Pecan nuts .... 
 
 English walnuts 
 
 Chestnuts, fresh 
 
 Chestnuts, dried 
 
 Acorns . 
 
 Beechnuts 
 
 Butternuts 
 
 Walnuts 
 
 Cocoanuts 
 
 Cocoanuts, shredded 
 
 Pistachios, kernels 
 
 Pine nuts or pinons (Pimis 
 
 edulis) 
 
 Peanuts, raw 
 
 Peanuts, roasted 
 
 Litchi nuts 
 
 Beefsteak 
 
 Wheat flour 
 
 Potatoes 
 
 Refuse. 
 
 Per ct. 
 64.8 
 49.6 
 52.1 
 62.2 
 53-2 
 58.0 
 16.O 
 24.O 
 
 35-6 
 40.8 
 86.4 
 74.1 
 
 4S.8 
 
 40.6 
 
 24-5 
 32.6 
 41.6 
 
 12 8 
 
 20.0 
 
 Edible 
 portion 
 
 Per ct. 
 35-2 
 50.4 
 
 47-9 
 
 37.8 
 
 46.8 
 
 42.0 
 
 84.0 
 76.0 
 
 64.4 
 
 59' 
 13 
 
 25' 
 
 51. 
 
 roo. 
 100. 
 
 59-4 
 75 5 
 67.4 
 58-4 
 87.2 
 100. o 
 80.0 
 
 COMPOSITION AND FUEL VALUE OF THE EDIBLE PORTION 
 
 Water. 
 
 Per ct. 
 
 4.8 
 5-3 
 
 3-7 
 3-7 
 3.o 
 2.8 
 45-o 
 5-9 
 4 
 4 
 4 
 2 
 
 14 
 
 3 
 
 4-2 
 
 •4 
 .2 
 .6 
 9 
 ■9 
 12.8 
 
 78.3 
 
 17 
 61, 
 
 Protein. 
 
 Per ct. 
 21 .O 
 17.O 
 15.6 
 
 15-4 
 
 21 
 
 27 
 
 27.6 
 5-7 
 6-3 
 
 22.6 
 
 14.6 
 25.8 
 30.5 
 
 2-9 
 18.9 
 10.8 
 
 2.2 
 
 Fats. 
 
 Per ct. 
 54-9 
 
 66.8 
 
 65 3 
 67.4 
 71.2 
 64.4 
 5-4 
 7.0 
 37-4 
 57-4 
 61.2 
 
 56.3 
 50.6 
 
 57-3 
 54-5 
 
 61 
 
 38. 
 49 
 
 Car- 
 bohy- 
 drates. 
 
 Per ct. 
 
 17-3 
 
 7.o 
 13.0 
 11. 4 
 
 13-3 
 14.8 
 42.1 
 74.2 
 48.0 
 13.2 
 3-4 
 11. 7 
 27.9 
 31.6 
 15.6 
 
 17-3 
 24.4 
 16.2 
 
 77-5 
 
 74.8 
 18.4 
 
 Ash. 
 
 Per ct. 
 
 3-1 
 
 2.8 
 
 2.0 
 
 2.5 
 
 1-5 
 
 1.0 
 
 . 5 
 1.0 
 
 Fuel 
 
 value 
 
 per 
 
 pound. 
 
 Cat. 
 
 3,030 
 
 3>329 
 
 3,432 
 
 3,495 
 
 3,633 
 
 3,305 
 
 1,125 
 
 1,875 
 2,718 
 3,263 
 
 3,37i 
 3,105 
 2,986 
 3,125 
 3,oio 
 
 3,364 
 2,560 
 
 3,177 
 1.453 
 1,130 
 1,640 
 
 385 
 
 ,f The meat of nuts, excepting chestnuts and cocoanuts, contains 
 nearly 50 times as much fat and less than one fifth as much carbo- 
 hydrates as wheat flour, and has about double the fuel value — i. e., 
 energy-producing power. A pound of unshelled nuts will furnish 
 
I92 FOODS AND FOOD PREPARATIONS 
 
 about half as much protein and the same amount of energy as a 
 pound of flour. Owing to their high fuel value and low protein con- 
 tents, nuts would not make a well-balanced food when eaten by 
 themselves " (C. F. Langworthy). 
 
 V. FATS AND OILS 
 
 Fats and oils contain but three elements — namely, carbon, oxy- 
 gen, and hydrogen. In the starches and sugars the proportion of 
 oxygen and hydrogen is such as to form water, H 2 0, when their 
 molecules are split up ; but in the group of fats oxygen is not present 
 in sufficient quantity to form water with all the hydrogen atoms, and 
 in their combustion with oxygen considerable heat is evolved. In 
 some fats, like butter, very little oxygen is present, and carbon and 
 hydrogen compose the bulk of the substance. The amount of fat 
 which from time to time is stored in the body is regulated to a greater 
 degree than any other substance by muscular exercise, which, if ac- 
 tive, always tends to prevent its accumulation. The storage of fat is 
 favoured by sleep as well as inactivity. (See Obesity and Leanness.) 
 
 About one fifth of the entire body weight is composed of fat, 
 but only about a quarter of an ounce is contained in the blood. 
 Before death results from starvation 90 per cent of the body fat is 
 consumed. The chief sources of this fat in the human body are 
 undoubtedly starches and sugars, but it is probable that under cer- 
 tain conditions it may also be derived from fatty food. 
 
 Fat is required to promote the earlier stages of growth and de- 
 velopment of the organism, and there are also, many forms of disease 
 and degenerative changes which are accompanied by increased accu- 
 mulation or production of fat in and between the tissues and cells. 
 It is impossible to live in perfect health without fatty food, and it is 
 equally impossible to live long upon fat alone, for it soon disorders 
 the digestion and causes absolute disgust. 
 
 Fat constitutes one of the ingredients of pus, and is found in the 
 normal living white blood-corpuscles, and after the ingestion of fat 
 in excess as food, a sufficient quantity of it may be absorbed into 
 the serum of the blood to give rise to a thin film upon its surface 
 when shed. 
 
 In hot climates where fat meats are scarce, or their use is pro- 
 hibited by the religion of the inhabitants, they employ the oils of 
 fish, vegetables, or fruits instead. 
 
 Uses of Fats. — The chief uses of fatty food are : 
 
 1. To furnish energy for the development of heat. 
 
 2. To supply force. 
 
 3. To serve as covering and protection in the body. 
 
 4. To make more plastic various structures of the body and give 
 rotundity to the form. 
 
IM.ATK IX 
 
 Beef Fat x 40. 
 
 ANIMAL FATS, WfAGNIFIED. 
 
 {From liiillctin No. 13, Division of Chemistry, United? States Agricultural Bureau). 
 
FATS AND OILS 1 93 
 
 5. To spare the tissues from disintegration, for, although their 
 combustion in the body results largely in the production of heat, they 
 also take part to some extent in tissue formation. 
 
 6. To serve for storage of energy. 
 
 The various forms of energy manifested in the different nitro- 
 genous tissues — as muscular action, secretion, nerve force, etc. — are 
 more or less intimately dependent upon fat combustion. It was 
 originally believed that the force of the body was supplied by the 
 oxidation of nitrogenous materials. Fat eaten with the food was 
 supposed to be deposited again as fat in the tissues of the body 
 without material change, but of recent years this theory has been 
 very largely recast, and the primary value of fatty food consists un- 
 doubtedly in its contribution to force production and its power of 
 saving other tissues, especially the albuminous, from destruction by 
 oxidation, whereas its secondary use is in connection with tissue 
 formation. Fats do, however, enter into the composition of many 
 different tissues, even those of the nervous system. 
 
 The fats and oils which are employed as food all serve essen- 
 tially the same purpose, and may therefore be grouped together as 
 a distinct class. There is a general resemblance in their physical 
 properties, although they differ considerably in the melting point. 
 The several food fats and oils are of various chemical composition, 
 but after being absorbed they are recognised mainly in one or two 
 simple forms, chiefly as stearin and olein. 
 
 The use of animal oils, such as lanolin, and of the petroleum 
 products, like purified vaseline, has very largely superseded the ex- 
 ternal application of other fatty substances — lard, etc. — to the skin 
 for the purpose of lubrication. 
 
 It is not possible to get very much nourishment into the body 
 by osmosis through the integument, but some improvement seems to 
 follow the rubbing of fats and oils, such as cacao butter, olive oil, or 
 cod-liver oil through the skin of marasmic children and other pa- 
 tients. (See Marasmus.) One or two teaspoonfuls of the oil may be 
 rubbed in twice a day on the thighs, abdomen, and chest. The state- 
 ment that the application of fats to the surface of the body by 
 inunction reduces the body temperature is not substantiated by 
 experience. 
 
 The treatment of biliary calculi by the administration of large 
 doses of olive oil — two or three ounces at a time — given upon an 
 empty stomach, has been suggested, apparently with the idea that it 
 might have some local lubricating action. Cases have been reported 
 in which gallstones have been said to appear in the feces as a result 
 of this treatment, but it has been shown that the oil itself may 
 become mixed with inspissated intestinal mucus and form small, 
 hardened masses, which have been mistaken for gallstones. There 
 is no foundation for the belief that oil is of anv value for cholelithia- 
 
194 FOODS AND FOOD PREPARATIONS 
 
 sis, nor is it possible that it should enter the bile ducts to " lubricate '? 
 them. 
 
 Fats and oils are useful preservatives of many foods by prevent- 
 ing access of air, drying, and decomposition. A layer of oil floating 
 on top of a flask of wine is capable of preserving its delicacy of 
 flavour for a long time (Chambers). Oil preserves fish, like sardines, 
 and layers of lard are used to protect jars of potted meats, pdte-de- 
 fois-gras, etc. Oils and butter protect eggs from decomposition. 
 
 Digestibility of Fats. — There is some difference of opinion as 
 to what extent fat may aid or retard the process of digestion, but 
 it is a matter of very common experience that those persons whose 
 digestive organs are feeble do not tolerate fats or oils well when 
 eaten with other forms of food. This is no doubt owing to the fact 
 that fats are practically unaltered in the mouth and stomach, and 
 in the latter, when melted, they coat the mucous membrane and 
 surround the particles of food with a thin film which materially 
 interferes with the normal action of the gastric juice. For this 
 reason fats are to be avoided by dyspeptics, and the fats selected for 
 special nutritive processes should be in the form of good butter, 
 cream, or cod-liver oil. On the other hand, fats may sometimes aid 
 the digestibility of starchy foods by preventing them from forming 
 lumpy masses in the mouth and stomach. For example, a well- 
 roasted mealy potato may be made all the more digestible for an 
 invalid by being mashed with a little butter or cream. The diges- 
 tibility of fats may be much enhanced by the process of emulsification 
 — i. e., of securing an extremely fine subdivision of the oil globules. 
 More than fifty years ago Horace Dobell, of London, emulsified 
 beef fat and lard by means of pancreatic juice, and recently John F. 
 Russell, of New York, has modified and extended the principle so 
 as to emulsify all fats, fluid or solid, deriving products of permanent 
 fine emulsion, capable of dilution with hot water, and possessing high 
 nutritive value. These emulsions consist of one half fat, which is 
 predigested and easily assimilated. 
 
 It is stated by Ringer that fats taken fasting lessen the secretion 
 of bile, whereas if taken with or after food they increase it, but, as 
 many kinds of food promote the secretion independently of fat, it 
 is doubtful whether the latter possesses any very decided action in 
 relation to bile formation. 
 
 Most of the fat used as food melts at the temperature of the body, 
 which facilitates its digestion. 
 
 Children often eat butter more readily than any other form 
 of fat. 
 
 As a rule, the stomach is less disturbed by animal than by vege- 
 table fats taken in excess, and the former may be tolerated for a 
 longer time. The limit of digestibility of increasing quantities of 
 food is much sooner reached with fats than with other articles of 
 
FATS AND OILS I95 
 
 diet, and they produce satiety early in a meal, but, as in the case of 
 many foods, toleration may be acquired for the ingestion of fat, 
 which is exemplified in the fact that many persons who cannot digest 
 cod-liver oil completely at first may do so after two or three weeks' 
 trial. This is, in part, due also to the general improvement in health 
 which follows in some cases the administration of easily digested 
 fat. Overdoses of fat at any time are apt to give rise to the forma- 
 tion of irritating acids which cause nausea and vomiting, with pos- 
 sibly abdominal cramps and loose evacuations. Fat taken too liber- 
 ally with other food ceases to be economical for the system and 
 becomes positively harmful. 
 
 Since fat is exclusively digested in the small intestine, diseases of 
 any part of the alimentary canal are contraindications for its use. 
 
 Liquefied fats and oils are usually administered as a matter of 
 routine when corrosive poisons have been swallowed, with the idea 
 that they coat over the mucous membrane of the stomach and 
 oesophagus and protect them from the action of the irritant. This 
 protective action is overestimated, for it is difficult to coat to a 
 sufficient degree a mucous membrane which is already moistened 
 with watery mucus. 
 
 The digestibility of all fat depends somewhat upon its cooked 
 state. Many persons are nauseated or made dyspeptic by eating 
 hot mutton fat who can eat the same with impunity when it is cold. 
 In the latter condition it becomes more friable, and, if thoroughly 
 mixed in chewing with starchy food, or used as suet in the form of a 
 farinaceous pudding, it becomes very much more digestible. Chil- 
 dren usually dislike fat meat, but they are quite willing to take suet 
 puddings, which, if light and well cooked, are wholesome. 
 
 While the various fats and oils, in general, have the same bene- 
 ficial effect upon nutrition, there is considerable difference in their 
 force value and in the facility with which one variety or another may 
 be assimilated in individual cases. The animal fats have a higher 
 nutritive power than those derived from vegetables, and liver fat, 
 butter and cream, are the most serviceable of all. 
 
 Animal Fats 
 
 The principal animal fats and fatty foods are butter, cream, suet, 
 lard, oleomargarine, the fat of beef, mutton, pork and bacon, bone 
 marrow, pemmican, fish, and cod-liver oil. Oil is also made from 
 the yolk of eggs. 
 
 Butter and cream have been discussed under the heading Milk 
 Derivatives (pp. 93-97). 
 
 Lard is hog fat separated by melting from the areolar connective 
 tissue. Considerably over half a billion pounds are annually pro- 
 duced in the United States. Crude lard contains glycerides of oleic. 
 
I96 FOODS AND FOOD PREPARATIONS 
 
 stearic, and palmitic acids, besides a little gelatin and other sub- 
 stances. 
 
 " Cuisine " is a preparation of cotton-seed oil designed to replace 
 lard and cheap cooking butter. 
 
 " Cottolene " is another substitute for cooking purposes. 
 
 Stearins are the solid residue of animal fats remaining after pres- 
 sure has separated the fluid fats. They are used in making com- 
 pound lard, butterine, and similaB foods. 
 
 Suet is the fat which surrounds the kidneys of the ox, sheep, and 
 other animals. 
 
 Oleomargarine. — Oleomargarine was invented in 1870 by a 
 French chemist, Mege-Mourier, who discovered that beef fat from 
 particular portions of the bullock would melt at the same tempera- 
 ture with butter, and would keep longer without becoming rancid. 
 The fresh fat is mashed in a grinding machine to free it from mem- 
 brane. " The fragments fall into a tank heated with steam, which for 
 every thousand parts of fat contains three hundred parts of water and 
 one part of carbonate of potash and two stomachs of sheep or pigs. 
 The temperature of the mixture is raised to 45 C." (Clark). After 
 two hours the fat is withdrawn from the membranes, which have been 
 digested away, and is heated still more with the addition of 2 per 
 cent of salt. It is then cooled, pressed, and packed for market. 
 
 Much discussion has arisen in regard to the wholesomeness of 
 oleomargarine, and its sale has been regulated by act of Congress 
 since 1886 and by many State laws. It has been declared perfectly 
 innocuous, and the object of the legal control of its sale is mainly 
 intended to prevent it from being fraudulently offered as butter. It 
 certainly tastes better than poor butter. 
 
 Butterine, which has now largely replaced oleomargarine in this 
 country, is made in a similar manner, but with a somewhat different 
 proportion of ingredients, and some of the leaf fat of the hog is added 
 during the manufacture. 
 
 Beef Fat, Pork, etc. — Beef, mutton, and pork fat consist prin- 
 cipally of the glycerides of such common fatty acids as stearic, pal- 
 mitic, and oleic. 
 
 The fat of good roast beef is nutritious, and a very digestible 
 variety of fat is good bacon thinly sliced and thoroughly cooked. 
 This form of fat is crisp and dry, and it is often digested by invalids 
 w 7 ho cannot tolerate other kinds. Ham fat and pork fat, on the other 
 hand, are usually very indigestible — the more so when hot. 
 
 Bone Marrow. — Bone marrow is an easily digestible and whole- 
 some fat which has long been used as a food. The long bones of 
 the ox are cut crosswise in pieces about two inches in length and 
 cooked with the marrow within them. Red marrow is a useful food 
 in cases of tuberculosis, secondary and pernicious anaemia, and chlo- 
 rosis. But it is doubtful whether the marrow acts otherwise than 
 
FATS AND OILS I97 
 
 in furnishing an assimilable fat to patients who are much in need 
 of such food, and also a very digestible form of iron, which exists 
 in it in considerable quantity. The marrow of young animals, such 
 as the calf or lamb, is preferred for this purpose, because their tissue- 
 building power is so active. Fraser reported the first case of anaemia 
 treated by means of marrow, and he prefers a glycerin extract. 
 
 J. S. Billings, Jr., recommends a similar preparation made as fol- 
 lows : 
 
 11 Twelve sheep's ribs, carefully scraped, are chopped into small 
 fragments and rubbed in a mortar with one pound of glycerin. This 
 is allowed to macerate for three or four days, being kept in a refrig- 
 erator during that time. It is then strained through gauze, and the 
 resultant liquid administered in teaspoonful doses three times a day." 
 
 Henry F. Walker, of New York, uses a sort of emulsion made 
 by mixing thoroughly the red marrow of the long bones of the ox 
 with Cctraria (Iceland moss). This makes an exceedingly agreeable 
 preparation, a whitish paste pleasant to the eye, and tasting not un- 
 like good butter. It may be spread upon bread and eaten three or 
 four times a day. 
 
 Pcmmican is made of meat cut into slices and thoroughly dried in 
 the sun ; to this are added fat, sugar, and dried fruit, such as raisins 
 and currants. It is used on long voyages, especially to the Arctic 
 circle, where a fatty diet is essential to furnish heat and force to en- 
 able the body to withstand the rigour of the climate. It is easily 
 masticated, and the sweet fruit promotes the flow of saliva. 
 
 Calves' brains and liver contain considerable fat. 
 
 The common fish which contain most fat are eels, salmon, her- 
 ring, and mackerel. Sardines contain some fat, but derive most of it 
 from the oil in which they are immersed for preservation. 
 
 Many fish oils have special uses. The Eskimos eat whale and 
 seal oil and blubber, and dugong oil is eaten to some extent in Aus- 
 tralia. The oil of the sturgeon is employed for preserving caviare. 
 Turtle oil and butter is made extensively in Brazil from both the eggs 
 and fat of the animal (Clark). 
 
 Cod-liver oil will be separately considered. 
 
 Eggs contain considerable fat in their yolks. Some eggs, like the 
 plover's are very rich in this ingredient. They are elsewhere de- 
 scribed in detail. (See Eggs, p. 101.) 
 
 Vegetable Fats and Oils 
 
 The principal vegetable fats or oils and fatty foods are derived 
 from seeds. Such foods are olives, olive oil, cotton-seed oil, and 
 nuts. Traces of fat are found in the legumes. 
 
 Olive Oil. — Olives and olive oil constitute a very digestible form 
 of fatty food, and may sometimes be eaten by consumptives in lieu 
 
190 FOODS AND FOOD PREPARATIONS 
 
 of cod-liver oil. French olives gathered while young and tender are 
 very wholesome. 
 
 Olive oil is made by crushing the fruit with stones, after which 
 the pulp is pressed in bags. The first oil thus obtained is the best. 
 A- second oil is got by adding boiling water to the pulp residue, and 
 pressing it again. This oil is more likely to become rancid than the 
 first (Clark). The best oil generally obtainable is from France and 
 Italy, but an excellent quality is manufactured in Southern Califor- 
 nia. The paler variety is preferable, but, unfortunately, it is con- 
 stantly adulterated or imitated. (See also Olives.) Olive oil is eaten 
 with salads, and is also useful for frying. 
 
 Cotton-seed oil, and to some extent poppy-seed oil, are now fre- 
 quently substituted for olive oil in the preparation of various foods, 
 and the sardines which were formerly preserved in pure olive oil are, 
 for the most part, immersed in cotton-seed oil. This oil is not ran- 
 cid, but its flavour and odour, which resemble linseed oil, are not 
 agreeable when it is eaten raw with salads or fish, and, unless ex- 
 tremely pure, it leaves an unpleasant after-taste in the mouth. It is 
 composed principally of palmitin and olein. It is a harmless food. 
 
 Linseed oil is sometimes substituted for olive oil, but it is not very 
 digestible. 
 
 Cacao butter, oil of theobroma, is a firm oil obtained from ca- 
 cao seeds during the manufacture of chocolate. It easily melts at 
 the body temperature. It is used for inunctions and for making 
 suppositories, and sometimes as an ingredient of infant foods, such 
 as Lacto-preparata. 
 
 Nuts, especially English walnuts, cocoanuts, hickory, pecan, and 
 Brazil nuts, all contain a good deal of vegetable oil. (See Nuts, 
 p. 190.) 
 
 The oil of nuts which have been too long kept sometimes be- 
 comes rancid and unwholesome. 
 
 Cocoanut oil is principally used in Oriental countries. 
 
 Peanut oil is used to some extent in this country, like cotton-seed 
 oil, mainly to adulterate or imitate olive oil, which is much more ex- 
 pensive. 
 
 Java almond oil may also be used for cooking. 
 
 Dietetic Uses of Fats and Oils. — Since fats are essential for growth 
 and nutrition as well as force production, fatty food is indicated for 
 convalescence from severe acute diseases, and for patients suffering 
 from chronic wasting diseases, in both of which classes there has 
 been considerable waste of the tissues. Persons whose general 
 health has been impaired by bad hygienic surroundings, children 
 who have been wrongly fed by ignorant or poor parents who could 
 not obtain proper food for them, and aged persons in whom the 
 nutritive processes are becoming less and less vigorous, may all be 
 benefited by supplying a sufficient amount of fatty food in the dietary. 
 
FATS AND OILS 199 
 
 For scrofulous and tuberculous patients fats are especially indicated. 
 There is therefore a very large variety of diatheses and diseases, 
 both local and general, which may be benefited by improving the 
 nutrition of the body and increasing force production through the 
 agency of easily digestible forms of fatty foods. 
 
 Diseases in which Fats are Particularly Beneficial. — Tuberculosis, 
 pulmonary as well as other forms ; anaemia ; chronic wasting diseases 
 with secretion of pus, as empyema, chronic abscesses, etc. ; maras- 
 mus ; rickets ; chronic bronchitis ; many chronic diseases of the skin 
 and nervous system. 
 
 Diseases in which the use of Fats should be forbidden or re- 
 stricted. — All forms of acute gastro-intestinal disease ; chronic gas- 
 tritis ; dilatation of the stomach ; chronic diarrhoea ; obesity ; fatty and 
 waxy liver ; gallstones ; acne ; urticaria. 
 
 Generally speaking, fats are laxative, and oils should not be given 
 in severe intestinal disorder. 
 
 By most persons fat cannot be eaten continuously in large quan- 
 tity without producing indigestion. The stools become offensive 
 and diarrhceal, there is nausea and gastric indigestion, and disgust 
 for such a diet very soon arises. There are those who are unable 
 to digest fats in any amount, however small, and they must derive 
 all their energy from carbohydrates. 
 
 GTycerin. — Glycerin plays an inconspicuous role as a food. It 
 is mainly useful for its sweetish taste as a substitute for sugar in the 
 diet of diabetics, but to many persons the taste of glycerin itself is 
 nauseous. It is now largely superseded by saccharin. It is highly 
 hygroscopic, and if taken in the mouth undiluted makes the mucous 
 membrane sticky and unpleasant, but it is used as a mouth wash 
 in a diluted form in the proportion of a drachm to the ounce of 
 water. The mouth may be rinsed or swabbed with it in cases of 
 acute fever, such as typhoid, where the mucous surface has become 
 dried or the tongue is glazed or fissured. It acts by protecting the 
 mucous membrane from evaporation, making the mouth more com- 
 fortable. In such cases it sometimes diminishes thirst, although its 
 effect in this respect is very uncertain. Glycerin is also laxative, 
 and it may be given either per os or in the form of the well-known 
 glycerin suppositories for the purpose of increasing peristaltic action 
 and evacuating the bowels. It is also used as an enema. 
 
 Cod-liver Oil 
 
 The best cod-liver oil is known as " cold-drawn oil," and is pre- 
 pared from the raw fresh livers of the codfish by subjecting them to 
 heavy pressure, by which the oil is squeezed out. 
 
 Chemical and Physical Properties. — Cod-liver oil, according to 
 analyses made by De Jongh, contains glycerin, olein (70 per cent), 
 15 
 
200 FOODS AND FOOD PREPARATIONS 
 
 myristic, butyric, acetic, margaric, and other acids, biliary elements 
 such as cholesterin. also iodine, bromine, chlorine, and phosphorus 
 in small amount, and a peculiar material which is called " gaduin." 
 Gautier and Mourges obtained besides a half dozen substances re- 
 sembling alkaloids and other materials, a basic substance which they 
 call morrhuine, about one half milligramme of which occurs in each 
 gramme of the oil, and has, it is claimed, all of its active medicinal 
 properties. 
 
 The refined oil may contain no iodine, and it is seldom present 
 in greater amount than 0.5 per cent : hence the value of the oil does 
 not depend upon this substance, as at one time suggested. 
 
 When pure, its odour resembles shoe leather. On adding strong 
 acid, the biliary odour is intensified if the oil is unadulterated. If 
 the odour is absent, the oil is spurious. 
 
 Cod-liver oil is one of the most easily absorbed of all the oils, 
 owing to the quantity of its fatty acids. It is quickly oxidised in 
 the body. It is highly nutritious and alterative, and is slightly 
 laxative, especially for infants. 
 
 Some of the oil supplied in market is derived from the livers of 
 other fishes than the cod, but the cod-liver oil is undoubtedly the 
 best. Pains should be taken to secure a pure preparation thoroughly 
 clarified from the impurities which oil may contain, such as traces of 
 iodine, phosphorus, and sometimes bile salts. None of these sub- 
 stances add to its food value, and, if present in excess, the oil is 
 much more likely to disagree. 
 
 The crude " straits " oil contains products of decomposition, is 
 strong, malodorous, and of a dark-brown or even black colour. It 
 is so disagreeable and indigestible that it possesses no advantage 
 over the " shore " oil. The clarified Norwegian oil is the best variety 
 to prescribe. 
 
 Cod-liver oil is sometimes adulterated with the cheaper cotton- 
 seed oil, to which a fishy flavour is artificially given, and it should 
 therefore only be purchased from a well-known and responsible 
 firm. 
 
 An advantage of cod-liver oil is that when pure it can be taken 
 longer than any other fat excepting butter and cream, and in larger 
 quantities than those substances without disordering the stomach. 
 This is no doubt owing to the fact that the oil is already in a con- 
 dition in which it has once served in the animal body for nutrition 
 or at least for storing up energy. This form of oil is readily emul- 
 sified and saponified, and is absorbed by the intestinal villi with 
 probably greater facility than any other fat. 
 
 Dosage. — Many patients who dislike the taste of the oil at first 
 soon acquire tolerance for it if given in small and gradually increas- 
 ing dosage, commencing sometimes with not over 10 to 30 drops 
 twice a day, and children not rarely become so fond of it as to ob- 
 
FATS AND OILS 201 
 
 ject to its discontinuance. Infants may be given from 5 to 20 drops 
 two or three times a day. It is so valuable a food that where its use 
 is clearly indicated every effort should be made to secure its tolera- 
 tion, and even though it may at first disagree, exciting nausea and 
 vomiting, perseverance and care in its administration may enable it 
 to be very well borne. If it is not digested at first, but one dose of 
 two or three teaspoonfuls a day need be given, and this should be at 
 night. 
 
 Those who like it can sometimes take as much as an ounce three 
 times a day with advantage, although half an ounce is all that can 
 usually be tolerated without disturbing digestion. 
 
 The oil must be given under proper supervision if its successful 
 use is to be continued ; otherwise it defeats its own object by upset- 
 ting digestion. Patients who dose themselves with it often use too 
 much, and almost invariably take it at the wrong time in relation to 
 meals. 
 
 It is best to prescribe it about two hours after dinner. If given 
 earlier, it remains in the stomach, interfering with the digestion of 
 other food, whereas if digestion is already well under way, it passes 
 with the chyme into the intestine, where it is absorbed. While the 
 oil is being taken the stools should be occasionally examined, as 
 the absence of fat globules in them is a proof of its complete ab- 
 sorption. 
 
 Methods of Administration. — Many patients can take perfectly 
 pure, well-clarified cod-liver oil better than the emulsions and prep- 
 arations in which it is offered in the market, while others prefer it 
 in the form of the so-called emulsions with hypophosphites of lime, 
 soda, or iron, or with other substances. Some of these emulsions are 
 rendered almost tasteless, while others are flavoured with winter- 
 green, ginger, or some other aromatic. 
 
 Emulsions are seldom as good as the pure oil, and are only to be 
 preferred when the latter is not digested or when the taste proves too 
 nauseous. They usually do not contain above 50 per cent of the 
 oil, and often only 33 per cent; hence the dose is unnecessarily 
 bulky. Moreover, they rapidly deteriorate with age, so that if emul- 
 sions are to be used they should be freshly made with yolk of egg 
 and glycerin or mucilage of tragacanth. 
 
 Dr. James Stewart, of Montreal, gives excellent formulae for this 
 purpose as follows : 
 
 Cod-liver oil 6 ounces. 
 
 Oil of wintergreen 1 drachm. 
 
 Chloroform 2 drachms. 
 
 Glycerin, yolk of egg, each 5 " 
 
 Orange-flower water, sufficient to make 12 ounces. 
 
 M. Dose, one tablespoonful. 
 
 This is not too thick. 
 
202 FOODS AND FOOD PREPARATIONS 
 
 Cod-liver oil 6 ounces. 
 
 Oil of wintergreen (or any essential oil) I drachm. 
 
 Mucilage of tragacanth 2 ounces. 
 
 Orange water, sufficient to make 12 " 
 
 M. Dose, one tablespoonful. 
 
 This emulsion is somewhat thicker than the preceding one. 
 
 Oil of bitter almonds may be used in the proportion of three 
 drops to the ounce, instead of the wintergreen oil. 
 
 Lefaki recommends an emulsion made with an equal part of lime 
 water flavoured with lemon sirup or vanilla. This can be pre- 
 scribed when diarrhoea exists. Another method is to add two ounces 
 of finely chopped and strained fresh pancreas to the gallon of oil to 
 produce an emulsion. 
 
 Stewart suggests rinsing the mouth before taking the oil with 
 undiluted brandy or whisky and two or three drops of oil of pepper- 
 mint. Children may be given a peppermint lozenge. If preferred, 
 the dose of pure oil may be poured upon the surface of some fluid, 
 such as orange or ginger bitters, strong black coffee, lemon juice, 
 weak brandy and water, or even ale or beer. Pains should be taken 
 to float the oil in the centre of the surface of the fluid, so that it is 
 to some extent coated by it and does not come in contact with the 
 glass or cup and produce a lingering, disagreeable taste in the mouth. 
 Ringer suggests adding a few drops of catsup to disguise the taste, 
 or the use of a mixture of equal parts of the oil and fresh aqueous 
 solution of gum acacia with two minims of oil of lemons added to 
 each ounce. A little salt taken in the mouth before and after each 
 dose may neutralise the taste. He also refers to the use of a cod- 
 liver-oil jelly containing 70 per cent of the oil. This disguises the 
 flavour. The oil is sometimes given with different preparations of 
 meat juice. 
 
 In this country cod-liver oil is extensively used in the form of 
 capsules of gelatin which are shaped like an olive, and which some 
 patients can swallow with ease, although they are rather bulky and 
 not always reliable. A child of ten years came under my observa- 
 tion who for some time previously had been given four or five of 
 these capsules daily, each containing a teaspoonful of cod-liver 
 oil. She had developed an exceedingly irritative stomach cough, 
 for which a variety of sedatives had been administered without any 
 effect. To my astonishment, she at one time vomited seventeen of 
 the undissolved capsules, which represented four or five days' dosage. 
 
 The oil is sometimes administered in the form of " oleochyle," 
 in which it is claimed it has been predigested and rendered easier of 
 absorption. 
 
 Claude Bernard, to whom we are indebted for much valuable 
 research upon the physiology of digestion, first showed that ether 
 given by the mouth acts as a stimulant to the secretion of the pan- 
 
FATS AND OILS 203 
 
 creas and the glands of Brunner which aid the digestion of fat, and 
 that it increases the absorption of fats. Acting upon this sugges- 
 tion, Dr. Balthazer Foster found that pure ether added to fats and 
 oils in the proportion of five or six minims to a drachm of the oil 
 would often insure its digestion, whereas previously it had excited 
 nausea and vomiting, and this method has proved of service in the 
 hands of others. The ether itself disguises somewhat the taste of 
 the oil, but I have sometimes found it to produce disagreeable eruc- 
 tations. In fact, in some hospitals a " malingerer's mixture " has 
 been employed composed of a disagreeable combination of ether, 
 oil, and asafcetida, which has the result of causing eructations and 
 maintaining an exceedingly disagreeable taste in the mouth. Lime 
 water is sometimes added to cod-liver oil to produce a temporary 
 emulsion, and it may prevent nausea. 
 
 Cod-liver oil is advantageously combined with malt, and when 
 not so sweet as to be disliked by the patient it proves a very service- 
 able food. Cod-liver oil is added in the proportion of 30 per cent to 
 maltine, or 50 per cent to malt extract. 
 
 In very hot weather it is usually best to suspend the administra- 
 tion of oil, as it is liable to disagree, even if it does not become rancid. 
 
 Substitutes. — Many substitutes for cod-liver oil have been pro- 
 posed, but it is doubtful whether any of them can be made to yield 
 all the benefits to be derived from the genuine substance. 
 
 Efforts have long been made to determine whether the alkaloidal 
 or other substances obtainable from cod-liver oil do not possess all 
 the nutritive and stimulating properties of the oil itself in equal or 
 even greater degree. Some of them are doubtless capable of pro- 
 ducing active symptoms, but if the oil itself is a true food, there can 
 be no advantage in attempting to concentrate it beyond the minor 
 consideration of avoiding its nauseous, fishy taste. M. Chapoteau 
 describes a crystalline substance which he terms morrhuol, and 
 which exists in the oil in the proportion of 1.5 to 6 per cent, the 
 lesser quantity being found in the purest oil. It is claimed that three 
 to five drops of this substance possess all the properties of a drachm 
 of cod-liver oil. It may be given in capsules or disguised with 
 olive oil, fat, or cream. Much interest is at present manifested in 
 testing the clinical worth of preparations of this class, but although 
 their use has been favourably reported by some observers within the 
 past year or two, further evidence is required before their general 
 substitution for the oil itself can be indorsed. 
 
 Von Mehring and Hauser recommend " lipanin," made by add- 
 ing to olive oil 6 per cent of oleic acid. This is devoid of disagree- 
 able taste and odour, and may be given in doses of from one to four 
 teaspoonfuls three times a day. 
 
 Uses. — Cod-liver oil is not a specific for any disease, and there 
 are many clinicians who prefer to prescribe other forms of fat when 
 
204 FOODS AND FOOD PREPARATIONS 
 
 possible. Fothergill wrote that " out of five persons taking cod-liver 
 oil probably only two require fat in that particular form, while three 
 take it because it is the only fat put up in such a form as can be 
 readily purchased." 
 
 Nevertheless, there are often seen cases of phthisis in which a 
 decided gain in weight follows the administration of a disproportion- 
 ately small quantity of the oil. It is a most useful food in many 
 conditions of debility, and is indispensable in the treatment of rickets 
 and general tuberculosis. 
 
 It is found clinically to be of great service in a variety of forms 
 of chronic inflammation and in cases in which there is old purulent 
 discharge from any part of the body, as from the middle ear, or from 
 a chronic abscess, like empyema, and in chronic bone diseases, such 
 as caries. 
 
 Among other chronic diseases for which cod-liver oil is recom- 
 mended may be mentioned chronic rheumatism and gout, arthritis 
 deformans, a variety of skin affections, and advanced syphilis. It 
 is of service also in pulmonary emphysema and in cases of chronic 
 bronchitis with tenacious purulent expectoration, and by many it is 
 believed to be of some specific value in loosening cough. It should 
 be observed that oil when absorbed passes through the lymphatic 
 system and is carried with tolerable directness into the pulmonary 
 circulation, where fats in general are believed to be oxidised. It is 
 suggested that this fact may possibly have some bearing on the in- 
 fluence attributed to cod-liver oil as an expectorant, although it 
 seems more probable that the effect is derived from the improvement 
 produced upon the general nutrition. Brunton attributes it to a 
 stimulating action upon the epithelium of the bronchi.. In cases of 
 atonic dyspepsia, particularly among elderly people, cod-liver oil 
 often relieves the " sinking " feeling at the epigastrium and the faint- 
 ness of which they complain. 
 
 Ringer recommends cod-liver oil for vertigo in the aged which 
 originates from feeble heart action, and for chronic endocarditis in 
 children. It is also serviceable in relieving constipation in young 
 infants, and it may be sometimes given with advantage in lieu of cas- 
 tor oil. Its loosening effect is more decided in children than in 
 adults, and it is less likely to produce subsequent constipation than 
 castor oil, besides being less disagreeable to take. 
 
 For marasmus the use of cod-liver oil is particularly indicated, 
 and in infants when chronic diarrhoea obtains, some benefit may be 
 derived from the topical application of the oil to the skin. To tuber- 
 culous children of the emaciated marasmic type in whom the skin is 
 dry and wrinkled 15 or 20 drops of the oil may be given at night 
 without fear of increasing the diarrhoea. 
 
PART II 
 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 STIMULANTS AND BEVERAGES 
 
 It is the almost universal experience of mankind that the taking 
 of food and drink merely to satisfy the cravings of physical needs 
 does not at the same time wholly satisfy the desire of the mind for 
 occasional invigoration, for restoration of bodily function after fa- 
 tigue, for support during sustained muscular exertion, for an incen- 
 tive to activity, and for conviviality. In some form or other, 
 although in greatly varying degree, a stimulant is demanded by 
 almost every one to meet the emergencies with which he is from time 
 to time confronted. 
 
 To this end the civilised European imports his tea from China, 
 his coffee from Java, his cocoa from Brazil, his tobacco from America 
 or Cuba, his opium from India, and his alcohol from more immediate 
 neighbours. His semicivilised or wholly barbaric brother who lacks 
 the ability or means to procure such refreshment from foreign 
 sources relies upon his own ingenuity to devise fermented drinks 
 from every available substance. Thus, the Tartar ferments milk into 
 koumiss, the Mexican ferments the Maguey (Agave Americana) into 
 pulque, the Central African ferments a wine from the palm, the 
 Apache of southern Arizona ferments a cactus into the intoxicating 
 mescal, the Kamtchatkan ferments a peculiar drink from a poison- 
 ous fungus, and honey, rice, corn, barley, rye, grapes, dates — in fact, 
 nearly every cereal and every fruit — is in some part of the world 
 made to yield the cup which cheers, and too often inebriates as well. 
 
 It is true that there are those who find it possible to live without 
 ever tasting even the mildest stimulants of any kind, and there are 
 sects of men, like the Mohammedans and Buddhists, to whom the 
 use of alcohol in every form is absolutely forbidden by their religion ; 
 but most of them discover other means of satisfying an instinctive 
 craving for occasional stimulation, and ready substitutes for the 
 prohibited intoxicants are found close at hand in hasheesh, opium, 
 excessive tea consumption, etc. The economic and social aspects 
 
 205 
 
2o6 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 of this subject alone are of vast importance, and the question of the 
 utility of stimulants and beverages is in itself no small branch of 
 dietetics. 
 
 The several substances classed under these headings are found to 
 serve in one or more of the following ways : 
 
 I. To relieve thirst and introduce fluid into the circulation. 
 
 II. As diuretics. 
 
 III. As diaphoretics. 
 
 IV. As diluents of the food and of the waste material in the body. 
 
 V. As stimulants of the nerves and other organs. 
 
 VI. As intoxicants. 
 
 VII. As demulcents. 
 
 VIII. As tonics, and to promote digestion. 
 
 IX. As astringents. 
 
 X. For nutrition. 
 
 The effects of all beverages and stimulants are far more pro- 
 nounced if they are taken into an empty stomach, which insures their 
 prompt absorption. 
 
 I. To relieve thirst all fluids which are not too sweet may be used, 
 but sour beverages, such as acid lemonade or raspberry vinegar, the 
 effervescing carbonated waters, solutions of potassium bitartrate, or 
 dilute mineral acids in water, are generally the most acceptable. 
 
 II. As diuretics the mineral waters and carbonated waters hold 
 the first rank. With many persons coffee is also an active diuretic. 
 So are beer, gin, champagne, and, to a lesser degree, other forms of 
 alcohol, and tea. 
 
 III. As diaphoretics, hot spirits and water or hot tea may be 
 used. 
 
 IV. As diluents of the ingested food and of the waste material of 
 the body the alkaline and carbonated effervescing or bland waters 
 are the best. 
 
 V. As stimulants of the nerves and other organs, the milder 
 forms of alcoholic beverages, diluted spirits, tea, and coffee are used. 
 
 VI. As intoxicants, beers, ales, strong wines, champagne, and 
 strong liquors are the most powerful agents. Koumiss as originally 
 made in the steppes of Russia, and many fermented substances, are 
 also employed for the same purpose. 
 
 VII. As demulcents, mucilaginous, farinaceous, and gelatinous 
 beverages are used for fevers, etc. Such are decoctions of Iceland 
 moss (cetraria) or Irish moss, barley or oatmeal water, arrowroot and 
 other light gruels, solutions of gelatin, flaxseed tea, etc. When 
 taken hot they are soothing for coughs and promote expectoration. 
 
 VIII. For use as tonics and to aid digestion may be mentioned 
 malt extracts, ales, light wines, clarets, Burgundies, diluted brandy 
 or whisky, chalybeate and arsenical waters, and alkaline waters 
 drunk before meals. 
 
. ; STIMULANTS AND BEVERAGES 207 
 
 IX. As astringents, red wines and tea are of chief importance. 
 
 X. For nutrition, cocoa, chocolate, malt extracts, " grape food," 
 and, because of the milk or cream added, tea and coffee. 
 
 Stimulants have two separate actions : First, a prompt exhilarat- 
 ing effect or exaltation of the nervous system, which endures for a 
 few hours, and, secondly, a period of depression which usually bears 
 a more or less definite relation to the degree of previous excitation. 
 The second period is sometimes longer or more intense than the 
 first, producing an actual balance of loss of vitality in the system. 
 
 Various dietetic drinks have been advocated for their supposed 
 specific action in stimulating a torpid liver and as laxatives or as 
 diuretics; such, for example, are various " herb teas," etc., but they 
 are of doubtful efficacy. 
 
 Many fruit essences and sirups are offered for sale for use in 
 making cooling drinks and invalid beverages. When thoroughly 
 reliable preparations are obtained they are of good service, but 
 many of them are adulterated. For example — for lemonade, mix- 
 tures of malic, citric, and tartaric acids are often substituted. As a 
 rule, it is better to extract the juice from the fresh fruit, and unless 
 large quantities are required, this is almost as cheap. Unfermented 
 California grape juice may be had in very pure condition, and it 
 constitutes an excellent beverage for invalids, being wholly free 
 from alcohol. " Grape food " serves a similar purpose (p. 185). 
 
 The preparations under consideration may be diluted with ice 
 water, or with any one of the simple effervescing waters, such as 
 carbonic-acid water, Vichy, Seltzer, Apollinaris, etc. 
 
 Of all these beverages, lemonade and orangeade are perhaps the 
 most useful in the sick-room. These are agreeable, cooling, and 
 refreshing in fevers, mildly diuretic, and beneficial in many ways. 
 A very wholesome drink is made by putting the juice of two lemons 
 with three or four lumps of sugar into a tumbler of iced Vichy, 
 Seltzer, or Apollinaris, and stirring in a saltspoonful of bicarbonate 
 of sodium ; to be drunk while effervescing. 
 
 Root beer, sarsaparilla, and ginger ale are wholesome beverages 
 when pure. Ginger ale is likely to cause colic unless a reliable article 
 is obtained from a trustworthy dealer. It makes a useful " long- 
 drink " for alcoholic subjects who are attempting to recover from a 
 debauch. They crave some beverage which has life and sparkle, 
 and the ginger itself is helpful to the stomach. 
 
 Alkaline and Mineral Waters — Effervescing Waters 
 
 There are many spring waters which are used as beverages and 
 drunk either with or between meals. They possess, in addition 
 to the properties of plain water, a mildly tonic effect upon the 
 mucous membrane of the stomach, due either to the carbon-dioxide 
 
208 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 gas or salts, or both, which they may contain, and, owing to their 
 salts and water, they are also diuretic. Many of these waters are 
 sold " plain " — i. e., without free gas, and others either hold natural 
 C0 2 or are made " sparkling " by having this gas pumped into them 
 under pressure. 
 
 These waters are very useful, when taken half an hour before 
 meals, to cleanse the mucous membrane of the stomach and pre- 
 pare it for the reception of food. They also serve to dilute and 
 wash out waste materials from the system. 
 
 The effervescing or carbonic-acid waters are more highly 
 charged with gas as sold from " fountains " at the druggists' or in 
 siphons than when bottled. 
 
 Fruit sirups are combined in many ways with soda, carbonic- 
 acid, or other effervescing waters, to make soda water and similar 
 beverages. 
 
 Ginger ale, sarsaparilla, etc., are made effervescing, and are often 
 used as cooling and refreshing drinks. 
 
 The habit which some persons form of drinking large quantities 
 of alkaline waters independent of any special needs of the system 
 should be condemned. It leads to the condition which Trousseau 
 long ago described as " mineral-water cachexia." 
 
 All the effervescing waters when taken in excess are apt to ex- 
 cite or increase flatulency and give rise eventually to dyspepsia and 
 debility, especially when combined with sweet sirups. They should 
 be avoided in dilatation of the stomach, flatulent dyspepsia, and 
 palpitation. 
 
 Some waters are drunk for their laxative or purgative action, 
 and others for the salts which they contain, like those of sulphur, 
 iron, or arsenic. This leads to the classification of mineral waters 
 into alkaline, saline, chalybeate, sulphurous, acidulous, arsenical, etc. 
 
 Thermal waters are those which issue hot from their springs. 
 Many persons believe that these waters possess special properties 
 by virtue of being hot, which they lose as the heat departs, but there 
 is no physiological ground for this belief. 
 
 Many table waters, like Poland water (a plain carbonic-acid 
 water), Vichy, Johannis, Apollinaris, and Seltzer (effervescing car- 
 bonic-acid waters), are used mainly as an agreeable table beverage, 
 and to dilute spirits, wines, lemonade, etc. They are cooling, re- 
 freshing, and wholesome. People will often drink fluid of this kind 
 who are not willing to drink sufficient plain water. 
 
 Johannis water is an alkaline carbonated water which comes 
 from a spring at Zollhaus, in the Taunus Mountains. It contains 
 principally carbonates of lime, soda, and magnesia, besides traces 
 of other materials, and considerable free carbonic-acid gas. 
 
 A glass of Apollinaris or similar water taken an hour after a 
 too heavy dinner promotes digestion and helps remove waste prod- 
 
STIMULANTS AND BEVERAGES 200, 
 
 nets from the system. In fevers such waters are always useful, and 
 they may be given very freely. They often allay nausea and vomit- 
 ing. They may be employed for the dilution of liquors and milk 
 for invalids. Some persons can digest milk better when diluted with 
 Vichy, carbonic-acid water, plain soda water, or Seltzer. The addi- 
 tion of the latter tends to overcome the constipation which milk is 
 apt to cause. 
 
 Some waters are sold as natural lithia waters, but the quantity 
 of lithium contained in any spring water is usually very minute, 
 and beverages of this class are generally re-enforced artificially by 
 lithium salts. They are used to counteract the lithic-acid diathesis, 
 gout, and rheumatism. 
 
 Kronenquelle water is an alkaline lithia water from Obersalz- 
 brunn, in Silesia, which contains considerable sodium carbonate and 
 traces of iron and manganese. 
 
 The Buffalo, Londonderry (New Hampshire), and other lithia 
 waters are much prescribed in this country. 
 
 Below is given a list of some of the more noted waters which 
 are extensively used in conjunction with dietetic treatment : 
 
 1. Alkaline Waters. — Vichy, in France; Ems, in Germany; 
 Fachingen, in Germany ; Saratoga Vichy (rich in C0 2 ), New York ; 
 St. Louis Springs, Michigan (poor in C0 2 ) ; Bethesda Springs, Wis- 
 consin. 
 
 Other sodium chloride waters, containing also carbonates and 
 C0 2 , are those of Hathorn Spring, Congress Spring, and Kissengen 
 Spring, in Saratoga, New York ; Homburg, Wiesbaden, Kissengen, 
 and Seltzers, in Germany ; Bourbonne, in France. 
 
 The alkaline waters all contain more or less carbon dioxide, 
 and their most important ingredients are the alkaline carbonates. 
 
 They also contain sodium chloride, and sometimes sodium sul- 
 phate. Some have one variety of salts, some another, which pre- 
 ponderates. Generally speaking, the European waters are richer in 
 alkalies than are the American. 
 
 Alkaline waters are useful in the uric-acid diathesis and lithsemic 
 conditions, gout, chronic rheumatism, obesity, hepatic engorgement, 
 gallstones, hyperacidity of the gastric juice, chronic gastric ulcer, 
 and catarrhs of the mucous membranes, especially of the stomach, 
 respiratory tract, and bladder. 
 
 2. Alkaline Sulphur Waters. — Richfield Springs, Sharon Springs, 
 Avon Springs, in New York ; Greenbrier White Sulphur Springs, 
 in West Virginia ; Harrogate, in England ; Neuendorf and Meinberg, 
 in Germany ; Aix-la-Chapelle, in Rhenish Prussia. 
 
 These waters, containing sulphuretted hydrogen in addition to 
 other ingredients, are much used in gout, chronic rheumatism, 
 obesity, and chronic eczema. They are often supplemented by a 
 course of chalybeate waters. 
 
2IO STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Hot springs are found at the Hot Sulphur Springs of Arkansas 
 and Virginia, and Schlangenbad and Plombieres, in Europe. 
 
 3. Alkaline and saline purges contain a high percentage of sodium 
 and magnesium sulphates. These waters are often called " bitter 
 waters. 1 ' 
 
 Such are : Piillna, in Bohemia (the strongest of all, and one of 
 the oldest known) ; Carlsbad (Sprudel) and Marienbad (Kreuz- 
 brunnen), in Bohemia ; Friedrichshall, in Germany ; Franz Josef, in 
 Austria ; Kissengen Bitterwater, in Bavaria ; Hunyadi Janos, in 
 Hungary ; Rubinat Condal Spring and Villacabras, in Spain ; Epsom , 
 in England; Crab Orchard, Estill Springs, in Kentucky; Bedford 
 Springs, in Pennsylvania ; some of the Saratoga waters, and Mount 
 Clement Spring, in Michigan, which latter water contains iron. 
 
 These waters are useful to counteract indiscretions in diet and 
 the overloading of the liver. 
 
 The Rubinat water is effective and possesses the advantage of 
 being less disagreeable than many of the others. 
 
 Villacabras water is a Spanish sodium sulphate, strongly purga- 
 tive water, obtained not far from Madrid. 
 
 These waters should be taken either very cold or in a half-pint 
 of very hot water. If drunk lukewarm their taste is nauseous, and 
 may excite emesis. The dose varies from two to six or eight 
 ounces. 
 
 4. Chalybeate Waters. — Schwalbach (Stahlbrunnen), Pyrmont 
 (Neubrunnen) Spa, Belgium ; St. Moritz, Switzerland ; Rock Enon, 
 Virginia. These waters serve as tonics for the blood and nerves, 
 but if too long used they cause dyspepsia and anaemia. 
 
 5. Acidulous waters contain C0 2 in excess, and but little salts 
 of any kind. Such are the waters of Clysmic Spring, in Wisconsin; 
 Blue Lick, in Kentucky; Carlsbad (Dorotheenquelle), in Bohemia. 
 
 6. Various waters are the Alum Springs, in Virginia ; Oak 
 Orchard Acid Spring, in New York ; Bourboule, in France, which 
 contains arsenic. Roncegno water is a ferruginous arsenical water 
 from the Tyrolean Province of Trent. 
 
 Tannin 
 
 Tannin is an astringent of vegetable origin which exists in tea^ 
 coffee, and many wines, especially the red wines, and as such it is 
 worthy of brief separate consideration. It possesses no nutrient 
 power whatever, and is mainly of interest to the dietetist from the 
 harm it may occasion if taken too freely. In strong solution it 
 precipitates the ferment of the gastric juice and renders it inert, 
 and also gives rise to constipation by its astringency, which affects 
 the mucous membrane of the intestine. For these reasons strong 
 tea or tea drunk to excess materially hinders gastric digestion. 
 
STIMULANTS AND BEVERAGES 
 
 211 
 
 According to Fraser, the tannin in tea interferes with the diges- 
 tion of fresh meat, but to a less extent with that of dried or smoked 
 meat, such as tongue or ham, the fibres of which are already shrunk- 
 en by curing. 
 
 Coffee contains much less tannin than tea, thus it has not the 
 same effect upon the alimentary canal, in fact, it may be laxative. 
 
 Tannin is contained in red wines in considerable quantity, hence 
 clarets are mildly astringent and constipating. 
 
 Tannin is useful for a variety of local astringent applications. 
 
 Tea 
 
 Method of Preparation. — Tea is a preparation made from the 
 leaves of various species of a hardy evergreen shrub called Thea. 
 The manufacture consists in plucking the young leaves of the plant 
 and placing them in the sun ; after they have become withered they 
 are rolled and twisted. This process is sometimes conducted by 
 hand, or even by the feet of the natives in China, and sometimes by 
 machinery. The leaves are next pressed into small masses or rolled 
 into balls and allowed to ferment while still moist, after which they 
 are dried over a fire of a temperature sufficient to evaporate all the 
 moisture. They are finally sifted and assorted into different quali- 
 ties. The value of the tea depends upon its flavour, and this is 
 mainly influenced by the process of fermentation, which must be 
 supervised with great care. 
 
 Green and Black Tea. — The distinction between black and green 
 teas is due to the variations in their mode of preparation, and not 
 to separate species of the plant. Green tea is made by steaming 
 the leaves before they are rolled and dried. The further difference 
 between green and black tea consists in the relatively larger quan- 
 tity of astringent material (tannin) which predominates in green 
 tea. The following table, from an analysis by Mr. Y. Kozai, illus- 
 trates this point and exhibits the proportionate quantity of some of 
 the more important ingredients of tea. It presents the difference 
 in percentage composition between green and black tea prepared 
 from the same plant : 
 
 Crude protein. 
 
 Fibre 
 
 Ash 
 
 Theine 
 
 Tannin 
 
 Total nitrogen 
 
 Green tea 
 
 Black tea. 
 
 37-43 
 
 38.90 
 
 IO.06 
 
 IO.07 
 
 4.92 
 
 4-93 
 
 3.20 
 
 3-30 
 
 IO.64 
 
 4.89 
 
 5-99 
 
 6;. 22 
 
 Because green tea contains more than twice as much of the 
 astringent tannin than black tea it is generally regarded as less 
 
212 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 wholesome than the latter. It is also believed to have a somewhat 
 less stimulating effect upon the nervous system, though this can 
 hardly be accounted for by the slight variation in the percentage of 
 theine shown to exist by the above table, this latter substance being 
 the alkaloid, which is chiefly responsible for the stimulating influence 
 of tea upon the nerves. 
 
 There has been some discussion in regard to the identity of theine 
 with caffeine, and by many writers they are believed to be the same 
 alkaloid. Rice says that most of the commercial caffeine is derived 
 from tea leaves, but May finds that in frogs, at least, " theine pro- 
 duces spontaneous spasms and convulsions, while caffeine does not. 
 Theine impairs the nasal reflex early in the poisoning process, while 
 caffeine does not, if at all, until the very last stage." 
 
 Properties. — The peculiar stimulating properties which tea pos- 
 sesses, as well as its colour and agreeable flavour, depend upon the 
 season of the year at which the leaves are gathered, the variety of 
 the plant, the age of the leaves, which naturally become tough as 
 they grow older, and the care exercised in their preparation. The 
 flavour is produced by the formation of volatile oils which develop 
 during fermentation. It is these substances which cause the minor 
 differences in effect of tea and coffee. 
 
 The aroma as well as the flavour of tea is often artificially in- 
 creased by the addition of such substances as the leaves of orange 
 flowers, jasmine, or roses. 
 
 Tea made of small leaves packs closely, and if measured by the 
 spoonful gives a stronger beverage than the coarser-grained vari- 
 eties. 
 
 Infusion. — The flavour of tea depends not only on the character 
 of the leaves, but upon that of the water which is added to them. 
 About five grammes of leaves should be used for one infusion. The 
 water should be poured upon the tea leaves when boiling, and the in- 
 fusion should not last beyond three or four minutes if the flavour is 
 to be delicate ; if it is continued beyond this point materials become 
 extracted from the leaves which, while they may make the tea ap- 
 pear stronger, materially diminish the delicacy of its flavour. The 
 water should be neither too hard nor too soft. Soft water extracts 
 more of the soluble materials of the leaves and yields a beverage of 
 darker colour. Water which contains iron or lime salts should be 
 boiled with sodium carbonate before it is used for tea infusion. 
 
 PHYSIOLOGICAL AND THERAPEUTIC ACTION 
 
 Good Effects. — Tea is mildly stimulating to the nervous system 
 and tends to increase the activity of certain vital functions. It is re- 
 freshing and relieves bodily fatigue. For the latter purpose it has 
 been found especially useful for soldiers on the march in hot climates. 
 
STIMULANTS AND BEVERAGES 
 
 Major Woodruff, U. S. A., says : " The universal experience of 
 military men testifies to the absolute necessity of tea or coffee. The 
 latter is generally preferred, but the writer's experience points to 
 tea as preferable in the long run." For this purpose both these 
 substances are better preserved if compressed into small bulk. 
 
 In some persons a cup of hot tea affords prompt and decided re- 
 lief from headache, and when taken quite strong it is sometimes serv- 
 iceable in the cure of chronic alcoholism. It is also used as an 
 antidote for opium poisoning, but coffee is preferable. 
 
 The " strength " of tea as applied to the appreciation of its taste 
 in distinction from its effect on the nerves is due to the quantity of 
 tannin present, which is bitter. A bitter tea is not therefore neces- 
 sarily a strong one in its stimulating properties, which are owing to 
 the theine. 
 
 Tea, when employed as a beverage, possesses some effects which 
 are not strictly due to action upon the nerves. It introduces con- 
 siderable hot water into the system, which is beneficial when taken at 
 the proper time in relation to meals, and wdien milk or cream and 
 sugar are added its nutritive value becomes considerable. Tea is 
 moderately sudorific in action, and it has a slight influence in regulat- 
 ing the circulation and temperature of the body, which, if too cold, 
 becomes warm by the stimulating effect upon the heart, whereas if 
 the body is too hot, tea may exert a cooling influence by increasing 
 perspiration and evaporation from the surface. Hot tea will some- 
 times increase the action of aperients, but it is doubtful whether it 
 has any more effect than a similar quantity of hot water. 
 
 Roberts gives the following analysis of 
 
 The Effects of Tea and Coffee on Gastric Digestion 
 
 Digesting mixture : 2 grammes of dried beef fibre, 0.15 c. c. hydrochloric acid, 1 c. c. 
 
 glycerin extract of pepsin, varying proportions of tea and coffee, water to 100 c. c. 
 
 Proportion of Tea or Coffee 
 
 TIME IN WHICH DIGESTION WAS COMPLETED. 
 (NORMAL, IOO MINUTES.) 
 
 contained in the digesting 
 Mixture. 
 
 Tea, 5-per-cent 
 strength. 
 
 Coffee, 5-per-cent 
 strength. 
 
 Coffee, 15-per-cent 
 strength. 
 
 10 per cent 
 
 105 minutes. 
 140 " 
 180 
 Embarrassed. 
 
 105 minutes. 
 140 " 
 
 180 
 Embarrassed. 
 
 160 minutes. 
 
 20 " " 
 
 Embarrassed. 
 
 40 " " 
 
 60 " " 
 
 Almost no action. 
 
 
 
 Many elderly people find tea particularly grateful and soothing 
 after reaching a period of life when the functional activity of the 
 stomach is gradually weakened. A disproportion may exist between 
 the quantity of food which the stomach can digest and the actual 
 need of the body for nutritive materials to counterbalance the daily 
 waste. In such cases tea enables the aged poor to live on less food 
 than they would otherwise require, and is thus economical for them. 
 
214 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 The refreshing effect of tea when taken into an empty stomach 
 after bodily fatigue may continue between three and four hours, a 
 period considerably longer than that of coffee or light wine. 
 
 Ill Effects. — The ill effects of excessive tea drinking — the " tea 
 habit "—are referable to its action on the digestive and nervous 
 systems and are cumulative. If taken in large quantities with meals, 
 tea precipitates the digestive ferments, retards the activity of diges- 
 tion, and may even occasion gastric irritation and catarrh. Consti- 
 pation usually results, though there is sometimes diarrhoea, and 
 more or less flatulency. The latter may itself cause insomnia. The 
 effect of the " tea habit " on the nervous system is to overstimulate 
 and then depress it, first producing restlessness, worry, and insomnia, 
 and finally muscular tremors, sensory disturbances, and palpitation. 
 Persons who are subjected to some unusual strain or anxiety find 
 that tea for the time being disagrees with them, whereas they are 
 able to drink it regularly when in ordinary health. Cheap teas are 
 always much more apt to produce ill effects than the more expensive 
 varieties. In many persons five cups of strong tea per diem pro- 
 duce symptoms of the " tea habit." 
 
 Indian teas contain a larger proportion of tannin than do those 
 from China. For this reason they are more likely to produce disor- 
 ders of digestion and constipation. They also occasion nervousness 
 and sleeplessness to a marked degree when drunk in excess. 
 
 The ill effects of poor tea and of tea rich in tannin can be over- 
 come in some degree, as suggested by Roberts, by the addition of 
 carbonate of sodium in the proportion of ten grains to the ounce of 
 dried tea leaves ; this does not materially interfere with the taste. 
 
 When tea taken with milk and sugar is found to disagree, sub- 
 stitution of the juice of a slice or two of lemon makes it accepta- 
 ble and beneficial to many persons. Tea which is " steeped " is 
 more unwholesome on account of the extra tannin, etc., which is 
 extracted. 
 
 Tea must be avoided in dyspepsia, gastric irritability from any 
 cause, constipation, anaemia, insomnia, and " nervousness," and 
 usually in gastric catarrh, although Bauer recommends weak tea as 
 less likely than coffee to induce heartburn or aggravate diarrhoea. 
 The ill effects of the " tea habit " are even more pronounced in 
 children and youth than in adults. 
 
 A case of multiple neuritis caused by drinking between two and 
 three pints daily of strong tea has been reported by Spratling, and 
 several similar cases are recorded. 
 
 In a recent report upon insanity in Ireland tea is mentioned as a 
 contributing factor. A very poor quality is there used, and it is often 
 stewed nearly all day, water being added from time to time. This 
 report continues : " Undoubtedly the method of preparation adopted 
 and the excessive use of this article of diet, now so general among 
 
STIMULANTS AND BEVERAGES 21 5 
 
 our poorer population, tends to the production of dyspepsia, which 
 in its turn leads to states of mental depression highly favourable to 
 the production of various forms of neurotic disturbance." Excep- 
 tionally the " tea habit " has been acquired through chewing the 
 leaves. 
 
 Adulteration of Tea. — The adulteration of tea is extensively 
 practised, but it can rarely be said to be injurious to the digestion, 
 for the adulterants are either added in very minute proportion, as in 
 the case of plumbago, indigo, or Prussian blue,, for the purpose of 
 colouring or " facing " the tea, or foreign leaves are mixed with the 
 tea, which simply dilute it without necessarily making it injurious. 
 Green tea is more likely than black to be adulterated. Catechu as 
 well as salts of iron are sometimes added to increase the astringency. 
 
 Quantity Consumed. — It is interesting to make a comparison 
 between the consumption of tea and coffee in the United States. 
 The quantity of tea consumed in 1890 was 83,494,956 pounds, while 
 the consumption of coffee during the same period was 490,181,755 
 pounds. On the other hand, London consumed per annum 25,000,- 
 000 pounds of tea (or 1.38 pound per capita) as against 2,740,000 
 pounds of coffee (1898). The amount of tea consumed per capita 
 in the United States is 1.33 pound, while the amount of coffee con- 
 sumed is 7.8 pounds. Slightly more than half of the tea drunk in 
 the United States comes from China, and a large part of the re- 
 mainder from Japan. The India teas are nearly twice as strong as 
 the others, but they are much less commonly drunk in this country 
 excepting in mixtures where they have been added to Chinese or 
 Japanese teas to improve their flavour and strength. 
 
 Coffee 
 
 Composition. — Coffee consists of the berries or seeds of Coffca 
 arabica, which are dried, roasted, ground, and subjected to infusion. 
 The coffee drunk in the United States is mainly imported from 
 South and Central America, Mexico, and Java, 63 per cent being 
 imported from Brazil. The Rio berry is smaller than that from 
 Java. The composition of coffee beans varies somewhat, but an 
 approximate idea of it is obtained from the following table from 
 Konig, which gives the percentage of the important ingredients : 
 
 Water 115 
 
 Fat 14 48 
 
 Crude fibre 19.89 
 
 Ash 4-75 
 
 Caffeine 1 . 24 
 
 Albuminoids T 3-98 
 
 Other nitrogenous matter 45 -°9 i 
 
 Sugar, gum, and dextrin 1 . 66 
 
 16 
 
2l6 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 The exhilarating effect of coffee is said to be caused by the ingre- 
 dients caffeine, caffeotannic and caffeic acids, and a volatile oil de- 
 veloped during roasting. 
 
 The coffee berry contains no starch, and Wiley has shown that 
 its principal carbohydrate is cane sugar or sucrose. There are pres- 
 ent also a substance allied to dextrin and a reducing sugar. The 
 well-known stimulant effect of coffee upon the nervous system is 
 mainly due to the alkaloid caffeine, which is chemically identical 
 with theine and possesses the same physiological properties, its 
 action being chiefly upon the nerves and kidneys. Coffee also con- 
 tains a little aromatic oil which is moderately stimulating to the 
 nervous system. It has less oil than tea. 
 
 Method of Preparation. — The preparation which the coffee beans 
 require consists of drying them by roasting at a temperature of 
 fully 200° C, after which they are ground into small fragments to 
 facilitate the solution of their ingredients by hot water. The heat 
 converts the sugar of the beans into caramel and develops vola- 
 tile and aromatic substances to which the agreeable aroma of the 
 coffee is due. These substances being volatile, the aroma soon for- 
 sakes the beans, and they should not be roasted or ground long 
 before they are to be used. The roasting also liberates gases in the 
 beans, which cause them to increase in bulk while losing in weight. 
 
 The methods of preparing coffee as a beverage are three — 
 namely, (i) filtration, (2) infusion, and (3) decoction or boiling. 
 
 (1) In filtration boiling water is allowed to percolate slowly 
 through finely ground coffee. Air should be excluded as much as 
 possible during the process ; otherwise the oxygen alters the aroma. 
 According to von Liebig, filtration only dissolves from n to 15 per 
 cent of the coffee instead of 20 or 21 per cent, which is obtainable 
 by other means. 
 
 (2) Infusion is the common mode of preparation of coffee em- 
 ployed in this country and in Europe. It is said to reduce the ex- 
 citing influence of strong coffee without destroying its aroma or 
 otherwise altering it. In conducting this process the finely ground 
 coffee is put into water previously boiled, but removed from the 
 fire, and allowed to stand for about ten minutes at a temperature of 
 180 or 190 F. 
 
 (3) Decoction is the method principally used in Turkey and else- 
 where in the East. The coffee beans are ground to powder and 
 placed in cold water, which is then heated to boiling. The beverage 
 is drunk without straining. If boiled but a few minutes some aroma 
 still remains, but it is soon driven off, and continued boiling extracts 
 more caffeine than is obtainable by infusion. 
 
 Coffee long boiled or left standing in the coffee pot over the fire, 
 as in the case of tea, becomes more and more indigestible from 
 extraction of tannin. 
 
STIMULANTS AND BEVERAGES 217 
 
 Soft water extracts more coffee from the berries than hard, as 
 it does from tea leaves. 
 
 Coffee should always be made from newly roasted and ground 
 beans ; and when economy is to be considered, or when strength and 
 aroma are both desired, a larger proportion of the soluble ingredients 
 may be obtained by combining the second and third processes, as 
 described by Yeo : " After first preparing an infusion by passing 
 boiling water over the coffee, the grounds left should be boiled in 
 more water, and the boiling decoction thus obtained should be 
 poured over another portion of freshly ground coffee ; this, in turn, 
 is also boiled with more water, to be used again with fresh coffee in 
 the same manner, and so on. By this method all the soluble matters 
 in the coffee are extracted and none of the aroma is needlessly dis- 
 sipated." Ready-made coffee is sometimes preserved with con- 
 densed milk and sugar in tin cans. This preparation merely requires 
 to be put into a cup of hot water to be fit for drinking. 
 
 PHYSIOLOGICAL ACTION 
 
 Good Effects. — Coffee, when taken as a beverage, has well- 
 marked physiological effects, chiefly upon the muscular, vascular, 
 and nervous systems. It removes the sensation of fatigue in the 
 muscles and increases their functional activity ; it allays hunger to 
 a limited extent ; it strengthens the heart action, and constitutes a 
 valuable cardiac stimulant in some forms of collapse by its moderate 
 quickening effect upon the pulse and influence upon the vascular 
 tone ; it acts as a diuretic, and increases the excretion of urea ; it 
 has a mildly sudorific influence ; it counteracts nervous exhaustion 
 and stimulates nerve centres. It is used sometimes as a nervine in 
 cases of migraine, and there are many persons who can sustain pro- 
 longed mental fatigue and strain from anxiety and worry much 
 better by the use of strong black coffee. In low delirium, or when 
 the nervous system is overcome by the use of narcotics as in the 
 case of opium poisoning, or by alcohol, or by excessive haemorrhage, 
 strong black coffee is serviceable to keep the patient from falling 
 into the drowsiness which soon merges into coma. In such cases as 
 much as half a pint of strong black coffee may be injected into the 
 rectum. 
 
 Drunk in moderation, coffee is a mild stimulant to gastric diges- 
 tion. In the bowels coffee has an opposite effect to that of tea, for 
 it stimulates peristalsis, and for many people, when drunk early in 
 the morning, it possesses a distinctly laxative effect. It thus in- 
 directly benefits the liver. Strong coffee with a little lemon juice 
 or brandy is often useful in overcoming a malarial chill or a par- 
 oxysm of asthma. It is the universal testimony of army officers that 
 coffee is indispensable for troops in service to relieve fatigue and 
 improve their spirits. 
 
2l8 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 The stimulating and diuretic effect of coffee is more decided 
 when it is taken into an empty stomach. 
 
 The nutrient value of coffee alone is too slight to be considered, 
 but the addition of sugar and milk, as in the case of tea, makes it a 
 valuable food. It does, however, possess some effect in diminishing 
 tissue waste. The very general fondness which exists for the taste 
 of coffee makes it a useful means of flavouring many kinds of 
 foods for invalids, such as jellies, custards, etc. When the taste 
 of milk is objected to, the addition of a very little coffee will often 
 overcome the dislike for it. 
 
 Coffee is a useful temporary cardiac stimulant for children suffer- 
 ing collapse, but should not be given them as a daily beverage. 
 
 Ill Effects. — Strong black coffee taken after dinner tends to re- 
 tard the digestive processes somewhat, and for this reason it should 
 be avoided by dyspeptics ; but to persons with sound digestion who, 
 perhaps, have eaten rather more food than they need, this influence 
 may not prove a disadvantage, and meanwhile its stimulating effect 
 may arouse the overtaxed digestive functions. 
 
 Many persons find themselves able to perform much more active 
 brain work by the stimulus afforded by drinking coffee and strong 
 tea. If one is obliged to work late by night at severe mental 
 labour, sleepiness may be avoided by this means. The continuance 
 of this practice, however, soon results in forming a coffee or tea 
 habit, in which the individual becomes a slave to the beverage and 
 feels an imperative need for it at certain hours of the day, when, if 
 it cannot be obtained, the system suffers from languor, prostration 
 or restlessness, and craving. Exceptionally the coffee habit takes 
 the form of eating the coffee beans. By drinking two or three cups 
 of strong black coffee at every meal muscular tremors sometimes 
 are developed with " nervousness," anxiety, dread of impending ill, 
 with palpitation and feeling of precordial oppression, bradycardia 
 vertigo, heartburn, dyspepsia, constipation, and insomnia. In such 
 cases the symptoms usually promptly subside on suspending or 
 restricting the beverage ; but if they have been long continued, the 
 use of sedatives may be necessary to control the ill effects. Ex- 
 treme cases suggest the condition resulting from some drug habits, 
 and there is irritability of the whole nervous system and mental ex- 
 citement. Emaciation is common, and pruritus ani has been observed 
 by Brown-Sequard. Those who are habituated to immoderate tea 
 or coffee drinking do well to stop the habit abruptly in order to 
 observe the degree of craving which results and the influence which 
 these beverages is acquiring over the system. As an aid to break- 
 ing off the coffee habit, " postum " may be used. It is composed 
 of cereals and has a flavour which many find agreeable. The pub- 
 lished analysis gives 13.13 per cent protein, 66.11 per cent carbo- 
 hydrates, 1.60 per cent fat, besides salts and water. In children the 
 
STIMULANTS AND BEVERAGES 219 
 
 habitual use of coffee gives rise to insomnia, night terrors, nervous- 
 ness, and tremor. Acute coffee poisoning differs from the chronic 
 form in producing greater excitability, with tendency to delirium 
 and tachycardia. 
 
 Quantity Consumed. — In connection with the comments often 
 made in regard to the nervousness of temperament which character- 
 ises many Americans, it is not without interest to note a fact which 
 may stand in the relation of either cause or effect to this condition — 
 namely, that the people of the United States consume one third of 
 the total coffee produced, which in 1899 amounted to 831,827,063 
 pounds, or more than Germany, Austria, Hungary, France, and the 
 United Kingdom combined. On the other hand, England and her 
 colonies consume one half of the world's output of tea, and the 
 United States consumes but one fifth of it. 
 
 Adulteration. — The adulteration of coffee, more particularly 
 when it is ground, is so easily accomplished that it affords great 
 temptation to unscrupulous dealers. Almost all ground coffee sold 
 to the poor is adulterated, but the adulterants are not usually of a 
 character to render them injurious to health. Chief among them is 
 chicory, which is added both for dilution and for its influence on 
 the colour and flavour of the coffee. This substance, however, is 
 actually preferred by many persons, and, as it is in no wise injurious, 
 it is hardly fair to consider it as an adulterant when its admixture 
 with coffee is acknowledged. 
 
 Chicory is prepared from the root of the chicory plant, or wild 
 endive, which is roasted and ground. By roasting, an aroma is de- 
 veloped, as in the case of the coffee berry. Chicory contains no 
 caffeine, but it holds a volatile oil and a bitter principle. Its ad- 
 mixture with coffee is detected by bleaching with chlorinated soda, 
 which acts promptly on the pigments of chicory, but very slowly 
 on those of the natural coffee. 
 
 In France, coffee is frequently flavoured with caramel instead of 
 chicory, which is more extensively used in England and the United 
 States. 
 
 Coffee is also diluted with various substances, such as peas, beans, 
 peanuts, dried sweet potatoes parched, and ground acorns, corncobs, 
 or date stones are sometimes used. 
 
 Imitation coffee beans are composed of pellets of roasted wheat 
 flour, or sometimes wheat flour and chicory, or even sawdust. Rye, 
 corn, and barley are also mingled with wheat for the same purpose. 
 
 Fat globules are present in impure coffee in considerable quan- 
 tity. The substitutes for coffee are easily detected by the fact that, 
 unlike the true coffee bean, which, unless overroasted, floats after 
 roasting, they usually sink to the bottom of a glass of water. 
 
 Colouring matter, like ochre, burnt umber, charcoal, Prussian 
 blue, and lead chromate, is added occasionally before the roasting, 
 
220 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 as well as burned sugar and sirups, in order to affect the appearance 
 and colour of the beans. The beans are sometimes polished in 
 cylinders, in which they are made to revolve with soapstone. 
 
 Substitutes for Coffee. — A substitute for coffee may be made 
 from wheat, rye, or oatmeal, to which butter is added in the propor- 
 tion of one part to eight of meal. The butter is melted in a hot iron 
 frying pan and the meal is sprinkled over it and briskly stirred with- 
 out burning. Thus prepared, the meal resembles roasted coffee, and 
 when half an ounce is boiled in a pint of water it makes a beverage 
 which is rather agreeable in taste. In Bavaria this substitute for 
 coffee is used largely by the peasants, and it is also supplied in some 
 charitable institutions in this country. Its use necessitates boiling 
 the water, which, if it contains any impurities, is thus rendered harm- 
 less. There are several cereal substitutes for coffee sold in open 
 market which are advertised as being highly nutritious. A number 
 of them were analysed for the United States Department of Agricul- 
 ture (Bulletin 122, 1900) by C. F. Langworthy, who says of them: 
 
 " The average cereal coffee infusion had the following percentage 
 composition : Water, 98.2 ; protein, 0.2 ; and carbohydrates, 1.4, while 
 the fuel value was 30 calories per pound. Skim milk, which is ordi- 
 narily considered a rather " thin " beverage, contains 3.5 per cent 
 protein, 0.3 per cent fat, 5.15 per cent carbohydrates, and 0.8 per cent 
 ash, or almost twenty times as much food material as the average 
 of the beverages made from cereal coffee. If made according to 
 directions, one would have to drink 4J gallons of an infusion of 
 one of them which made an especial claim to high nutritive value 
 in order to get as much food as is contained in a quart of skim 
 milk." 
 
 Mate, called also Paraguay tea, is manufactured from the dried 
 leaves of a plant resembling holly. It is a mildly stimulating bever- 
 age which contains theine, but it has no special dietetic advantages 
 over tea or coffee. 
 
 Relative Value of Coffee and Tea. — Much argument has been 
 expended on the relative digestibility and usefulness of tea and 
 coffee, but about all that can be said definitely in regard to the matter 
 is, that many persons who can drink tea with impunity are made nerv- 
 ous and are kept awake by a similar quantity of coffee, whereas 
 there are others who find that coffee aids their digestion while tea 
 interferes with it, and that it affects them in every way more agree- 
 ably than tea ; and still a third class cannot take either tea or coffee 
 without producing indigestion, insomnia, and nervousness. Speak- 
 ing generally, coffee is believed in the United States to be 
 more digestible and useful than tea, but in other parts of the world, 
 especially in England, China, and India, tea is regarded as more 
 beneficial than coffee. In equal weight, tea contains more than 
 twice as much caffeine or, as it is also called, theine. In this country, 
 
STIMULANTS AND BEVERAGES 221 
 
 however, it is customary to use about 50 per cent more of coffee 
 than of tea to the same quantity of water. 
 
 Coffee is said to irritate the mucous membrane of the stomach 
 less than tea when drunk in very large quantities. 
 
 It has a more decided stimulant action than tea upon both the 
 force and frequency of the pulse. 
 
 Cocoa 
 
 Cocoa and chocolate are both prepared from the cocoa bean, or 
 pulpy seeds of the exotic cacao tree, Theobroma cacao. The major 
 portion of the supply consumed in the United States is derived 
 from Brazil, the British West Indies, Ecuador, Venezuela, and Dutch 
 Guiana. In the United States in 1890 the consumption of choco- 
 late amounted to 634,551 pounds, and of cocoa to 993,402 pounds. 
 
 The cacao tree attains a height varying up to twelve metres. 
 It blossoms frequently and yields two crops a year of a bright- 
 yellow soft fruit. The fruit, which bears some resemblance to a 
 small cucumber, contains two or three dozen colourless seeds em- 
 bedded in mucilaginous material. When dried in the sunlight, the 
 seeds acquire a bright-yellow or brown colour and harden. The 
 cocoa starch grains are spherical. 
 
 Preparation. — Cocoa may be either fermented or unfermented. 
 The former variety is dried in the sun at once, and the latter is 
 kept for some time, in quantity, in a cool, moist place, while fermen- 
 tation proceeds. The process of fermentation greatly improves the 
 flavour, for the natural acidity and bitter taste of the seeds suc- 
 ceeds to a milder, somewhat aromatic, and more agreeable flavour. 
 
 The husks of the cocoa beans are irritant to the alimentary canal, 
 and possess little nutrient material. 
 
 The kernels when finely ground constitute " cocoa nibs," from 
 which a decoction is made by boiling in water for about two hours, 
 and removing the insoluble residue by straining or decanting; but 
 the cocoa usually sold in market is made by grinding the kernels 
 into a paste, to which starch or sugar is added. If starch has been 
 used, the cocoa must be boiled for some minutes, but if diluted 
 with sugar it is only necessary to mix it with boiling water or milk. 
 
 The different preparations of cocoa are very numerous, but the 
 quantity commonly used for making a single cup of the beverage is 
 a heaping teaspoonful or more. 
 
 Composition. — The cocoa beans, after being husked and dried, 
 contain fat and theobromine, besides a little albumin, starch, pig- 
 ment, and salts. 
 
 The average percentage of the principal ingredients of cocoa 
 prepared for a beverage is shown in the following analysis by Stiit- 
 zer of a specimen of Holland cocoa : 
 
222 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Theobromine x • 73 
 
 Total nitrogenous substances 19.88 
 
 Fat 30.51 
 
 Water .. . 3.83 
 
 Ash 8.30 
 
 Fibre and non-nitrogenous extract 37^48 
 
 Theobromine is the principal alkaloid of cocoa, and is almost 
 identical, both chemically and in its physiological effect, with 
 caffeine. 
 
 Cacao Butter. — The fat, which is called cacao butter, is the 
 nutrient ingredient of most importance. It usually constitutes 50 
 per cent of the cocoa bean. It has an agreeable taste and odour, 
 and it may be kept indefinitely without change. Because it melts 
 readily at low temperatures, it is quickly dissolved in the alimen- 
 tary canal, and it is used by itself for making suppositories. 
 
 Uses. — Cocoa is not as digestible as is generally supposed, be- 
 cause it leaves a large residue of unabsorbed material from the 
 nitrogenous ingredients, and its relative deficiency in starches and 
 salts prevents it from being regarded as a " complete " food. What- 
 ever nutritive power cocoa possesses depends upon its fat and a 
 small percentage of digestible albumin. If the cocoa is roasted by 
 too high a temperature, the latter is destroyed. 
 
 The term " soluble cocoa " is erroneous, because neither the fat 
 nor much of the albuminous material is truly soluble, and if they 
 are removed the food value of the cocoa preparation is much 
 impaired. These substances may, however, be reduced to a fine 
 state of subdivision and held in suspension, but the cocoa bean 
 contains so much fat that it cannot be powdered unless the fat is 
 removed by artificial process or diluted with sugar or some form of 
 starch. The various powders recommended for invalid diet, and 
 which are sold as cocoa or broma, under different proprietary 
 names, are made in this manner. They possess rather less strength 
 than chocolate, but, on the other hand, because they contain less fat, 
 they may be better borne by an enfeebled stomach. The Holland 
 cocoa and other preparations are made with the object of obtain- 
 ing a digestible cocoa without removal of the fat, which for this pur- 
 pose is saponified by the use of sodium and potassium hydrate and 
 magnesia. These alkaline substances, while they may be beneficial 
 in some forms of dyspepsia, in other cases tend to interfere with 
 digestion by neutralising the gastric juice. 
 
 Both cocoa and chocolate differ from tea and coffee in the fact 
 that besides making an agreeable and very slightly stimulating 
 drink, they contain more food substance. Their actual use for this 
 purpose, however, is exaggerated. Cocoa further differs from tea 
 and coffee in that the insoluble material is consumed as well as the 
 soluble. 
 
STIMULANTS AND BEVERAGES 227, 
 
 Various cocoa powders, essences, etc., are sold for use by infants, 
 a teaspoonful of which may be dissolved in a half pint of hot water. 
 Or an infusion of cocoa nibs may be made. Such preparations 
 should never be given to very young infants, and, as a rule, it is best 
 not to allow their use before the completion of the third year, but 
 for young growing children after that age they afford an excellent 
 beverage. 
 
 After suspension in hot water cocoa is apt to exhibit a scum of 
 fat floating upon the surface of the cup. This may be skimmed off 
 on a piece of bread or cracker and eaten in lieu of butter — a practice 
 common among the Italians. Cocoa, on account of its large per- 
 centage of fat in comparison with starchy ingredients, forms a very 
 good addition to a vegetarian diet. 
 
 Adulteration. — The sophistication of cocoa is very easy of ac- 
 complishment as well as profitable. It is principally done with sug- 
 ars, starches, and fats. Iron salts and other colouring matters are 
 often added. These adulterations are fraudulent, but not necessarily 
 harmful. 
 
 Chocolate 
 
 Preparation. — Chocolate is manufactured from the husked, dried, 
 ground, and fermented cocoa seeds, which are then roasted and 
 made into paste and compressed into cakes by moderate pressure. 
 To increase the flavour and nutrient power of the cakes more or less 
 sugar (but at least 50 per cent) is added, and various flavouring ex- 
 tracts, such as vanilla, etc., or spices, are mixed with the paste before 
 compressing it. The husks of the seeds are separately sold, and are 
 used for adulteration in making cheaper varieties of chocolate. They 
 are inferior to the seeds in all their properties. 
 
 Uses. — The value of chocolate as a concentrated food is in part 
 derived from the sugar which is added, but it is very nutritious. 
 Tested at the Austrian army manoeuvres in 1900, a chocolate ration 
 was found to equal five times its weight of beef. Like cocoa, if pure 
 and carefully prepared, its ingredients are easily digested and ab- 
 sorbed. In cases of dyspepsia and various gastric disorders it forms 
 an agreeable and wholesome drink, and it enables the patient to 
 take additional nourishment in the form of the milk and sugar mixed 
 with it. It is also mildly stimulating and exhilarating to the nerv- 
 ous system when exhausted through overwork or worry, and it 
 possesses the advantage over tea and coffee that it does not produce 
 wakefulness. The free use of chocolate, either eaten or drunk as a 
 beverage, constituting what almost might be called a " chocolate 
 habit," is not injurious to the nervous system after the manner of 
 overindulgence in tea and coffee, but it produces more or less gas- 
 tric dyspepsia on account of the large quantity of sugar which it 
 already contains or which is added to it when drunk. 
 
224 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Chocolate made into compressed cakes forms a convenient port- 
 able food that will keep well for a long time, especially when pro- 
 tected from drying by a coating of tinfoil or otherwise. These cakes 
 contain condensed nutriment which makes them very serviceable 
 upon expeditions where provisions can only be carried in limited 
 quantity. Condensed milk may be carried to drink with the choco- 
 late. The fact that its flavour is so universally liked is an additional 
 advantage. 
 
 The chocolate cakes are sometimes prepared with meat extract, 
 or when dissolved and drunk, meat powder or raw meat may be 
 added to them for phthisical patients or other invalids who require 
 concentrated food. 
 
 Chocolate, when not too rich in fat, is a very wholesome food for 
 growing children, and is better for them than the more stimulating 
 beverages tea and coffee. Its agreeable flavour causes it to be ex- 
 tensively used as an ingredient of starchy foods and confections, and 
 also to disguise the taste of disagreeable or bitter medicines, such as 
 quinine. Many articles of invalid diet, such as cornstarch, farina, 
 gelatin, etc., may be made palatable by the addition of chocolate, 
 while their nutritive qualities are enhanced. 
 
 Kola 
 
 Composition. — The kola nut is the fruit of a tall tree of the order 
 Sterculiacece, growing in the island of Jamaica, on the west coast 
 of Africa, East India, and Ceylon. It resembles both coffee and 
 chocolate in some of its properties, and its uses are practically the 
 same. It contains caffeine, or theine and theobromine, besides a lit- 
 tle fat, glucose, dextrin and starch, cellulose, albumins, tannin, mu- 
 cilaginous material, a diastatic and a milk-digesting ferment, and 
 other substances. 
 
 Uses. — Kola is believed to exercise a restraining influence upon 
 tissue waste. It is also mildly stimulating to the heart and nervous 
 system, and is diuretic as well as somewhat tonic in its action on the 
 stomach. It is said to increase the capacity for endurance of mus- 
 cular work. 
 
 Its efficacy has been repeatedly tested by European army sur- 
 geons — especially in France and Switzerland — for troops on the 
 march, and has been shown to lessen fatigue and diminish the craving 
 for both food and drink. 
 
 Kola made into an infusion like coffee, but only one third or one 
 half the strength of the latter, forms a smooth, rich, dark-brown fluid 
 without sediment or oily scum. It is drunk, like coffee or chocolate, 
 with milk and sugar, and has a not unpleasant taste. It is said to be 
 well borne by delicate stomachs, and may be prescribed in fevers. 
 In large doses it may cause insomnia. As a substitute for food on 
 
STIMULANTS AND BEVERAGES 225 
 
 forced marches or in mountain climbing it is said by those who 
 have tried it to sustain strength for as long as forty hours, and to 
 serve better than tea or coffee. 
 
 Alcohol 
 
 Alcohol is a substance produced by a process developed in cer- 
 tain sugar-yielding substances (such as grains, molasses, sugar cane, 
 etc.) by the action of an organised ferment, the yeast fungus Saccha- 
 romyces cerevisice. The chemical changes involved are complex, but 
 the chief products are ethyl alcohol and carbon-dioxide gas. A little 
 glycerin, succinic acid, and other bodies may be formed. The fungus 
 is always floating in the air, so that when saccharine fluids are ex- 
 posed to it the fermentation proceeds of itself. Two parts of sugar 
 yield approximately one of alcohol. 
 
 Alcoholic drinks may be economically distilled from a great vari- 
 ety of cereals, vegetables, and fruits which contain sugar, or sub- 
 stances which can be artificially converted into it. There are no 
 civilised races, and but few uncivilised or semicivilised people, with 
 the exception of the Mohammedans, the northern Eskimos, and one 
 or two other tribes mentioned below, who do not practise the distil- 
 lation of alcohol in some form or other from the materials most avail- 
 able. For example, the spirit fermented from the potato is drunk 
 in Lombardy, and that from rice in Japan, and the Fiji Islanders use 
 a drink, " kava" made by fermenting with their own saliva the Piper 
 mcthysticum. Even the stems of plants are used, as in the case of 
 alcoholic beverages made from the sugar cane and the palm. The 
 expressed juices of many fruits besides the grape and apple can be 
 easily fermented into intoxicating drinks, and when the alcoholic 
 fluid obtained lacks flavour it is often re-enforced by some organic 
 extract. 
 
 General Discussion of the Value of Alcohol. — The question 
 whether alcohol is, properly speaking, a food, or is only to be 
 regarded as a beverage and stimulant without power of nutrition, 
 has given rise to much warm discussion, and it invariably plays an 
 important role among the advocates of teetotalism. A full presen- 
 tation of the alcohol question would be foreign to the limits of the 
 present work, but the following general propositions comprise the 
 belief of many authorities who have devoted careful research to 
 this exceedingly important topic : 
 
 t. The use of alcohol in any form is unnecessary for the human 
 organism in health. It does not exist as a natural product. The 
 very lowest types of man — Australian and many Polynesian sav- 
 ages — know nothing of it, and drink only water and fresh fruit juice, 
 such as that of the cocoanut, although they speedily acquire a fond- 
 ness for alcoholic beverages when given them. 
 
226 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 2. A large number of persons are undoubtedly better without 
 alcohol and may prolong their lives by total abstinence. 
 
 3. The lifelong use of alcohol in moderation as an occasional 
 beverage with meals does not necessarily shorten the duration of 
 life or induce disease in some persons, while in others it undoubted- 
 ly produces gradual and permanent changes, chiefly of a cirrhotic 
 character, in the blood vessels and in viscera, such as the liver and 
 kidneys. These alterations, which may be slow and subtile in char- 
 acter, may not in themselves materially impair the health or cause 
 an ultimately fatal result, but they tend to weaken vital organs and 
 produce premature senility, so that if the patient acquire any severe 
 disease — as, for example, an acute infection, like pneumonia, or a 
 chronic one, like tuberculosis — the resistance of the body to the 
 invasion of the disease is impaired. There is a prevalent belief that 
 these cirrhotic changes are as much due to toxic products of indiges- 
 tion caused by alcohol as to the alcohol per se. 
 
 4. There are many persons whose constitutional inheritance is 
 such that they should be particularly warned against the use of 
 alcohol, and in some such cases, as, for example, among those who 
 are subjects of well-marked gouty diathesis, it is better that the use of 
 alcohol should be imperatively forbidden. 
 
 5. The abuse of alcoholic stimulation is invariably injurious, 
 although the extent to which evil influences become manifest de- 
 pends upon the constitution of the individual, in connection with 
 the two factors of heredity and environment. 
 
 6. There are a number of diseases in which the temporary use 
 of alcohol is of positive service, and there are a number of cases 
 in which it becomes a necessity in order to prolong life. 
 
 7. In many cases of malnutrition and malassimilation of food, 
 alcohol is itself a food, and its consumption under proper direction 
 results in an increase of body weight and strength and improve- 
 ment of functional activity. These results are accomplished in part 
 through the action of the alcohol as a definite food, and in part 
 through its remarkable effect in force production. The latter is due 
 to its own direct combustion, by which in chronic diseases and in 
 critical acute and exhausting affections it spares that of the tissues 
 of the body. 
 
 Although alcohol is such a strong force producer and heat 
 generator, its effect in this direction is very soon counterbalanced 
 by its stronger influence in lowering the general tone of the nerv- 
 ous system and in producing positive degeneration in the tissues. 
 In the condition of health more food is usually eaten and more 
 force is developed than is actually necessary for the body, and there 
 is always a reserve supply of energy on hand which may be util- 
 ised for any extraordinary exertion, and hence the constant use of 
 alcohol as a food or stimulant in health is both unnecessary and 
 
STIMULANTS AND BEVERAGES 227 
 
 inadvisable. When alcohol is consumed in health in addition to a 
 normal or excessive quantity of solid food by its more ready com- 
 bustion it prevents the complete oxidation of the latter and favours 
 the accumulation of suboxidised waste products, which are always 
 harmful in the system. Excesses in eating are thus doubly aggra- 
 vated by the effects of alcohol. It is the almost universal testi- 
 mony of army surgeons and the experience of those who, like 
 Greely, Stanley, and others, have led long and perilous exploring 
 expeditions, involving great fatigue and unusual endurance, that 
 muscular overwork and climatic hardships are much better endured 
 if alcohol is entirely abstained from. 
 
 It has always been found in armies that when good food was at 
 hand the issue of alcohol with the regular ration produced an 
 increased percentage of sick days and of incapacity for work. 
 Colonel Alfred A. Woodhull, Surgeon, U. S. A., writes me in re- 
 gard to this matter : k4 I do not think that any of our medical offi- 
 cers would seriously advocate the issue of alcohol as a measure of 
 health, but I believe that its habitual use during the civil war was 
 prohibited for reasons of discipline, while it still might have been 
 occasionally issued as if for health. On the rare occasions when it 
 might serve a good purpose as a temporary stimulant after a long 
 and wet march, the waggons would be in the rear owing to the same 
 conditions that fatigued the men." 
 
 While all this applies to prolonged effort of any kind and to 
 conditions where other food can be obtained and assimilated, it 
 does not detract from the fact that alcohol is a most helpful food 
 and stimulant in emergencies when other food cannot be had or 
 when the body is temporarily endangered from acute disease and 
 the higher rate of combustion in fever, or from failure to assimilate 
 other nourishment. 
 
 Major Woodruff, U. S. A., says : " Spirits can never be used 
 in the army as a regular issue ; the practice is thoroughly vicious, 
 and was virtually abandoned sixty years ago. On extraordinary oc- 
 casions of great fatigue they are allowable in moderation. Under 
 such temporary stimulation the men will brace up and perform the 
 necessary work of making earthworks, etc., when without it they 
 would be too exhausted to do anything. Without stimulation a 
 man is not worth much after he has made a forced march of forty 
 miles." 
 
 The problem whether the world as a whole is better or worse for 
 the existence of alcohol aside from all ethical questions, and viewed 
 merely from the scientific standpoint of the influence of alcohol 
 upon mortality, is difficult of solution, for to offset the numerous 
 cases of fatal alcoholism and the still larger number of cases of dis- 
 eases which would not presumably be fatal without the existing 
 condition of chronic alcoholic poisoning of the system, are very 
 
228 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 many cases among both infants and adults in which life is un- 
 doubtedly saved by the prompt resort to this food and stimulant 
 and its energetic use. So long as man is exposed to hardships and 
 conditions arising from improper and deficient food supply as well 
 as to the numerous infectious diseases to which he is heir, alcohol 
 must still be regarded rather as a blessing than a curse, for there is 
 no form of stimulant and food combined or stimulant alone which, 
 taken all in all, can be so completely relied upon in cases of emer- 
 gency. Alcohol when taken alone will prolong life beyond the 
 period at which it would terminate from starvation. 
 
 Physiological Action. — The physiological effects of alcohol may 
 be considered under several headings : 
 
 I. Action as a Food. II. Action as a Stimulant to the Nerves 
 and Circulation. III. Action upon the Muscular System. IV. Ac- 
 tion upon the Body Temperature. V. Action as a Diuretic. VI. 
 Action upon Mucous Membranes. VII. Action upon Gastric Di- 
 gestion. VIII. Alcohol Absorption — Hypodermic Use. IX. 
 Elimination of Alcohol. X. Alcohol Poisoning. XL Alcohol and 
 Climate. 
 
 I. Action as a Food. — As a food, alcohol adds to the nutrition of 
 the body by its prompt absorption, requiring no preliminary prep- 
 aration by the digestive organs, which are therefore not taxed in 
 any degree, and it is immediately conveyed in the general circula- 
 tion to the liver and other parts of the system. The chemical 
 changes involved in the assimilation of this form of hydrocarbon are 
 but ill understood. Alcohol, even when digested in very large quan- 
 tity, does not reappear to any extent unaltered in the urine, and, 
 if not taken in excess, it is not exhaled from the breath, demonstrat- 
 ing that its combustion is complete. This combustion results in the 
 formation of water and carbon dioxide. The fact that the body 
 weight may increase under its use, and that the storage of fat in the 
 tissues may be also increased even to an abnormal degree, does not 
 absolutely prove that the alcohol itself has entered into their struc- 
 ture. Its action may be exerted through modification of oxidation 
 processes or by preventing the burning up of other food materials, 
 which are thereby enabled to be themselves added to the protoplas- 
 mic elements of the body ; yet there is reason to believe that while 
 the latter is the chief effect of alcohol as a food, it also may be 
 directly stored in the body in the form of some other product, 
 although this has been denied by M. Chauveau. Whatever con- 
 troversy still exists over the physiological effect of alcohol as a 
 food, it is undeniable that in some cases of disease it is clinically 
 indispensable. 
 
 Writing of the nutritive value of alcohol in disease, Atwater 
 says : 
 
 " What is wanted is a material which will not have to be digested, 
 
STIMULANTS AND BEVERAGES 229 
 
 can be easily absorbed, is readily oxidised, and will supply the requi- 
 site energy. 
 
 " I know of no other material which would seem to meet these 
 requirements so naturally and so fully as alcohol. It does not re- 
 quire digestion, is absorbed by the stomach, and presumably by the 
 intestine, with great ease. Outside of the body it is oxidised very 
 readily, within the body it appears to be quickly burned, and it sup- 
 plies a large amount of energy." 
 
 Professor Atwater, in 1899, made valuable experiments upon 
 man in his respiration calorimeter (described on p. 10), in which 
 500 grammes of pure alcohol was given, disguised in a coffee mix- 
 ture, and intended to replace a portion of the fats, starches, and 
 sugars of ordinary diet. He found that " the alcohol was almost 
 completely oxidised. The kinetic energy resulting from that oxida- 
 tion agrees very closely with the potential energy of the same amount 
 of alcohol as measured by its heat of combustion as determined by 
 the bomb calorimeter, and the alcohol served to protect body pro- 
 tein and fat from oxidation." 
 
 It is, however, inferior to carbohydrates as a protector of body 
 protein from consumption. In some cases it may even increase 
 protein consumption, as, for example, when taken in such excess as 
 to affect the nervous system and inhibit normal metabolism (At- 
 water). 
 
 In referring to the influence of alcohol upon metabolism Bauer 
 says : " The increase of albumin suffers thereby no appreciable 
 change ; that of fat, on the other hand, is reduced by small quantities 
 of alcohol, while by very large doses it is increased at any rate in 
 animals. Alcohol also, in consequence of its fat-sparing action, 
 behaves in the character of a food." The sugar which is contained 
 in considerable quantity in sweet wines, liqueurs, etc., is an addi- 
 tional source of nourishment or of fat production. It is a matter of 
 common observation that many heavy drinkers are stout. They 
 usually indulge more freely in unsweetened liquors or malt liquors 
 than in wines, however. Heavy drinkers are often heavy eaters, 
 and may be as unable to control their appetite for food as for drink. 
 This of course does not apply to cases of alcoholic gastritis, in which, 
 temporarily at least, all desire for food may be in abeyance. In a 
 general way, alcohol is believed to lessen tissue waste. 
 
 The consumption of alcohol is said to increase the quantity of 
 oxygen inspired and lessen the carbonic acid exhaled. 
 
 II. Action as a Stimulant to the Nerves and Circulation. — As 
 a stimulant, alcohol acts primarily upon the nervous system and 
 the circulation, although it increases the functional activity of many 
 organs in the body, and gland secretion may be promoted by its use. 
 The influence of alcohol upon the nervous system in moderate doses 
 is to quicken the transmission and enhance the effect of nerve cur- 
 
23O STIMULANTS, BEVERAGES, CONDIMENTS 
 
 rents, accelerating slightly the heart action and, to a lesser degree, 
 the respiration, while the mental processes are stimulated in part by 
 its direct influence upon the cerebrum, and in part also by the greater 
 rapidity of the circulation. 
 
 If alcohol is given in large doses at frequent intervals, it may 
 overstimulate the heart, which subsequently becomes exhausted as 
 the result of the stimulation. This is sometimes true of the senile 
 heart. 
 
 III. Action upon the Muscular System. — Alcohol used within 
 physiological limits tends to remove muscular fatigue and to increase 
 the force of muscular action. 
 
 In the training of athletes for contests in rowing, sparring, and 
 other sports, alcohol is usually absolutely forbidden, and it is believed 
 that the breakdown in health which by many athletes is ascribed to 
 overwork is not infrequently due to violations in regard to the sim- 
 ple physiological laws of the effect of alcohol which the accompany- 
 ing features of a " sporting " life tempt them to infringe. The ques- 
 tion is well stated by Ringer, who says : " There can be no doubt that 
 healthy persons capable of the fullest amount of mental and physical 
 exercise without the stimulation of alcohol not only do not require 
 it, but are far better without it." But, as he remarks, the statement 
 applies to the continued use of strong alcoholic spirits, and not to 
 beers and light wines which, in addition to the alcohol, contain 
 other ingredients which may be serviceable as food. In the latter 
 form of beverages the quantity of alcohol is comparatively small, 
 and the constant use of them is found, by the practical experience 
 of many persons whose occupations preclude them from abundant 
 exercise in the open air in the country, to improve their digestion 
 and enable them to sustain various functions of the body which 
 would otherwise be impaired by their mode of life. This is espe- 
 cially true of elderly people and those who suffer from insomnia and 
 retardation of gastric digestion. Experiments to test the sustaining 
 power of alcohol were made upon three regiments of the British 
 army and reported in 1899. The men were subjected to fatiguing 
 exercises. To one regiment a ration of whisky was allowed, to a 
 second a ration of malt liquor, and to the third no alcohol. The 
 men taking whisky exhibited more energy for about four days than 
 either of the other groups, but then became fatigued and weak; 
 whereas those taking none steadily gained in endurance, and those 
 taking malt liquor showed an intermediate condition. As a result 
 of these experiments, the use of liquor was absolutely forbidden in 
 Kitchener's Soudanese campaign, which was characterised by re- 
 markable immunity from disease in the desert. 
 
 IV. Action upon the Body Temperature. — The physiological 
 effect of alcohol upon the body temperature may also be regarded 
 as proceeding primarily from its stimulating influence, acting 
 
STIMULANTS AND BEVERAGES 23 1 
 
 through the vasomotor nerves. In moderate doses, alcohol, by 
 quickening the rapidity of the circulation and by dilating the pe- 
 ripheral blood vessels, enables more blood to reach the surface of the 
 body and to pass through the superficial capillaries in a given time, 
 and hence there is a tendency to lower the body temperature. On 
 the other hand, the combustion of the alcohol itself within the body 
 results in the production of a large number of heat units. The total 
 balance of these processes is usually on the side of an absolute reduc- 
 tion of the temperature. It is in part for this reason that alcohol is 
 of benefit in fevers. 
 
 As a result of an elaborate series of experiments made by 
 Reichert to determine the action of alcohol on animal heat func- 
 tions, he concludes " that alcohol does not affect the total quantity 
 of heat produced ; that more heat is dissipated than produced ; that 
 the fall of temperature is due to the excess of dissipation, and is 
 in direct proportion ; and that in all likelihood alcohol, by under- 
 going oxidation, yields energy in the form of heat, thus conserving 
 the tissues and acting as a food." 
 
 V. Action as a Diuretic. — Alcohol in some persons, although 
 not in all, is a very strong diuretic, and its effect depends largely 
 upon the variety of the beverage used. For some persons gin has 
 a much more decided diuretic action than other strong liquors, such 
 as rum or brandy, and in many beer possesses a diuretic action 
 which indicates a special stimulating effect upon the total quantity 
 of urine excreted beyond that produced by a similar bulk of water, 
 but the total of urea, sulphates, and phosphates eliminated is dimin- 
 ished. Chittenden found that uric-acid excretion is doubled. As a 
 general rule, alcohol which is moderately diluted, and which is taken 
 upon an empty stomach, is much more promptly absorbed and pos- 
 sesses a stronger diuretic action than when taken with food or when 
 given in a concentrated form. 
 
 VI. Action on Mucous Membranes. — Strong alcohol is astrin- 
 gent to mucous surfaces, and it is sometimes used diluted with equal 
 parts of water as a gargle for sore throat. Claret, which also con- 
 tains tannin, may be employed in this way. 
 
 If taken in too large quantity or too strong, the astringent effect 
 upon the stomach is highly irritating, causing local congestion, and 
 even inflammation upon the mucous coat, which becomes covered 
 with tenacious mucus. The tongue soon becomes coated, and the 
 appetite is destroyed as well as the secreting power of the gastric 
 glands. 
 
 VII. Action upon Gastric Digestion. — Taken with food in the 
 stomach, alcohol in small quantities, not exceeding the equivalent 
 of half an ounce of the pure substance, given in the form of any 
 alcoholic beverage, does not materially affect the action of the 
 gastric juice. In larger quantities, or if the gastric juice itself is 
 
 17 
 
232 
 
 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 feeble, alcohol precipitates pepsin, coagulates the albuminous ma- 
 terials of the food, and greatly retards if it does not altogether de- 
 stroy gastric digestion. On the other hand, while not interfering 
 with the action of the gastric juice, alcohol may stimulate its secre- 
 tion so that, as Moleschott says, " a glass or two of good old wine 
 increases the quantity of gastric juice, which performs mainly the 
 digestion of albuminous foods." 
 
 Some interesting experiments are reported by Roberts (Lec- 
 tures on Dietetics and Dyspepsia) upon the effect of malt liquors 
 on gastric digestion. They were conducted as follows : By add- 
 ing together 2 grammes of dried beef-fibre, 0.15 c. c. of hydro- 
 chloric acid, 1 c. c. of glycerin extract of pepsin, and varying 
 quantities of malt liquors, with water up to 100 c. c. The result 
 is tabulated : 
 
 Proportion of Malt Liquors con- 
 tained in the Digesting Mix- 
 ture. 
 
 TIME IN WHICH DIGESTION WAS COMPLETED. 
 (NORMAL, IOO MINUTES.) 
 
 Burton ale. 
 
 Light English 
 table beer. 
 
 Lager beer. 
 
 10 per cent 
 20 " " 
 40 " 
 60 " " 
 
 115 minutes. 
 140 " 
 200 " 
 Embarrassed. 
 
 100 minutes. 
 115 " 
 140 " 
 180 
 
 100 minutes. 
 
 115 
 
 140 " 
 
 180 
 
 In considering the relation of alcohol to other foods, the fact 
 should be emphasised that monotony of diet with bad cooking of 
 coarse, tasteless food, especially when associated with overwork, may 
 be a potent factor in establishing a liking for liquors among the 
 poor. In the United States, among the poorer classes the art of 
 varying the diet and of serving food in an agreeable and properly 
 seasoned manner is but imperfectly understood, and the statement 
 is confidently made by Williams, who has given years of personal 
 attention to the matter, that " the raw material of the dietary of the 
 French and Italians is more inferior than that of the English, but a 
 far better result is obtained by better cookery, and the same un- 
 favourable comparison can undoubtedly be made with the poorer 
 classes in America." The Italians have the art of making compara- 
 tively tasteless food, such as macaroni, into very savoury and nutri- 
 tious dishes. Osier expresses the opinion that more ill arises from 
 abuses of eating than of drinking, especially in America. 
 
 VIII. Alcohol Absorption. — Alcohol is highly diffusible, and is 
 promptly absorbed from mucous surfaces as well as from subcu- 
 taneous tissue. 
 
 Its effect is always more immediate when taken into an empty 
 stomach. It is then rapidly absorbed, and its influence is exerted 
 suddenly. When there is food in the stomach, some of the alcohol 
 is temporarily taken up by it like water by a sponge, its absorption 
 
STIMULANTS AND BEVERAGES 233 
 
 is delayed, and, since its elimination is quite rapid, the system is less 
 likely to become overcharged with it. 
 
 Alcohol is well absorbed from the rectum, and to patients who 
 for any reason are unable to retain it in the stomach it may be 
 given in this manner. For this purpose it is best to use spirits 
 diluted with from one to four parts of water, and an ounce of whisky 
 or brandy should be given for a dose. 
 
 Hypodermic Use. — Very little alcohol can be made to pass into the 
 body by rubbing it upon the skin, although it is a diffusible sub- 
 stance, but it is very promptly absorbed when injected hypodermic- 
 ally, and where its immediate stimulating effect is required it can 
 be thus sooner obtained. Owing to the local irritant action of 
 alcohol, not over a drachm or two should be placed beneath the 
 skin at any one point, for it is often quite painful. The surface 
 should be rubbed to promote its absorption. In emergency, two 
 or three ounces may be quickly given in this way in divided doses. 
 
 IX. Elimination. — The questions of what intermediate products 
 may be formed by the splitting up of alcohol in the blood or tissues, 
 of the influence of the combustion of alcohol, and of the combustion 
 of the tissues themselves, involve great difficulties in the way of 
 chemical analysis, and the liabilities to error are considerable. It 
 may be regarded as proved, however, that when taken in moderation 
 alcohol is completely consumed within the body, or so completely 
 that a mere trace escapes in the urine and perspiration, and a little 
 more in the exhaled air. If the dosage of alcohol is very much 
 increased, however, its elimination, unaltered, becomes proportion- 
 ately active, although it is still consumed in large amount in the body. 
 The excretion of C0 2 by the lungs is lessened. 
 
 Alcohol is believed to prevent the elimination of tissue waste 
 under some conditions, and, in spite of the fact that it acts as a 
 diuretic, it may lessen the excretion of urea and uric acid. 
 
 X. Alcohol Poisoning. — This topic will be more conveniently dis- 
 cussed with the treatment under the heading Alcoholism. 
 
 XL Alcohol and Climate. — It is an established fact that climatic 
 conditions exercise an important influence upon the degree to which 
 alcohol influences the system. Many persons find that they can 
 drink more spirits and wine during a prolonged residence in a cli- 
 mate like that of England without apparent ill effect than they can 
 in the more stimulating and bracing climate with greater extremes of 
 temperature which exists in many parts of the United States. If men 
 are to be exposed to cold and hardship for a considerable period of 
 time it is highly unwise for them to indulge freely in alcoholic drinks 
 on account of the rapid fall in the body temperature, which is pro- 
 moted by the external cold when alcohol relaxes the capillaries. 
 In illustration of this principle, a story is told of a party of engi- 
 neers who were lost during the winter in the Rocky Mountains, 
 
234 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 where, after prolonged exposure to cold and hardship, they were one 
 night obliged to sleep without shelter with the thermometer below 
 zero. They had whisky with them and but little food ; some of the 
 party drank heavily, others drank in moderation, and a few of the 
 wiser took no alcohol at all. In the morning the latter awoke, cold 
 but refreshed by the night's rest, while others Avho drank in modera- 
 tion were very much more uncomfortable and had suffered far more 
 from the exposure, and one or two of those who had drunk freely 
 were frozen to death. 
 
 Otto Snell interrogated sixty expert mountain-climbers, and only 
 five declared that liquor was not injurious if taken before or during 
 their exertions. 
 
 In the arctic expeditions of Greely, De Long, and others, al- 
 though pure alcohol was carried for cooking purposes, very stringent 
 regulations had to be enforced to prevent the men from drinking 
 alcoholic beverages, which were only kept for emergencies and sick- 
 ness. The northern Eskimos are ignorant of such drinks, having 
 nothing which they can ferment to produce them. On the other 
 hand, the natives of tropical climates are in the habit of distilling 
 many varieties of alcoholic drink from the fermentation of vege- 
 table food. 
 
 Clinical Uses of Alcohol 
 
 i. Use as a Tonic. — Very moderate doses of alcohol increase the 
 flow of gastric juice, and for this reason it may be employed with 
 advantage in cases such as the following : i. By those whose nervous 
 system is readily overtaxed and who when fatigued or worried lose 
 all appetite. 2. By persons of sedentary habits who have greatly 
 enfeebled digestions. 3. In protracted convalescence from severe 
 forms of acute diseases. For any of these patients a mild cocktail, 
 a little whisky and water, or a glass of simple bitters may be 
 ordered to be taken directly before meals in order to improve the 
 " tone " of the stomach. In all cases care should be exercised, espe- 
 cially among persons who may possibly inherit the alcoholic habit, 
 that the beverage be not prescribed too often, for sometimes cases of 
 chronic alcoholism originate among persons who begin by resorting 
 to this food and stimulant to tide them over emergencies such as the 
 above, and who find when the emergency is passed that they are 
 unable to relinquish the acquired fondness for the drink. When 
 troops have been exposed to exhausting service in a hot, humid 
 atmosphere such as that of some of the Philippine Islands they 
 suffer greatly from nervous exhaustion and insomnia. In such 
 cases, besides an ample ration, the use of from two to four ounces 
 of whisky or other liquor per diem, greatly diluted, appears to be of 
 value as a tonic and digestible food. Writing of this matter, Major 
 Charles E. Woodruff says : " Experience has demonstrated that in 
 
STIMULANTS AND BEVERAGES 2y y 
 
 a hot climate the moderate use of intoxicating drink is essential to 
 continued health and efficiency." 
 
 2. Use as a Vascular and Cardiac Stimulant. — If there is general 
 arterial relaxation from debilitating disease, the use of alcohol in 
 proper quantities contracts the vessels and improves the firmness 
 and quality of the pulse to a remarkable degree. Alcohol undoubt- 
 edly can be given the first place among the cardiac stimulants, for 
 its combined action in strengthening the heart and regulating the 
 calibre of the blood vessels is most useful. For this purpose it is 
 best to use strong liquors, such as brandy or whisky, which vary but 
 little in composition, and which may be diluted according to need. 
 In all cases of sudden heart failure occasioned by shock, violent hem- 
 orrhages, either internal or external, fainting, etc., it is best to give 
 alcohol in the form of diluted spirits. 
 
 It is an interesting fact that the mere mechanical action of deglu- 
 tition stimulates the heart action and increases the rate of pulse beats 
 by fifteen or twenty in the minute. Stimulants sipped slowly by re- 
 peated acts of swallowing for this reason alone may have a greater 
 effect than the same quantity of fluid drunk all at once. In extreme 
 emergencies, whether the patient is able to swallow or not — as, for 
 example, in shock from prolonged anaesthesia, or from the use of 
 anaesthetics which are not well tolerated, and in an urgent case when 
 the alcohol is given by hypodermic injection — it may be used undi- 
 luted. Its influence in these conditions is almost immediate, and the 
 stimulation of the pulse may be appreciated in two or three minutes. 
 A little more time is required for the full effect if the stimulant is 
 given by the stomach or rectum. The benefit of alcohol is further 
 shown by the tongue and skin becoming more moist, by the slowing 
 of the pulse, and by the breathing becoming more tranquil. Since 
 alcohol regulates arterial tone and brings the pulse to a nearer nor- 
 mal standard, the volume of the pulse is not so important a consider- 
 ation as is its compressibility as a factor in estimating the value of 
 alcohol in a given case. The very soft pulse of considerable volume 
 may diminish in volume under the use of alcohol, but it becomes 
 firmer and of better character, showing an improvement in the 
 arterial tone. The rules for observing the effect of alcohol may be 
 definitely applied in almost every case, and the dosage can be regu- 
 lated accordingly. In acute diseases, such as pneumonia, in which 
 the emergency of cardiac failure or great prostration may be fairly 
 anticipated, it is often better to withhold alcohol until there are defi- 
 nite indications for its use than it is to prescribe it in a routine man- 
 ner at the commencement of the disease ; its effect when actually 
 needed is enhanced if it has not been already given for too long a 
 time. For persons with feeble constitutions, however, and for aged 
 people it may be necessary to commence the use of alcohol at an 
 earlier period. In urgent cases full doses, such as an ounce an hour, 
 
23^ STIMULANTS, BEVERAGES, CONDIMENTS 
 
 may become necessary for a few times, and the quantity and inter- 
 vals for its administration may then be gradually reduced. Usually 
 when the stimulating and supporting influence of alcohol is urgently 
 needed it is better to give it in quite frequent doses and in moderate 
 quantity than in large amount infrequently. The stimulation is then 
 more uniform and constant, and the digestive organs are less likely 
 to be deranged. 
 
 3. Use in Nervous Diseases. — Alcohol is of service for many 
 forms of diseases of the nervous system. Neuralgic pains are some- 
 times allayed by the use of alcoholic drinks which contain volatile 
 ethers, but they should be prescribed with care. In any neuralgic 
 or nervous affections, such as hysteria, which are more or less 
 chronic, it is well to observe that many of the so-called elixirs, nerve 
 tonics, etc., which are recommended for cases of this nature, and 
 especially for treatment of nervous prostration, contain a large per- 
 centage of alcohol, and their constant and indiscriminate use is liable 
 to establish permanent alcoholism. In the stomach alcohol may act 
 as an anaesthetic in cases of irritant nervous dyspepsia. 
 
 4. Use in Fevers. — The whole question of the employment of 
 alcohol in fevers is obviously of grave importance. 
 
 The value of alcohol in the treatment of fevers is now universally 
 recognised, and its beneficial effect is manifested in two ways : first, 
 upon the vital functions of the nervous system, circulation, and heat 
 regulation ; and, secondly, in sparing the tissues from too rapid com- 
 bustion and wasting by furnishing fuel in their stead. In fever the 
 increased nitrogenous waste is evidenced by the greater elimination 
 of urea from the kidneys, while the quantity of urine and perspira- 
 tion are lessened. The use of alcohol meets all indications by 
 lessening the production of nitrogenous waste, by acting as a diu- 
 retic, and by regulating the peripheral blood pressure and increasing 
 the perspiration. To accomplish these results, usually six or eight 
 ounces in the twenty-four hours, and often much more, must be 
 given. 
 
 As a mere antipyretic the influence of alcohol is less striking 
 than that of many special remedies which have the power of reduc- 
 ing the body temperature, but it has the decided advanta'ge over 
 most of these remedies that its proper use is accompanied by stimu- 
 lation rather than depression of the heart action. 
 
 It may be regarded as a general rule that when given in large 
 quantities if the odour of alcohol is not present in the breath several 
 hours after it has been ingested, and if the pulse is slowed and deli- 
 rium is reduced under its use, the amount taken is clearly being 
 oxidised as a food and is doing good. On the other hand, if the 
 odour persists in the breath and the pulse is not improved, or the 
 patient becomes more delirious, it indicates that too much alcohol 
 is being given, and the dosage should be accordingly reduced. 
 
STIMULANTS AND BEVERAGES 237 
 
 The effect of alcohol in fevers is shown by the fact that in health, 
 when drunk in large quantities, it excites gastric catarrh and occa- 
 sions dyspepsia, whereas a similar amount taken in the height of an 
 acute fever may be very beneficial. 
 
 It must not be inferred from the foregoing statements that alco- 
 hol should be given at once in fever, or that it should be given in 
 every fever. There are many cases in which it is contraindicated. 
 Such are of sthenic type and of short duration. There are others in 
 which it is a mistake to give it too early, and its use should be post- 
 poned until the conditions are present of prostration and nervous 
 exhaustion. There are still other cases in which it should be pre- 
 scribed at once, as, for example, in pneumonia in feeble or elderly 
 subjects. 
 
 The general indications for the use of alcohol as a food in con- 
 tinued fevers or for an increase of the quantity already being given 
 are found in the predominance of one or more of the following symp- 
 toms : Increased weakness or faintness, low muttering delirium con- 
 tinued even when the patient is undisturbed, tremor of the tongue 
 and hands, great dryness of the tongue, extreme feebleness of the 
 voice, irregularities in the respiration and pulse, enfeebled or irregu- 
 lar heart action, and absence of either of the cardiac sounds. 
 
 There is a tendency at the present time to abandon excessive 
 dosage of alcohol in severe acute febrile infectious diseases, such 
 as pneumonia and typhoid fever, in which it was formerly given 
 at the rate of an ounce an hour or twenty-four ounces per diem, 
 for it is found that other stimulants, such as digitalis, strychnine, 
 caffeine, etc., make it possible to use less spirits. A full discussion 
 of this topic will be found under the heading Dietetic Treatment of 
 Fever. 
 
 In the treatment of convalescence, when patients are able to 
 digest and assimilate more and more food, less alcohol is required. 
 
 Proper Time for giving Alcoholic Beverages. — Whenever an alco- 
 holic beverage is prescribed by the physician, the time at which it 
 is to be given should be explicitly stated, and there should be super- 
 vision over the quantity used, depending upon the influence upon 
 appetite and activity of digestion. When needed as a tonic, the 
 beverage should be given either immediately before or in connection 
 with meals, in order that its effect may be modified by that of other 
 foods. There is less fear of establishing a craving for drink if this 
 rule be observed. It is the habit of drinking between meals without 
 definite purpose which is particularly dangerous. 
 
 In some cases of neurasthenia, anaemia, etc., it may be advisable 
 to recommend a glass of claret or sherry between the principal meals, 
 in the middle of the morning or afternoon, but even then it should 
 be taken with some article of light and easily digestible food, such 
 as a. biscuit or sandwich. The fact that moderate doses of alcohol 
 
238 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 improve the functional activity of the stomach affords an oppor- 
 tunity for the better digestion of food given in connection with alco- 
 hol, which should not be lost by giving the latter alone. 
 
 There are some patients having chronic atonic dyspesia and per- 
 sons with but limited nervous energy for whom it is better to pre- 
 scribe alcohol half an hour or more before eating in order that its 
 stimulating influence may be felt in the system before the nervous 
 forces are called upon for digestive functions. 
 
 Selection of the Proper Form of Alcoholic Beverage. — In all 
 severe cases in prescribing alcohol it is a rule that the stomach is 
 much less likely to be upset by adhering to a single form of bever- 
 age than by making frequent changes. Persons having robust phy- 
 siques may be able to assimilate several kinds of wines, including 
 champagne, at dinner, followed by liquors and brandy ; but these 
 beverages, if taken in such variety without food, will almost in- 
 variably derange the stomach, and the unpleasant after-effects which 
 characterise even moderate overindulgence in this respect are usu- 
 ally more decided if a variety of beverages have been used than if 
 only one kind has been taken. The combination of whisky and 
 beer or strong liquors and champagne will promptly disagree with 
 many persons who could take either form of alcohol alone with 
 impunity. In fever the stomach is always temporarily enfeebled, 
 and the importance of adhering to one simple form of alcoholic 
 beverage is emphasised. It may be changed from time to time in 
 conformity with the taste of the patient, but mixtures of beverages 
 should never be given. 
 
 With persons who are predisposed to irritating coughs the use 
 of malt liquors sometimes increases the difficulty, whereas strong 
 liquors and wines may prove beneficial. Beer, ale, porter, stout, etc., 
 cannot be drunk by some persons without producing a subsequent 
 feeling of lassitude and drowsiness with headache and suffusion of 
 the face, and yet diluted spirits may be well borne. Some persons 
 find that sherry produces acid dyspepsia, and others find that dif- 
 ferent sweet wines, such as port, similarly disagree, and in others 
 again they excite attacks of gout. When porter, ale, or stout do 
 not derange the stomach, they may be advantageously used by those 
 who suffer from exhausting discharges or by women who are weak- 
 ened by prolonged suckling. Alcohol should be emphatically for- 
 bidden in all forms of gonorrhoea and syphilis, and a single infringe- 
 ment of this rule may often aggravate the complaint. Some 
 clinicians prefer the use of wines which are well charged with vola- 
 tile compound ethers as a stimulant for enfeebled heart action and 
 weak digestion. The use of beer as a beverage for fevers is more 
 common in Continental Europe than in the United States. If there 
 is no tendency to flatulent dyspepsia, it may sometimes be used with 
 advantage in such cases, when it will slake the thirst which is not 
 
STIMULANTS AND BEVERAGES 
 
 239 
 
 quenched by other drinks. Passing fashion to some extent influ- 
 ences the variety of alcoholic beverage consumed, as illustrated by 
 the fact that in this country the annual importation of Scotch whisky 
 has lately risen from 30,000 to 100,000 gallons for a single firm. 
 Rum and port are much less drunk than formerly. 
 
 As a preventive of drunkenness and the evils of chronic alcohol- 
 ism, the introduction of the milder malt liquors into this country to 
 partially supersede the use of strong spirits has proved a decided 
 advantage. The total annual consumption of all alcoholic beverages 
 in the United States exceeds one billion gallons. In 1870 the per 
 capita consumption of distilled liquors was 2.07 gallons, and twenty- 
 five years later this fell to 1.12 gallons, whereas during the same 
 period the consumption of malt liquors rose from 5.31 to 14.95 g^l- 
 Ions. The consumption of wines has remained at about 0.32 gallon. 
 
 The annual per capita consumption of alcoholic beverages in 1900 
 in several countries as compared with the United States is estimated 
 in gallons as follows : 
 
 England 
 
 France 
 
 Germany 
 United States. 
 
 Beer. 
 
 30.3I 
 
 5-1 
 25-5 
 12.3 
 
 Wine. 
 
 0.39 
 
 21.8 
 
 i-34 
 0.44 
 
 Spirits. 
 
 I.02 
 I.84 
 I.84 
 O.84 
 
 Italy, France, and Spain grow two thirds of the world's wine, 
 and in France the annual consumption of spirits is only 3.80 litres 
 per capita. 
 
 A Committee of Fifty for the Investigation of the Liquor Prob- 
 lem was organised in this country in 1893. The committee con- 
 sists of eminent jurists, physicians, physiologists, philanthropists, 
 and others, and their object is to collect and study impartial scien- 
 tific data regarding the consumption of liquor which shall furnish 
 a reliable basis for controlling future legislation in regard to the 
 liquor problem and influence public opinion in regard to its evils. 
 In co-operation with this investigation, Prof. Henry W. Farnam 
 states (in T899) tnat " tne native-born Americans fall midway, being, 
 as a rule, more addicted to liquor than the Germans and Scandi- 
 navians, but less so than the English, Canadians, and Scotch. The 
 coloured race, however, as compared with the white, shows a good 
 record." 
 
 Malt Liquors 
 beer 
 
 The lager-beer industry was introduced into the United States 
 about the year 1842. 
 
 Composition. — Beer contains alcohol in strength varying between 
 3 and 8 volumes per cent (sometimes even 10 per cent). Besides 
 
240 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 this alcohol and much water, beer contains a variety of ingredients, 
 such as bitter and resinous extractives from hops, sugar, dextrin, 
 albuminates, glycerin, free acids, and ash — the latter only as a trace. 
 The sugar of beer is fattening, and the bitter matter is more or less 
 of a stomachic tonic. 
 
 By process of manufacture much beer is made to contain only 
 water, alcohol, and bitter principles. Hop extracts possess a nar- 
 cotic influence, and hence beer may give rise to drowsiness, whereas 
 other alcoholic beverages — like champagne or whisky — prove enliv- 
 ening. This effect is, however, quite variable. 
 
 Beer produces biliousness in persons of weak digestion. It is 
 sometimes called " fluid bread," but the expression conveys a wholly 
 exaggerated idea of its food value, although it is certainly fattening 
 when drunk in large quantity. 
 
 Beer Brewing. — Malt is the name given to any germinating 
 cereal, but to prepare it for beer brewing, malt is made from barley 
 grains as follows : The grain is steeped in water at a temperature 
 which causes germination and the development of diastase. It is 
 next couched and " floored," during which process germination con- 
 tinues, and it is finally kiln-dried. 
 
 Brewing of beer is accomplished as follows : The prepared bar- 
 ley malt is first cleaned by screening, sifting, and blowing, is crushed 
 and then " mashed " or infused with water in large tubs at a proper 
 temperature. This process extracts the existing sugar and dextrin 
 and aids in converting the residue of starch into maltose and dex- 
 trin. The " wort " thus formed is a solution of diastase, dextrin, 
 sugar, proteids, and salts. It is drawn off, and the residue of grain 
 is washed with hot water by a process called " sparging," which 
 extracts any remaining useful material. The wort is run into cop- 
 per kettles and boiled for about four hours. During the last hour 
 hops are poured in. The boiling concentrates the wort, extracts 
 the hop essence or lupulin with tannin, causes coagulation and pre- 
 cipitation of any albuminous substance, and finally it checks further 
 fermentation for the time being. The wort is next cooled and yeast 
 is added in the proportion of about a pound to the barrel. The 
 yeast sets up a new fermentation, which converts the saccharine 
 substances into alcohol and carbon-dioxide gas. This fermentation 
 is retarded by continued application of cold. When it is concluded, 
 the beer is drawn into settling tuns, and then into casks, where it is 
 stored from five to eight months, after which it is ready for bottling. 
 While resting in the casks the beer is subjected to " fining " — i. e., 
 beech-tree shavings are added to it, to collect any floating solid par- 
 ticles. This process allows so much carbonic acid to escape that a 
 second fermentation is sometimes set up by adding new beer to the 
 old in the proportion of I to 5. 
 
 Beer which is kept long fermenting increases in alcohol and 
 
STIMULANTS AND BEVERAGES 241 
 
 diminishes in extractives. Its natural intensity of colour varies 
 with the method of drying the malt, and increases with long 
 boiling. 
 
 White beer is brewed from wheat instead of rye. It is less clear 
 than rye beer, paler, and more frothy and sour. 
 
 The low Bavarian beer is fermented by a variety of saccharo- 
 myces, which acts at a temperature of 6° to 8° C. 
 
 Certain varieties of saccharomyces, acting at different tem- 
 peratures, set up undesirable fermentation in both beer and wine, 
 making them sour, and developing peculiar odours. 
 
 Ale. — Ale is made from pale malt by processes resembling the 
 brewing of beer. It contains from 3 to 6 per cent of alcohol. 
 Strongly alcoholic ales are less used than formerly, having been 
 largely supplanted by the lighter varieties and by beer. The amount 
 of hops used determines the bitterness of the ale, and their aromatic 
 bitter principles furnish the peculiar flavour. Bitter ale has been so 
 far fermented as to contain but little sugar. 
 
 Porter. — Porter is made from pale malt with the addition of high 
 dried malt, which gives it colour and flavour. It contains about 6 
 per cent of alcohol, and is regarded as more digestible than ale of the 
 same alcoholic strength (Pavy). Both ale and porter contain sugar 
 and acid, but these substances are present in less degree in malt 
 liquors than in wines. 
 
 Stout. — Stout is similar to porter, but is characterised by a pre- 
 ponderance of extractives. 
 
 The stronger malt liquors, such as porter, stout, and heavy ales, 
 are nutritive and fattening. 
 
 All stale, flat malt liquors without a " head " are apt to nauseate 
 and prove unwholesome. 
 
 WINE 
 
 Composition. — Wine made from the expressed juice of different 
 varieties of the grape consists of an alcoholic solution varying in 
 strength from 6 to 25 volumes per cent, and containing flavouring 
 and other substances. 
 
 The maximum normal percentage of alcohol which fermenting 
 grapes are capable of developing is not above 15 per cent, but alco- 
 hol is often added to equal 18 or 25 per cent or more. 
 
 The pulp of the grape furnishes sugar for fermentation of alcohol, 
 and also organic acids or their salts, such as citrates, malates, and 
 tartrates. The stones or seeds furnish essential oils, some of which 
 give the " bouquet " of volatile ethers, and the skins and stems fur- 
 nish pigments and tannin. The latter is preservative ; it precipitates 
 albuminous substances and prevents mouldiness. The chief pigment 
 of wines is primarily of a blue colour, but it is reddened, like litmus, 
 by free acid, more or less of which is always present. 
 
242 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 The fermentation of wines is caused by germs, which exist upon 
 the stems or skins of the grapes. 
 
 Besides water, sugar, alcohol, volatile ethers, and carbonic acid 
 are added in the manufacture of the different kinds of wine. 
 
 Leoser gives the following list of minor substances, traces of 
 which are more or less constantly present in wines : " Gelatin, gum, 
 fat, wax, albumin, gluten, tartaric acid, potassic tartrate, racemic 
 acid, malic acid, calcic malate, oxide of manganese, oxide of iron, 
 potassium sulphate, sodium chloride, calcium phosphate, magnesia, 
 silicic acid, tannic acid." 
 
 The composition of the subtle substances which impart the fla- 
 vour and aroma or bouquet to different wines is unknown. Most 
 of these substances develop during fermentation, but a few grapes, 
 such as the Muscatel, yield their own aroma to the wine. 
 
 According to Konig, the average percentage composition of 
 grape must is water, 74.49 ; sugar, 19.71 ; nitrogenous material, 0.28 ; 
 non-nitrogenous material, 4.48 ; ash, 0.40 ; acid, 0.64. 
 
 The sugar fluctuates sometimes as much as 24 per cent and the 
 acid 1.2 per cent, and these substances usually stand in inverse pro- 
 portion to each other. 
 
 General Properties. — The perfected wine has the properties of 
 colour, " body " or substance, and flavour, aroma, bouquet, or 
 " fruitiness." Different wines are valued for their astringency (tan- 
 nin), sweetness (grape sugar), strength (alcohol), acidity (organic 
 acids), colour or sparkle, flavour, and ability to stimulate the appetite 
 and digestion. 
 
 Fermentation. — Wines are both naturally and artificially ferment- 
 ed, and many varieties are re-enforced by flavouring extracts and 
 fortified by addition of alcohol. The latter method has the twofold 
 effect of adding to their strength and of preserving them from further 
 fermentation, and hence is used especially for the wines of the Cape, 
 Madeira, and Portugal. In the cooler climate of France, Germany, 
 and Hungary fermentation proceeds more slowly and fortification is 
 less necessary, for the wines of these countries are drier, less fruity, 
 and require less time to mature. They also have stronger bouquet, 
 because they possess more acid, which combines with alcohol to fur- 
 nish the aroma (Pavy). 
 
 Sugar. — The quantity of sugar present in wines varies consider- 
 ably. It is sometimes almost completely eliminated by fermentation 
 into alcohol, or it may be added in excess to make the natural flavour 
 sweeter. 
 
 Flavour and Bouquet. — Some Greek wines have a peculiar flavour, 
 the liking for which is an acquired taste. This flavour is derived 
 from rosin contained in the wood of casks used for preserving the 
 wines, which induces chemical changes. 
 
 The Hungarian wines have agreeable fruitiness, but they are not 
 
STIMULANTS AND BEVERAGES 243 
 
 so completely ripened as French wines, and are hence likely to turn 
 sour when transported. 
 
 Both glucose and saccharose can be oxidised into acids instead 
 of fermenting to alcohol, and when this process occurs extensively 
 in a wine it becomes sour, like vinegar, and is unfit for consump- 
 tion. 
 
 In general the flavour and bouquet of a wine depend upon (1) the 
 nature of the soil in which the grape is grown, (2) the climate and 
 temperature, (3) the quality of the grape, (4) the use of but a single 
 variety of grape for a given wine, (5) the ripeness of the grape, (6) 
 the duration of fermentation, (7) the addition or subtraction of ma- 
 terial by the art of the wine grower, (8) the age of the wine. 
 
 In vineyards where the best wines are made the grapes are tested 
 from day to day to determine the right time to pick the vines, for 
 the quantity of sugar and acid present depend upon the degree of 
 ripening and influence the flavour of the wine. 
 
 White Wines. — White wine is made from grapes of any colour, 
 the greatest care being taken not to macerate the berries in express- 
 ing the juice, and to allow no coloured juice to flow. As a rule, 
 however, the better class of white wines is made from selected white 
 grapes, which are crushed with their skins. The mass is left for 
 several days, so that the skins may impart what little soluble matter 
 they contain to the pulp. The juice is then obtained by further 
 pressure and allowed to ferment. The crushing of grapes was for- 
 merly done by the feet of men who trampled upon them, but several 
 lives were lost by carbonic-acid gas poisoning, and the process is 
 now generally conducted by machinery. 
 
 After several months, or longer, the ferment and the salts which 
 are insoluble settle in a sediment called lees, and the supernatant 
 fluid is carefully drawn off and casked or bottled. 
 
 During the first year or so of storage some wines are recasked 
 several times, for they continue to deposit lees on the bottom and 
 sides of the cask, consisting mainly of " argol," an acid salt from 
 which cream of tartar may be prepared. 
 
 When fermentation has proceeded long enough it is stopped, 
 according to the nature of the wine, by the addition of alcohol or 
 strong sugar solution, or if left to continue after the wine is stored, 
 the sugar and extractives very gradually disappear, and alcohol con- 
 tinues to develop. 
 
 Hence, if a wine can be bottled early without being too green 
 or immature it is sometimes a decided advantage, for more of the 
 aroma and flavour may be thus retained. 
 
 In other cases wines should remain in the casks for from one 
 to four years before bottling — the more delicate varieties being kept 
 the longest — for certain changes depend upon the size and nature of 
 the containing receptacle, which are checked by bottling. Pavy 
 
244 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 says : " By keeping in a cask, wine increases in alcoholic strength. 
 This is to be accounted for by wood being more easily penetrated 
 by water than by alcohol. Thus it happens that water is lost by 
 evaporation from the outside of the cask in larger quantity than 
 the alcohol, and the wine is left in a more concentrated con- 
 dition." 
 
 White wines are produced in more variety than red wines. On 
 the average they contain from 9 to 12 per cent of alcohol, from 
 0.30 to 0.50 per cent of sugar, and about 0.50 per cent of acid. 
 
 Red Wines. — In making red wine dark grapes are used, and 
 both skins and stones are left to ferment with the pulp, to which 
 they furnish tannin, pigment, and extractives. 
 
 Red wines, on the average, contain from 8.5 to 11 per cent of 
 alcohol, 0.55 to 0.65 per cent of acid, and 0.15 to 0.20 per cent of 
 tannin and pigment. The red wines are, as a rule, more easily di- 
 gested than white, and are more nutritive. 
 
 The following practical statements are quoted from Leoser : 
 
 " Bottled red wines that are rich in tannic acid, like port, for 
 instance, deposit a sediment and grow lighter in colour. Those 
 that contain less tannic acid generally grow darker. The cause of 
 this is a gradual diminution in the quantity of free acid in the wine. 
 The effect of this acid is to turn the colouring matter red, and as it 
 diminishes, therefore, the wine grows darker or more purple." 
 
 Red wine (claret) is often drunk diluted with Vichy, when " the 
 potassium carbonate of the water saturates the free acid of the wine, 
 and so destroys the red colour and permits it to become darker, 
 while the action of the alkali upon the colouring matter gives it a 
 cloudy appearance." 
 
 The deeper the colour the rougher is the flavour of the wine in 
 most cases. 
 
 " If two wines of equal alcoholic strength be taken it will be 
 found that equal doses of each will produce their effect much more 
 quickly in the case of the white wine than in that of the red. The 
 reason of this is that the astringent action of the tannic acid retards 
 the effect of the alcohol upon the organism. It may be that this 
 indicates in a general way the superiority of white wines as stimu- 
 lants and red wines as tonics." 
 
 Various substances are used for " fining " — that is, to clarify wine 
 — such as cream, milk, blood, solutions of egg albumin, gelatin, 
 isinglass, nutgalls, lime, etc. Their effect is largely mechanical, but 
 the alkalies neutralise part of the acids. 
 
 Other substances are occasionally employed, having in view the 
 better preservation of wine, but many of these are unhealthful in 
 their effects on the system. Such, for example, is the use of calcium 
 sulphate, which is converted into potassium sulphate, or the use of 
 alum, sulphuric or other acids, etc. Impure alcohol holding fusel 
 
STIMULANTS AND BEVERAGES 245 
 
 oil is sometimes added. The object of storing wine in enormous 
 tuns is to diminish the surface exposed to the air in comparison with 
 the bulk. 
 
 THE VARIETIES OF WINES 
 
 The following classification of wines, with the examples and 
 comments, is largely derived from Chambers, and will be found 
 convenient and practical from a purely dietetic standpoint. 
 
 Wines may be classed as — 
 
 I. Strong Dry Wines. II. Strong Sweet Wines. III. Aromatic 
 Wines. IV. Acid Wines. V. Sparkling Wines. VI. Perfect W"ines. 
 VII. Rough or Astringent Wines. 
 
 I. Strong Dry Wines are those in which the sugar of the ex- 
 pressed grape juice or " must " has fermented into alcohol, either 
 by process of time or by artificial means. When left to itself, this 
 alcoholic fermentation is extremely slow, occupying many years 
 before its completion, but the natural process is better than any 
 artificial one yet discovered. These wines also contain considerable 
 alcohol, often 17 or 18 per cent, which makes them less available for 
 general dietetic uses than weaker wines. Examples are strong, dry 
 old sherry, port, Madeira, and Johannisberg. (The name " sherry " 
 is often used as a generic term for white wines grown in Spain.) 
 
 These wines, especially sherry, are sometimes used for stimula- 
 tion in fevers or other diseases, in lieu of spirits, where the taste of 
 the latter is strongly disliked. If drunk too freely they congest the 
 stomach, and have the evil effects of strong spirits or of strong 
 alcohol in general. (See Alcohol, Evil Effects.) They often con- 
 tain some sugar, and taken with meals they may interfere with diges- 
 tion, causing acetic fermentation, and especially disturbing the di- 
 gestion of fats. 
 
 Port is a wine in which the original fermentation has been ar- 
 rested by the addition of alcohol, and it has a proverbially bad 
 reputation for precipitating attacks of gout. In England, where 
 much more is consumed than in the United States, it is even held 
 responsible for causing the disease in some instances. 
 
 It is well known that port improves more by long rest in the 
 bottle than does any other wine. It is a useful temporary tonic, 
 and, like claret, its astringency makes it serviceable in diarrhceal 
 diseases, but many persons, especially in this country, find it alto- 
 gether too heavy for daily use. This is not altogether due to its 
 high percentage of alcohol, for a greater quantity of strong spirits 
 will sometimes be found to do less damage. It is a poor wine for 
 dyspeptics, and should be proscribed in all bilious states, lithiasis, 
 cases with tendency to gallstone formation, gravel, gout, and rheu- 
 matism. It has been largely replaced by claret of late years as a 
 dinner wine. 
 
246 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Port as well as Burgundy is sometimes spiced or " mulled," 
 and prescribed diluted, as a tonic for elderly people. Taken before 
 retiring, with a biscuit, or mixed with a light gruel, it may promote 
 their sleep. 
 
 II. Strong Sweet Wines are those which contain, either natural 
 or artificially added, fruit sugar in sufficient quantity to exercise a 
 preservative influence, and further fermentation is checked by boiled 
 grape juice. Examples are Tokay, Malaga, sweet sherry, sweet 
 champagne, Malmsey, Madeira, Lachrymse Christi, and other vins 
 de luxe. They are much too sweet to be drunk in quantity, but this 
 quality is sometimes made to disguise the bitterness of other sub- 
 stances, as when Tokay is added to coca extract to make " wine 
 of coca." If long kept, the sweetness is reduced but the peculiar 
 agreeable flavour remains. Alcohol may be added to further insure 
 preservation and increase the strength of the wine, and sweet port is 
 sometimes made in this manner. 
 
 The sweet heavy wines, such as sweet port, sherry, and Madeira, 
 contain about 19 to 22.5 per cent of alcohol, 3.5 to 6 per cent of 
 sugar, and about 0.50 per cent of acid. Malaga and Tokay contain 
 more sugar and less alcohol. 
 
 The chief use of these wines is not for tonic or dietetic purposes, 
 but for their agreeable flavour. They are better taken between 
 meals, if at all, both because the delicacy of their flavour is more 
 appreciated when the mouth is free from other tastes and because 
 their sweetness may interfere with digestion. Like all sweet wines, 
 they must be forbidden to the gouty, rheumatic, bilious, lithsemic, 
 and dyspeptic. 
 
 III. Aromatic Wines have a peculiarly choice bouquet, and con- 
 tain abundance of essential oils with considerable alcohol. They are 
 best when drunk in their native countries — in Spain, France, Italy, 
 etc. — for they bear transportation poorly unless re-enforced by ad- 
 ditional alcohol, which detracts from their delicacy of flavour and 
 aroma. Examples are the choicer Rhine wines, Moselle, Capri, Cha- 
 teau-Yquem, and Orvieto. Some wines of this class are " more 
 noted for their acid than aroma " (Chambers). Such are white 
 Burgundy (Chablis) and white Bordeaux (Sauterne), which are 
 often drunk with salads and rich foods. The Moselle and Rhine 
 districts produce acid grapes with abundant aroma, and the 
 wines which bear these names are many of them almost free from 
 sugar. 
 
 IV. Acid Wines owe their distinguishing property to tartaric acid 
 chiefly, but wines which have turned sour on keeping or by exposure 
 to the air contain acetic acid and resemble vinegar. 
 
 V. Sparkling Wines are those in which carbon-dioxide gas, 
 formed by fermentation after the wine is bottled, is set free upon 
 uncorking, and continues to be liberated for some time thereafter. 
 
STIMULANTS AND BEVERAGES 247 
 
 The gas gives additional flavour to the wine and increases its ex- 
 hilarating effect. Such wines are champagnes, sparkling Moselle, 
 and vino d'Asti. The better the wine, the longer it continues to 
 give off gas and aroma after uncorking. Good champagne is bottled 
 under a pressure of about five atmospheres. 
 
 These wines, especially good champagne, are very serviceable 
 for invalids, and some persons with delicate stomachs can digest no 
 other form of alcohol ; but poor champagne causes gastric derange- 
 ment sooner than any other wine. 
 
 When nausea and vomiting exist they have special power for 
 allaying the gastric irritation. ■ They are absorbed with great rapid- 
 ity, and act promptly by invigorating the nervous system and cir- 
 culation. They may sometimes be substituted for spirits in fevers 
 when there is need of alcoholic stimulation. Their cost, unfortu- 
 nately, places them out of the reach of many, and it also affords much 
 temptation for adulteration. 
 
 Champagne. — The essential difference between champagne and 
 other wines is that it contains carbon-dioxide gas in solution. 
 
 Manufacture. — Champagne is made of different grades, repre- 
 senting the first, second, and third expressing of the grape juice 
 respectively. It contains approximately 12 per cent of alcohol, 
 or less. 
 
 Good champagne is made as follows: The juice is allowed to 
 ferment for about two weeks, when it is poured into casks and kept 
 for a period varying from two to six months, after which it is bottled 
 and kept from two to nine years in racks arranged to hold the bottles 
 with their mouths down, so that on opening them all sediment which 
 has collected in their necks can be removed or " disgorged." The 
 final process is the addition of sugar-candy sirup dissolved in old 
 wine and white cognac brandy. For the " sec " brand 8 per cent of 
 sirup is added ; for other brands varying quantities up to 16 per cent 
 are poured in. A little alcohol, too, may be added, after which the 
 wine is again corked, and left standing. 
 
 French champagnes sometimes have liqueurs or cordials added 
 for flavouring, but American champagnes depend solely upon the 
 grape flavour. 
 
 Dryness. — Much emphasis is placed on the value of " dry " cham- 
 pagne for invalids, which means that the sugar which it originally 
 contained has disappeared, and hence the wine is less apt to pro- 
 duce flatulent dyspepsia or aggravate conditions in which saccha- 
 rine food is harmful. True " dryness " is the result of age, and is 
 due to a very slow conversion of sugar into alcohol, such as goes 
 oil in port wine which has been kept for several decades, but, as 
 pointed out by Chambers, this process of slow ripening does not 
 remunerate the dealer, so he induces a quicker acetous fermentation 
 by which all the sugar is transformed in a few months, instead of 
 iS 
 
248 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 many years, or else he puts but half the quantity of sirup into the 
 wine — 4 instead of 8 per cent. It is champagne manufactured in this 
 manner which is usually shipped out of France for foreign consump- 
 tion, and hence this wine often has a " dry " taste because it is sour, 
 and not because it is wholly free from sugar. When this is the case, 
 it imparts a bright-red colour to blue litmus, even after the free car- 
 bonic acid which it contains has been allowed to escape. The various 
 brands called " dry," " extra dry," or " sec" " tres sec," usually rep- 
 resent only varying degrees of acidity. " Brut " refers to wines left 
 to undergo natural fermentation. 
 
 Undoubtedly one of the reasons why champagne is so exhilarat- 
 ing to many persons is the fact that it is promptly and completely 
 absorbed, even when taken with food. Its effects are therefore 
 suddenly felt by the nervous system. 
 
 VI. " Perfect " Wines are those which are classified by Cham- 
 bers as having their several ingredients — " alcohol, water, sugar, 
 ethereal flavours, fruity extractives, and acids " — commingled with- 
 out giving characteristic prominence to either one. Such are many 
 of the best clarets, but the red wines usually, from one cause or 
 another, fall under some other class. 
 
 Bordeaux, Burgundy. — The best Bordeaux is fully fermented, 
 but the commoner Burgundies and red Rhones contain " too much 
 fruity extractive, which decomposes unless re-enforced by alcohol, 
 and are unwholesome unless ripe when drunk " (Chambers). When 
 a red wine is so decomposed it is unfit for consumption. Re-fer- 
 mentation in it may be discovered by lightly corking a half-filled 
 bottle, letting it stand for some hours in a warm place, and then 
 shaking it. If carbonic acid is present, it will rise in bubbles and 
 expel the cork. Wine of this sort deranges digestion, causing acid 
 eructations and gastric discomfort. 
 
 Prime Burgundies, on the contrary, like Chambertin, have more 
 " body," and, because they contain a larger percentage of alcohol, 
 do not ferment. Moleschott gives the average volumetric percent- 
 age of alcohol in red wines as follows : Clarets or red Bordeaux, 
 10.61 ; red Rhone, 10.39; rc( ^ Burgundy, 11. 19. 
 
 Therapeutic Uses. — Prime clarets, Bordeaux, and Burgundies are 
 useful tonics for invalids, to be given in moderation with meals, or 
 in some cases with a biscuit or light sandwich as a luncheon between 
 meals. They contain little or no sugar, and are of excellent service 
 in convalescence from protracted fevers, such as typhoid, or from the 
 grippe, etc. The lighter forms, if of good quality, are the best form 
 of wine for daily consumption by brain workers or those whose 
 sedentary habits or whose advanced age make desirable a slight 
 stimulus to appetite and digestion. Claret is almost the only wine 
 which it is at all safe to allow gouty or diabetic patients. Of red 
 Bordeaux or clarets, Pavy says : 
 
STIMULANTS AND BEVERAGES 
 
 249 
 
 " There is scarcely any condition in which they are calculated to 
 disagree. They form a most suitable beverage for persons of a gouty 
 or rheumatic disposition, and also for the dyspeptic. It may be said 
 that they are not prone to turn sour upon the stomach themselves, 
 nor to cause other articles to become sour ; neither do they provoke 
 headache or derangement in those who are subject to bilious dis- 
 orders." 
 
 Burgundy, being a much fuller wine than claret, is more service- 
 able where anaemia and malnutrition exist if it can be borne without 
 giving rise to headache. 
 
 Beaujolais is intermediate in its effects between claret and Bur- 
 gundy. 
 
 Some years ago, when scurvy was common in the English navy, 
 it was found that the substitution of red wines for spirits in the 
 ration had a decided prophylactic influence. 
 
 In diarrhoea, the red wines, according to Lichtenstern, have a 
 twofold beneficial action : first, by depressing exalted reflex excita- 
 bility in visceral nerves, and, secondly, by controlling intestinal 
 putrefaction. Those which contain considerable tannin are also 
 mildly astringent. 
 
 VII. Rough Wines are those in which an excess of tannin causes 
 decided astringency. They usually contain pigment, but not much 
 alcohol. Some clarets belong with this group. 
 
 As a rule, these wines are not available for general dietetic or 
 invalid use, and are mainly employed to add to other wines to 
 aid in their preservation and otherwise alter them, although they 
 are drunk by the peasants in the countries where they are pro- 
 duced. 
 
 Raisin Wine. — An inferior quality of wine is made by restoring 
 the water of the grapes which has been lost by drying them into 
 raisins. Wine is now sometimes made in France from raisins dried 
 in California. 
 
 Influence of Wines upon Digestion. — Roberts has thus determined 
 the effect of several wines upon peptic digestion by adding together 
 two grammes of dried beef-fibre, 0.15 per cent of hydrochloric acid, 
 1 c. c. of glycerin extract of pepsin, varying proportions of hock, 
 claret, or champagne, and water to 100 c. c. 
 
 Proportion of Hock, Claret, or 
 Champagne in the Digesting 
 Mixture. 
 
 TIME IN WHICH DIGESTION WAS COMPLETED. 
 (NORMAL, IOO MINUTES.) 
 
 Hock. 
 
 Claret. 
 
 Champagne. 
 
 10 per cent 
 
 100 minutes. 
 
 115 
 150 
 Embarrassed. 
 
 100 minutes. 
 140 " 
 180 " 
 
 90 minutes. 
 IOO " 
 
 20 " " 
 
 40 " " 
 
 no " 
 
 60 " •• 
 
 Embarrassed. 180 
 
 
 
 
STIMULANTS, BEVERAGES, CONDIMENTS 
 
 Liquors 
 
 Strong spirits, such as rum, whisky, brandy, and gin, are the 
 worst forms of alcohol for daily drinking, and liquors of this class 
 are responsible for nine tenths of the evils of inebriety. In locali- 
 ties where their consumption has been brought into competition 
 with or has been superseded by that of beer, drunkenness has often 
 diminished. As the system acquires toleration for the stronger 
 forms of liquor, it is found that its desired effects can only be 
 obtained by constantly increasing the strength or the frequency of 
 the drinks, and meanwhile the alcohol absorbed is gradually con- 
 verting the different tissues of the body into pathological specimens. 
 
 The drinking of new and raw liquors is particularly injurious, 
 for time mellows them somewhat and reduces the quantity of their 
 most hurtful ingredient — fusel oil — while their flavour improves. 
 The difference in taste of liquors depends upon the substances from 
 which they are made much more than upon any 'skill in their manu- 
 facture or modifications in their fermentation, circumstances which 
 so materially affect wines. The taste varies with the relative quan- 
 tity present of aldehyde, compound ether, higher alcohol (fusel oil), 
 and volatile bases. 
 
 Brandy and other strong spirits are distilled from a variety of 
 carbohydrate foods : such are potatoes, corn, rye (whisky), beets, 
 rice (arrack and sake), molasses (rum), crushed grapes, apples 
 (applejack), peaches, plums, cherries (Kirsch), and other fruits. 
 These spirits contain from 45 to 60 per cent of alcohol, besides cane 
 sugar and extractives. 
 
 French Cognac is a strong, pure brandy, distilled either from 
 wine, or directly from crushed grapes. It may be coloured by cara- 
 mel. Common brandy is distilled from wine. 
 
 Whisky. — American whiskies are classed as (1) rye and (2) Bour- 
 bon, from the county of that name in Kentucky. 
 
 Manufacture. — The proportion of materials used in making the 
 " mash " for distillation is, on the average, cornmeal 0.8, rye 0.1, and 
 malt 0.1 (Leoser). This mixture is placed in tubs, and scalded with 
 " slop," the refuse from former distillation. After cooling, it is 
 raked, or mixed by a stick called a " masher." Water is added, and 
 the mass ferments for two or three days. 
 
 Sweet mash is scalded with water instead of slops, and yeast is 
 added to induce fermentation. 
 
 Sour-mash whisky is made without yeast but with slop. The 
 wort is then heated by steam, and the low wines, called " singlings," 
 are run off from the residue or slop and redistilled, and the whisky 
 is ready for barrelling (Leoser). It should then be kept from three 
 to five years to ripen, according to the details of its manufacture. 
 
STIMULANTS AND BEVERAGES 2$I 
 
 Pure rye whisky is distilled by an identical process, but the corn 
 is wholly replaced by rye. 
 
 Scotch and Irish whiskies are distilled from a barley mash. 
 
 American whiskies are kept in charred barrels, and grow darker 
 from colour derived from the wood (Witthaus). Scotch whisky de- 
 rives its colour from lying in old sherry casks. 
 
 Proof whisky contains equal parts of absolute alcohol and water. 
 
 Leoser says : " The difference ill quality in different kinds of 
 whisky is infinitesimal, and for therapeutic processes may be neg- 
 lected, provided the taste of the patient is consulted." 
 
 The evil effects of poor whisky are largely due to the presence 
 in excess of a regular constituent, an aldehyde called furfural. 
 
 Gin is distilled from rye mash, and flavoured by immersing a bag 
 of juniper berries in the vat towards the completion of distillation. 
 
 It is variously known under the names Geneva, Hollands, and 
 Schiedam, the two latter referring to its Dutch source, the former 
 being derived from the French word for juniper, genievre, of which 
 gin is a corruption (Pavy). Gin may contain 17 per cent of alcohol, 
 but it is often diluted, and when sweetened besides, it is known as 
 " Old Tom." 
 
 Rum is distilled from a mash of molasses. The wort contains 
 about 15 per cent of sugar, and the fermentation process requires 
 from nine to fifteen days. Rum was formerly made in New England, 
 but it now comes chiefly from the West Indies, and that made in 
 Jamaica is considered the best. Other rum is made from rectified 
 proof spirit. It is a liquor which improves very much on keeping 
 for several years. The flavour of rum, which is principally due to 
 butyric ether, is produced by adding molasses, caramel, and some- 
 times fruits, such as pineapple or guava. Acetic and other ethers 
 are also present. 
 
 Therapeutic Uses of Liquors Compared. — The spirits in common 
 use have different physiological action. As their alcoholic basis is 
 substantially the same in quality, the effects are varied mainly by 
 aromatics. Gin is the most distinctly diuretic of the liquors. Given 
 with a little lemon juice and diluted with some effervescing water, 
 it promptly increases the urinary secretion. Brandy is somewhat 
 more astringent than whisky, which is sometimes laxative. Brandy 
 is therefore to be preferred in cases of diarrhoea, but in this country 
 at least it is very apt to be impure. The role of liquors as tonics 
 and stimulants will be referred to under the heading of the different 
 diseases in which they may be required, and their influence in pro- 
 ducing alcoholism is discussed under that heading. 
 
 Adulteration of Liquors and Wines. — Liquors are flavoured and 
 also adulterated by a variety of substances. Among those men- 
 tioned by Chambers as oftenest found are cocculus indicus, ginger, 
 quassia, wormwood, caraway and coriander seeds, hartshorn shav- 
 
252 
 
 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 nigs, nux vomica, gentian, alum, cream of tartar, chamomile, juniper 
 berries, bitter almonds, orange peel, licorice, honey, rhatany, and 
 catechu. 
 
 Much of the cheapest claret sold in this country is little more 
 than a decoction of logwood, and the flavour of some of the better 
 grades is cleverly imitated. For example, Chateau-Latour is sophis- 
 ticated with almonds or other nuts, Chateau-Lafitte with violets and 
 nuts, and to other grades cherry juice is added. Wines are often 
 adulterated with artificial pigments, alum, tannin, fusel oils, cider, 
 perry, and lime salts. 
 
 The cheaper grades of strong liquors contain an excess of fusel 
 oil or amylic ether, which is not an adulterant in the sense that it 
 has been added for sophistication, but because it is a poisonous 
 natural product which is difficult to eliminate. It is responsible 
 for much of the headache, foul tongue, nausea, dyspepsia, and even 
 cirrhotic changes in the viscera which are incident to dram drinking. 
 
 Liqueurs play no part in invalid diet. With the exception of 
 absinthe and Angostura, they contain a very high percentage of 
 sugar with essence, and they all have a large proportion of alcohol. 
 They are used as luxuries, and are seductive beverages, for their 
 agreeable flavour sometimes begets the habit of alcoholism. This 
 is especially the case with absinthe. 
 
 Analysts of Liqueurs (Rupp) 
 
 [OO C. C. LIQUEUR. 
 
 Absinthe. . . . 
 
 Anise 
 
 Kummel. . . . 
 Peppermint. 
 
 Angostura . . 
 Curacoa 
 Benedictine. 
 Chartreuse. . 
 
 ALCOHOL. 
 
 
 
 
 
 Extracts. 
 
 Sugar. 
 
 Volume. 
 
 Weight. 
 
 
 
 Per cent. 
 
 Per cent. 
 
 Grammes. 
 
 Gram.7nes. 
 
 55-o 
 
 44.O 
 
 I.80 
 
 1. 10 
 
 40.0 
 
 32.0 
 
 33- 20 
 
 30.9O 
 
 32.5 
 
 26.O 
 
 29.80 
 
 28.20 
 
 35-o 
 
 28.0 
 
 44. CO 
 
 43.20 
 
 48.0 
 
 38-4 
 
 12. CO 
 
 7-50 
 
 52.5 
 
 42.O 
 
 27.90 
 
 26.50 
 
 53-0 
 
 42.4 
 
 35-°o 
 
 33-40 
 
 44.0 
 
 35-2 
 
 35-40 
 
 34.OO 
 
 Salts. 
 
 Grammes. 
 0.220 
 O.3IO 
 O.IOO 
 
 0.090 
 0.140 
 
 0.075 
 
 O.IIO 
 
 0.091 
 
 The essences are distilled or expressed from aromatic plants, and 
 such colouring agents are used as saffron, cochineal, indigo, etc. 
 Vermuth contains only 17 per cent of alcohol. 
 
 The following table by Duckworth is a convenient summary of 
 the average percentages of alcohol in round numbers in the different 
 beverages above described : 
 
 Spirits 35 to 44 per cent. 
 
 Port wine 19 " 
 
 Madeira 18 " 
 
 Sherry 17 " 
 
 Champagne n " 
 
 Burgundy.. 10 " 
 
 Bordeaux 8 per cent. 
 
 Rhine wines 8 " " 
 
 Porter 6 per cent or more. 
 
 Ale 3 to 6 per cent. 
 
 Cider 4 per cent. 
 
CONDIMENTS AND SPICES 253 
 
 Fig Wine is made in countries bordering upon the Mediterranean, 
 and has an alcoholic strength of between 7 and 8 per cent. It also 
 contains considerable mannite. It is often used for the sophistication 
 of grape wines. 
 
 Cider. — Cider made from ripe apples usually contains from 4 to 
 8 volumes per cent of alcohol besides malic acid, extractives, sugar, 
 and salts. 
 
 It is slightly laxative. The excess of carbonic acid generated by 
 cider protects it from the atmospheric air, but when the gas dis- 
 appears acetic fermentation converts the cider into vinegar. 
 
 Cider is sometimes made from condensed apple juice, which is 
 added in the proportion of one part to twenty of water when ready 
 for use. 
 
 CONDIMENTS AND SPICES 
 
 Properties. — Condiments and spices are substances which are 
 used as adjuncts to food, and which in themselves supply but little 
 nourishment, their effect being mainly of a stimulating character 
 either to the nerves of taste or secretion. They add flavour to 
 otherwise insipid food, and relieve monotony in diet. Some condi- 
 ments, such as mustard, contain a slight amount of nutritious mate- 
 rial, but the total quantity of any of them which can be taken is so 
 small in comparison with the bulk of the food that they may hardly 
 be said to subserve nutrition. 
 
 Curry powders of various sorts are prepared by mixing strong 
 condiments, such as Cayenne pepper and ginger, with starchy food 
 and turmeric. 
 
 Some foods are themselves so stimulating to the mucous mem- 
 brane that they answer the double purpose of food and condiment 
 combined ; such, for example, are onions and garlic. 
 
 In the mouth condiments produce an agreeable taste, with an 
 increased flow of saliva, and the desire for food in the stomach is 
 stimulated. They also increase the secretion of gastric juice. 
 
 Uses. — In some dyspeptic conditions of the stomach accom- 
 panied by local sensation of weight or oppression, or even of pain, 
 the use with the food of strong condiments — such as mustard, Cay- 
 enne pepper, or Tabasco — affords relief by exciting the functional 
 activity of the stomach. Cayenne, in fact, is a favourite ingredient 
 of various dinner pills. 
 
 With the exception of salt, the use of which has been elsewhere 
 fully described (p. 45), none of the condiments are absolutely in- 
 dispensable in the sense of being essential for prolonging health, 
 but so accustomed are all classes of men to their use from heredity 
 or personal experience that, despite the aphorism of Plutarch that 
 " hunger and salt should be man's only sauce," without other rel- 
 
254 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 ishes the appetite soon fails. There are many cases of feeble diges- 
 tion and diminished activity of the gastric juice which are decidedly 
 benefited by their use in moderation. 
 
 Harmful Effects. — The use of some condiments is like!y to be 
 abused, and this is particularly true of peppers, curry, pickles, and 
 vinegar. If consumed habitually in excess, these substances excite 
 gastric hyperemia and catarrh by overstimulation, and may disorder 
 intestinal digestion as well. They at first cause more food to be 
 eaten than necessary, and eventually destroy the appetite, develop- 
 ing chronic dyspepsia of an aggravated type. Persons living in 
 tropical climates where food and service are cheap are apt to lead 
 indolent lives and indulge too liberally in the pleasures of the table, 
 and the overloading of the stomach tempts them to add quantities 
 of condiments to their food for the purpose of stimulating an already 
 overworked digestive system to the performance of further duty. 
 The heat of the climate prevents active exercise, which in turn re- 
 duces the oxidation processes of the assimilated food. The rational 
 diet for those not acclimated to the tropics should consist largely 
 of vegetables and fruits, while nitrogenous food, strong condiments, 
 spirits, bitter beer, etc., should be carefully shunned. I have seen 
 one case of the ginger habit, in Bellevue Hospital, in a woman thirty 
 years of age. It was first acquired by chewing the roots of Jamaica 
 ginger, and subsequently the patient drank large quantities of the 
 beverage sold under that name, and ate powdered ginger of every 
 variety. The patient became maniacal and greatly emaciated. The 
 symptoms in general resembled those of the cocaine habit. 
 
 Varieties of Flavouring. — Next to salt (see p. 45), the most 
 useful condiments are pepper, mustard, ginger, and vinegar, but 
 much difference in taste exists in the use of condiments, and their 
 selection is to some extent a race characteristic. Thus the Persian 
 prefers his asafcetida, which no one else can tolerate ; the Spaniard 
 and Mexican his garlic ; the East Indian his curry ; and the French- 
 man his salad with vinegar. 
 
 From long-continued association certain condiments appear to 
 serve best with definite foods, and so accustomed are most persons 
 to their combination that we cannot easily recall the one flavour with- 
 out the other; thus mustard is associated with ham, black pepper 
 with eggs, red pepper with raw oysters, vinegar with spinach and 
 raw tomatoes, etc., and when deprived of the usual relish the food 
 tastes insipid. Such details, insignificant as they may ordinarily 
 appear, become very important for certain classes of invalids in whom 
 it is necessary to preserve the appetite by pleasing the palate in order 
 that they may take food enough to sustain them. Such are cases of 
 phthisis, empyema, and other forms of chronic wasting diseases. 
 
 Often by varying the flavouring slightly from day to day two or 
 three times as much of the same food will be taken by the invalid. 
 
CONDIMENTS AND SPICES 255 
 
 A skilful use of condiments may do away with the necessity for alco- 
 holic stimulation and serve a better purpose. 
 
 Beef tea and meat broths, which become wearisome to many in- 
 valids, will be often relished if a taste of some savoury aromatic herb 
 be added, such as parsley, thyme, sage, marjoram, or mint. 
 
 Mustard does not greatly stimulate the gastric secretion, but many 
 persons find that it increases the appetite somewhat, and it often pro- 
 duces a sensation of warmth or mild burning in the stomach or a feel- 
 ing akin to hunger. It is used to advantage in moderation in salad 
 dressings or with cold meat, and is sometimes serviceable in those 
 cases in which the main difficulty is a lack of appetite without special 
 enfeeblement of the digestive organs, but it has very little positive 
 value, and while its use in health may be left as a question of indi- 
 vidual taste, it is scarcely ever to be specifically recommended, and 
 its abuse, like that of all condiments, may give rise to gastric irrita- 
 tion. The general irritating effect of mustard in large quantities 
 applied to the skin or gastric mucous membrane is well known, and 
 diluted with lukewarm water (a teaspoonful of mustard to a pint of 
 water) it constitutes a very prompt and valuable emetic. Mustard is 
 said to make the evacuations of the bowels somewhat more moist 
 (Ringer). The seeds are sometimes eaten for their laxative action. 
 The diuretic effect which has been attributed to mustard is not 
 established. 
 
 Black pepper is the berry of a plant, the Piper nigrum, which grows 
 in the West Indies, Sumatra, and other Eastern countries. The 
 whole berry is dried and ground for use. 
 
 While pepper is made from the same berry by previously soaking 
 off the outer husk in water. About thirteen million pounds of black 
 pepper are annually consumed in the United States. It is often 
 adulterated, and to avoid deception it may be purchased in corns 
 and freshly ground at the table. 
 
 Cayenne pepper is not a true pepper, but is made from the crushed 
 pod of various species of Capsicum. It grows in the tropics, espe- 
 cially along the eastern coast of Africa and in Zanzibar. 
 
 The Capsicum annnum is cultivated in this country for the making 
 of pickles from the large unripe green fruit. 
 
 The Capsicum fastigiatum is a variety employed medicinally, and 
 recognised by the Pharmacopoeia. 
 
 Chilies is a common name given to this pepper in England, and 
 chili sauce is an essence prepared from it. It is the strongest variety 
 of capsicum. 
 
 Capsicum, called also Cayenne or red pepper, like mustard, is a 
 strong irritant to both the skin and the mucous membranes. Over- 
 doses of it excite violent local inflammation and gastro-enteritis. 
 Like mustard, it is doubtful whether capsicum in any degree pro- 
 motes the secretion of the gastric juice, but it sometimes stimulates 
 
256 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 a flagging appetite and produces a feeling of warmth in the stomach ; 
 the latter readily becomes tolerant to increasing doses of capsicum, 
 and it is found that more and more is required by those who have to 
 use it habitually to excite the accustomed stimulation. Its chief use 
 is as a substitute for alcohol for dipsomaniacs, especially where the 
 effort is being made to stop drinking abruptly. Its fiery nature tem- 
 porarily satisfies the craving of the stomach. When chronic alco- 
 holic gastritis exists, the stomach digestion is often improved and 
 the craving to satisfy it by strong liquor may be relieved by the 
 tincture of capsicum given in doses of ten or fifteen minims diluted. 
 
 The use of capsicum in health is far from necessary, but it forms 
 an agreeable condiment for many persons. It forms an ingredient 
 of many dinner pills which are taken by elderly people with inactive 
 digestion for the purpose of promoting the appetite. 
 
 Red pepper, like black, is often adulterated. When pure it may 
 be entirely suspended in water. If any precipitate falls it is probably 
 red lead. 
 
 Capers are the flower buds of a bush, the Capparis spinosce, which 
 grows in Eastern countries bordering on the Mediterranean. They 
 are preserved in salt and vinegar, and are used for flavouring sauces 
 for mutton and other foods. They contain tannin, volatile oil, yel- 
 low pigment, and a bitter principle. 
 
 Spices are solely of value in giving variety of taste to the food, 
 and hence tempting invalids or convalescents with lagging appe- 
 tites to eat more. Comparatively tasteless food, such as rice, may 
 be made very attractive by spicing. 
 
 For children the most useful flavouring substances are cinnamon 
 and ginger, and, although not a spice, vanilla extract. For invalids 
 there may be added nutmeg and cloves, although any agreeable spice 
 may be used in moderation, such as mace or allspice. Patients who 
 will not drink hot water when it is ordered will often do so if they 
 can steep a few cloves or a small piece of cinnamon in it, and this 
 can rarely do harm. Those who object to the taste of milk punches, 
 custards, and simple farinaceous foods will often take these sub- 
 stances when slightly flavoured with a trace of some agreeable spice. 
 The latter as ordinarily used for flavouring is never injurious. Only 
 in large doses are such spices as those above mentioned capable 
 of such irritant action in the stomach as may be produced by curry 
 or mustard. Several cases of nutmeg poisoning are recorded. The 
 symptoms are excessive thirst, vertigo, and muscular prostration. 
 Such effects are produced by taking a whole nutmeg, ground and 
 mixed with hot water. 
 
 Ginger is useful both as a condiment and as a food. It is the 
 dried root of the Zinziber officinale, which grows in Jamaica, China, 
 and elsewhere. The rhizome is scraped and either dried and pow- 
 dered, or, if it is to be preserved, it is washed and boiled for twenty- 
 
CONDIMENTS AND SPICES 257 
 
 four hours, and then soaked for another day in salt water. It is 
 then washed, sun-dried, and boiled for half a day with an equal 
 weight of sugar (Clark). It is placed in jars for several days, and 
 then once more boiled, when it is finally sealed in jars. It is excel- 
 lent for flavouring rice and other insipid farinaceous foods for con- 
 valescents and children. 
 
 Vanilla is derived from vanilla beans, grown in Mexico,- Java, 
 and other tropical regions. It makes an agreeable flavouring ex- 
 tract for foods for invalids and children, such as farinaceous 
 gruels, custards, blancmange, or ice cream, for, unlike the spices, 
 it is very bland. Its chief use is in the manufacture of chocolate 
 (p. 223). 
 
 Vinegars are made from wine, beer, cider, various fruits, and even 
 from the dry distillation of wood. They contain, besides acetic 
 acid, traces of dextrin, sugar, organic acids, pigment, extractives, 
 and acetic ether. White vinegar is the best in taste and odour. 
 
 The acetic acid in good French vinegar exists in the proportion 
 of 5 per cent. Ordinary table vinegar contains between 2 and 7 
 per cent. 
 
 The acidity enables this condiment to soften muscle fibre so 
 that the digestion is facilitated of tough meat, such as corned beef, 
 boiled beef, and other foods with hard fibre, like salmon, lobsters, 
 or hard-boiled eggs. 
 
 The action of mild acids, such as vinegar, favours the digestion 
 of tough cellulose, and aids the formation of sugar. For this reason 
 vinegar is a wholesome addition to coarse, fibrous, or stringy vege- 
 tables, such as beets, cabbage, spinach, lettuce, celery, etc., and to 
 raw vegetables, such as cucumbers, cole, lettuce, and like ma- 
 terials used in salads. Vinegar is often eaten with baked beans, but 
 it is said to make their legumin less soluble (Chambers). If vine- 
 gar taken in a salad dressing disagrees, white wine may be substi- 
 tuted with pepper or mustard and oil. 
 
 Vinegar has a well-known antiseptic and preservative action, and 
 hence its use for pickling fish, oysters, fruits, and vegetables. 
 
 Pickles are indigestible, and should take no part in an invalid 
 dietary. 
 
 An excess of vinegar habitually consumed with pickles, or other- 
 wise, causes anaemia and emaciation by lessening the number of red 
 corpuscles and reducing the alkalinity of the blood. 
 
 Vinegar is often adulterated, or spurious articles are substituted 
 for it. This is especially true of that used for the cheaper varieties 
 of pickles, and weak sulphuric acid is quite commonly employed for 
 this purpose. 
 
 Sauces, such as Worcestershire, Tabasco, tomato catsup, etc., 
 are used to stimulate a flagging appetite, and add flavour to soups, 
 broths, etc. Taken in great moderation, they are not injurious, and 
 
258 STIMULANTS, BEVERAGES, CONDIMENTS 
 
 in cases of alcoholism they are sometimes useful by inducing the 
 patient to take more food and less liquor. 
 
 For invalids, for whom strong sauces of this kind should always 
 be forbidden, a very good substitute may be made for use with 
 broiled fish, etc., as suggested by Chambers, by boiling a few plain 
 aromatic herbs, like parsley or mint, in a little water, and adding 
 pepper and salt. 
 
 Horseradish is a condiment which excites the flow of saliva and 
 gastric juice when eaten early in the course of a meal with meat 
 or raw oysters, or otherwise. 
 
PART III 
 
 COOKING 
 
 FOOD PREPARATION AND PRESERVATION 
 
 THE QUANTITY OF FOOD REQUIRED 
 
 COOKING 
 
 The Object of cooking Food. — While man is so constituted that 
 it is possible for him to live upon raw food for a considerable length 
 of time, it is apparently designed by Nature that a large portion of 
 his food should be cooked, for there are no savage races known 
 who do not practise the art of cooking, in however elementary a 
 fashion, and progress in the scale of development and civilisation is 
 uniformly accompanied by advance in the art of cooking. Pre- 
 historic man may have lived wholly on raw food, berries, fruits, 
 shellfish, etc., but this diet is not suited for most tribes of man 
 to-day, although the northern Eskimo still prefers to eat his meat 
 raw and frozen. 
 
 It is owing to the practice of cookery that the dietary of civil- 
 ised man has been so much enlarged, and that it covers a wider 
 range of materials than that which serves for the nourishment of the 
 lower animals. There are many articles of diet in common use, and 
 many others which may be employed as food in an emergency, 
 which are not only unpalatable but are wholly indigestible in the 
 raw state, but which are rendered nutritious by cooking, and it is 
 far less difficult to modify the mechanical preparation of foods than 
 the secretions which digest them. 
 
 Generally speaking, foods, excepting fruits, having organised 
 structure require cooking. 
 
 Of the different varieties of food, that which is derived from 
 animals as a rule requires cooking more than vegetable food. It is 
 well known that some vegetables and most fruits are eaten raw by 
 preference without palling upon the appetite, but raw meat of almost 
 any kind soon becomes wearisome, and if consumed exclusively may 
 even excite disgust. Raw milk, eggs, and bivalves are an exception 
 
 259 
 
260 FOOD PREPARATION AND PRESERVATION • 
 
 to this statement. The process of cooking food accomplishes in 
 general the following purposes : 
 
 I. Cooking develops certain flavours in the food, in meat par- 
 ticularly, which are agreeable to the palate, and thereby enables man 
 to secure variety in taste, which is so important a stimulus to the 
 appetite. 
 
 II. Most food is altered in consistence and made softer by cook- 
 ing, although this is not always the case (eggs, for example, become 
 harder when boiled). The food is therefore easier masticated and 
 mixed with the various digestive fluids. It may be observed that 
 the mere question of solidity of food does not necessarily imply 
 greater toughness — in fact, the albuminous ingredients of meat are 
 coagulated and made actually more solid by cooking, but at the 
 same time they become much less tough or are more friable, in 
 which condition they are more easily ground, torn, and separated 
 by the teeth. 
 
 III. The chemical changes produced in food by cooking seem in 
 some instances to favour the action of the digestive juices upon the 
 food. This is particularly true of some of the forms of starch and 
 of many meats. 
 
 Comparatively little attention has been paid to the chemical alter- 
 ations produced in food by the various processes of cooking. Analy- 
 ses of food are usually conducted upon the raw materials, and the 
 important alterations which are occasioned by heat in various de- 
 grees are still imperfectly understood by most persons. 
 
 IV. By cooking, many varieties of parasites and germs which 
 may be contained in the food are destroyed, and bad food which 
 might otherwise be highly poisonous or injurious is made perfectly 
 harmless. 
 
 V. The temperature of food which is sometimes eaten hot may 
 in some cases favour the digestive processes, although the frnpor- 
 tance of this consideration may be exaggerated. 
 
 VI. The appearance of the food may be improved, and it becomes 
 more appetising on this account. 
 
 Varieties of Cooking. — The several processes of cooking which 
 are in common use are as follows : i. Boiling. 2. Stewing. 3. Roast- 
 ing. 4. Grilling, or broiling. 5. Frying. 6. Braising. 7. Baking. 
 8. Steaming. 
 
 There is undoubted advantage in varying the different methods 
 of cooking as well as of flavouring the food from time to time. Mo- 
 notony of diet and of flavours lessens the appetite and fails to stimu- 
 late the digestive organs into activity. When a reasonable variety 
 of food cannot be obtained, variety in cookery may be made to re- 
 place its advantages to a great extent. Every one is familiar with 
 the effect on the appetite of an occasional change of cooks or of a 
 meal served in unwonted surroundings. 
 
COOKING . 26l 
 
 It is not within the scope of this work to discuss the details of 
 cooking for the sick. Miss Nightingale wrote that " a good sick- 
 cook will save the digestion half its work," and invalid cookery 
 should form the basis of every trained nurse's education. It is 
 impossible here to do more than explain the theory of the chief 
 methods of cooking and suggest occasionally their influence upon 
 digestion. As a rule, twice-cooked meats are undesirable for in- 
 valids. They are apt to be drier and less nutritious and digestible 
 than when fresh. In meat " hash," for example, the meat fibre is too 
 much hardened. Such preparations are often made too greasy by 
 recooking for delicate stomachs. The same statement applies to 
 canned meats when warmed over, for they have been already cooked 
 once in the tin. 
 
 It is undesirable to combine foods which require different periods 
 for their thorough cooking. For example, soup needs less boiling 
 than the vegetables added to it, and they should be partially cooked 
 alone beforehand, or they will be underdone. 
 
 The necessary heat for cooking is obtainable in many ways — 
 from coal, wood, gas, oil, steam, and even electricity — and these 
 different methods each possess advantages for particular foods. 
 
 Cooking, as a rule, at a prolonged low temperature is more eco- 
 nomical in its results upon food than a much shorter application of 
 high heat, and this is the theory of the famous " Count Rumford 
 kitchen." 
 
 1. Boiling. — The primitive method of boiling water consisted in 
 heating the water in a hollow dug in the ground by plunging in hot 
 stones taken out of the fire. Later, as the arts of pottery making 
 and metal working became known, utensils were employed. 
 
 In some excellent remarks by Williams on the subject of so- 
 called boiled food, he points out that the expression " boiled " beef, 
 or eggs, or potatoes, implying that the food has been boiled in the 
 same manner in which the water is boiled, is an absurdity. The food 
 is merely heated by immersion in boiling water, and even such 
 water as is contained in the meat or potato is not itself boiled in the 
 process, for, he says, " its boiling point is higher than that of the 
 surrounding water, owing to the salts it holds in solution. Thus, as 
 a matter of chemical form the boiled leg of mutton is one that has 
 been cooked but not boiled, while the roasted leg of mutton is one 
 that has been partially boiled. Much of the constituent water of flesh 
 is boiled out and fairly driven away as vapour during roasting or 
 baking, and the fat on its surface is also more or less dissociated 
 into its chemical elements, carbon and water, as shown by the brown- 
 ing due to the separated carbon." 
 
 It is a scientific fact which is not appreciated by many persons 
 that when water has once reached the boiling point, its temperature 
 cannot be further elevated until it is all converted into steam, for all 
 
262 FOOD PREPARATION AND PRESERVATION 
 
 the additional heat which is required above that needed to warm the 
 water and drive off the air-bubbles in the process of ebullition is 
 expended in vapourising the water into steam. Consequently, how- 
 ever hot the fire, or however prolonged the cooking, the tempera-' 
 ture of the food suspended in boiling water cannot be increased 
 above that of the water itself; and, in fact, the temperature of the 
 interior of large masses of food, like potatoes or meat, is by no 
 means as great as that of the surrounding water. For this reason, 
 piling fuel upon the fire when water has once reached the boiling 
 point will have no further effect than that of accelerating the rate 
 of ebullition, without actually raising the temperature of the water 
 or any food immersed in it. 
 
 Five and a half times as much heat is required to convert water 
 at the boiling point into steam as that which is needed to raise water 
 from the freezing to the boiling point. Count Rumford over a cen- 
 tury ago remarked that, while the boiling temperature of water varies 
 considerably at different levels, meat or eggs are just as thoroughly 
 cooked at an elevation in which the water boils at 209.5 as they 
 are at the sea level, where the boiling temperature is 212 F. 
 
 There is practically no distinction to be made between " simmer- 
 ing " and boiling as a process of cooking. The violent boiling of 
 some foods tends to soften them somewhat on account of the effect 
 of the commotion produced in the water by the rising bubbles which 
 cause currents to form that carry particles of suspended food with 
 them and triturate them. 
 
 The operation of boiling if continued for an hour or more gradu- 
 ally converts the connective tissue of meat fibre into gelatin, which 
 is partially dissolved .in water, and the heat of the boiling water 
 usually melts a little of the fat, which, being unable to mix with the 
 water, forms a scum upon the surface. A small proportion of the 
 juices of meat usually osmoses or soaks out into the surrounding 
 water, and the aqueous solution thus formed is called broth or bou- 
 illon. The richness of the broth will depend principally upon the 
 method of conducting the boiling process. When it is desired to 
 have the broth as nutritious as possible the meat must be finely 
 minced and put into cold water, which is gradually warmed but not 
 actually brought to the boiling point. By this process the juices of 
 the meat are slightly dissolved out into the warm water, and there- 
 after, if the temperature is not carried above 160 F., coagulation 
 of the albumin in the muscle fibres does not occur, and more and 
 more of their constituents are dissolved out into the surrounding 
 water — but this is not true boiling. In this manner the natural 
 flavour is very much better preserved ; in fact, the common extracts 
 of meat are made by soaking finely chopped meat in cold water and 
 subsequently evaporating the water from the ingredients which are 
 found in it. 
 
COOKING 263 
 
 On the other hand, when broth is not wanted for nutriment it is 
 desirable to prevent the solution of the juices in the water as much 
 as possible, and this is accomplished by immersing the meat suddenly 
 into water actually boiling, where it should be left for five minutes, 
 by which time the outer layer of the mass will be hardened by coag- 
 ulation and will have a firm coating which is not permeated by the 
 juices within. When meat is cooked in this manner the broth is 
 scarcely of any food value, but the meat is much more palatable. 
 After the boiling temperature of the water has been maintained for 
 five minutes the further cooking should be continued at a lower 
 temperature of, say, 165 to 170 F. If the heat is less than this, the 
 interior of the joint or other piece of meat is imperfectly cooked 
 and its albumin is insufficiently coagulated, so that it has a raw 
 appearance. If the actual boiling point is long maintained, the 
 albumin is too firmly coagulated, and the meat becomes tough and 
 stringy. The latter error in boiling is very commonly perpetrated 
 by cooks, and it must be observed that the coagulation point of 
 different forms of albumin varies considerably, ranging from below 
 90 to above 165 F., and since many varieties of albumin occur in 
 the different kinds of animal food which are in common use, it will 
 be found that they are not all equally well cooked by exactly the 
 same temperature. It is important that the coagulation temperature 
 of a given albumin should not be greatly exceeded or long main- 
 tained if the food is to remain tender and digestible. Parkes says 
 that ammonium sulphite is liberated by continued boiling, and also 
 an acid resembling acetic acid. 
 
 When meat is plunged into boiling water so that the external 
 layers are solidified some of the water which they contain is squeezed 
 out into the surrounding fluid, and an actual loss of weight in the 
 meat occurs which may reach as high as 30 per cent. 
 
 The addition of salt to water in boiling fish or meat is described 
 by Williams as having a threefold action : (1) It directly acts on 
 superficial albumin with coagulating effect ; (2) it slightly raises the 
 boiling point of the water ; (3) by increasing the density of the water, 
 the exosmosis or oozing out of the juices is less active, and hence 
 the flavour is better retained. 
 
 When very salt meat is to be cooked, if steeped too long in boil- 
 ing water its nutritive properties are impaired, the muscle sarcolem- 
 ma becomes too hard, and the meat tasteless and tough. In such 
 cases it may be well to boil meat less completely, and finish the 
 cooking by some other method, such as frying. 
 
 2. Stewing 1 . — Stewing differs from boiling in the fact that the 
 juices of the meat or vegetables are dissolved in the heated water, 
 whereas in boiling, the juices are kept from passing out into the 
 water by the coagulation of the external surface of the food mass 
 produced by immersing it suddenly into boiling water. The proper 
 x 9 
 
264 FOOD PREPARATION AND PRESERVATION 
 
 temperature for stewing is between 135 and 160 F. In thick stews 
 the juices dissolved in the water are eaten together with the cooked 
 food, but in some instances, as in the making of beef tea and some 
 kinds of soups, the aqueous solution only is used. Obviously, the 
 more the food is subdivided the greater the surface exposed to the 
 solvent action of the water, and hence the object of mincing meat 
 thoroughly which is to be used in the preparation of beef tea. If 
 such minced meat has been soaked for a long time in cold water, a 
 part of the albumin and the extractive materials are obtained in 
 solution, but the meat which is left is colourless, tasteless, and un- 
 palatable ; in fact, animals fed upon it soon deteriorate in strength. 
 
 The manner in which stewing differs from other processes of 
 cooking is well described by Williams, who says : " Instead of the 
 meat itself surrounding and enveloping the juices, as it should when 
 boiled, roasted, grilled, or fried, we demand in a stew that the juices 
 shall surround or envelop the meat." And more or less water enters 
 the substance of the meat to replace the juices which have passed 
 out by osmosis and diffusion into the surrounding fluid. After meat 
 has been stewed for some time a scum containing a little coagulated 
 albumin and more or less fat is usually seen floating upon the sur- 
 face. This is usually removed in the preparation of beef tea for 
 invalids in order to make it more palatable and more agreeable to 
 the eye, but its removal is at the expense of considerable nutritious 
 material. In the preparation of extracts of meat, such as Liebig's 
 Extractum Carnis, the scum is removed before the solution is con- 
 centrated by evaporation. 
 
 Stews which are simply made in the manner described above, and 
 which consist largely of meat and plain sliced vegetables, are fairly 
 digestible ; but if other materials or rich sauces are added to them, 
 this is not the case, and if saturated with fat, they are quite unfit 
 for invalids. As both the solid substance of the meat and vegetables 
 and the fluid materials which have been extracted from them are 
 eaten together in the stew, this is an economical form of preparing 
 food. Nothing is lost by evaporation, and nothing is thrown 
 away. 
 
 3. Roasting. 4. Grilling. — The processes of roasting and grill- 
 ing or broiling, when performed over a very hot fire, result in cook- 
 ing the meat in a manner which is in some respects analogous to 
 stewing ; in fact, the interior portions of the meat are stewed in their 
 own juices instead of in water (Williams). A coating of coagulated 
 albumin forms upon the outer surface of the meat, while the albu- 
 minous material or myosin of the interior is gradually warmed and 
 more slowly coagulated. The outer coating prevents the evapora- 
 tion of the juices of the meat which, together with the extractive 
 materials, are retained, and add flavour to it. Roasted and broiled 
 meats therefore have a decided advantage in flavour as well as in 
 
COOKING 265 
 
 nutritive value over meat which has been boiled for a long time, 
 although the latter may be tender and easily digested. 
 
 Roasting and broiling are the most universal methods of cook- 
 ing. For them the savage or the hunter requires no utensils, but 
 boiling implies the aid of the potter or worker in metals. The 
 Polynesian cooks his meat by roasting it on a hot stone, and 
 sprinkles it with sea water to obtain the salt. The primitive hunter 
 incases his meat or fowl, skin and all, in damp clay and roasts it in 
 hot coals. The Australian savage, the lowest type of man, does all 
 his cooking by roasting. 
 
 In roasting, the high temperature which is applied suddenly to 
 the meat produces a firmer coagulation of its outer layers than 
 occurs with boiling. Owing to this fact, the natural juices of the 
 meat are almost completely retained, and, as in boiling, the heat 
 should be strong when first applied, but it may subsequently be 
 reduced to prevent charring of the surface. This may be accom- 
 plished by removing the meat farther away from the fire. 
 
 The process of roasting and grilling is conducted mainly by 
 radiant heat, although there is slight convection through the air. 
 The main object of an oven is to prevent burning by uneven 
 cooking. 
 
 The principle of a proper roasting oven is formulated by Wil- 
 liams, who says " the meat should be cooked by the action of radiant 
 heat projected towards it from all sides while it is immersed in an 
 atmosphere nearly saturated with its own vapour," and the heat 
 applied after reaching a maximum is kept uniform throughout the 
 process. 
 
 In boiling or stewing, the heat is applied to the meat by convec- 
 tion through water, and this is an important discrimination because 
 the air which surrounds the roasting meat is constantly removing 
 the water which tends to evaporate upon its surface, and therefore 
 to dry the external surface of the meat. From 20 to 24 per cent of 
 water is lost in this manner, and the meat therefore weighs less. 
 The evaporation of this water, which continually passes from the 
 interior of the meat towards the outer surface, produces a loss of 
 heat in the meat itself which keeps the interior from becoming over- 
 heated. If the roasting or broiling is long continued, the water 
 gradually passes out more and more from the interior of the mass, 
 which finally becomes dry and hardened or burned. If too much air 
 surrounds the meat, it is poorly roasted, dry, and leathery, whereas 
 if the heat is applied more directly by radiation from glowing embers, 
 the sudden hardening of the outer coating of the meat, even though 
 it be slightly burned, forms a barrier against the evaporation of 
 water from the interior. 
 
 Broiling or grilling is a means of quick cooking which requires 
 very much less time than roasting or boiling, because intense heat is 
 
266 FOOD PREPARATION AND PRESERVATION 
 
 applied to comparatively small pieces of meat or fish. It is really 
 roasting on a smaller scale. 
 
 The object of broiling as well as of quick roasting should be to 
 raise the interior of the mass promptly to the point of coagulation, 
 or about 180 F., so that the water formed shall not have time to 
 wholly evaporate. It is consequently advisable for the meat to be 
 cooked as near the glowing surface as possible to increase the radia- 
 tion and diminish the convection of air currents (Williams). It is 
 for this reason that steaks and chops are often better cooked in 
 restaurants, where specially adapted grills are used which bring the 
 meat in closer relation to a radiant surface of glowing coals than it 
 is usually possible in domestic cookery. A properly cooked steak 
 or chop is thickened in the centre, but if badly grilled it is thin and 
 dry. It should be remembered that the evaporation depends upon 
 the extent of the surface of the meat, and for this reason thinly cut 
 steaks or chops become comparatively dry and shrivelled in the 
 centre. This principle is well described by Williams, who says that 
 " the smaller the joint to be roasted, the higher the temperature to 
 which its surface should be exposed," and when very large masses 
 of meat are being cooked, it becomes necessary to secure time for 
 the heat to penetrate into the interior without drying up the outside. 
 This object is accomplished by constantly basting the surface in 
 order to keep it wet and prevent evaporation, for while the surface 
 is moistened, its temperature will not rise above the boiling point 
 of the liquid which is used to moisten it. Pouring melted fat or 
 melted butter over the meat checks evaporation almost completely, 
 and in the case of large joints it prevents the external portion from 
 becoming too dry and indigestible before the albumin of the interior 
 has been coagulated. Small lean joints of meat require more fre- 
 quent basting with fat. 
 
 The roasting of any meat, however, cannot be accomplished 
 without the effusion of some of the meat juice and the melting of a 
 portion of the more superficial fat and of gelatin. These substances 
 together constitute the meat gravy, which is itself quite nutritious 
 and which is advantageously used for basting the meat to prevent 
 drying, as well as to distribute the heat more uniformly over the 
 surface. In overroasted or " burned " meat the external layers be- 
 come scorched or charred, and this is due chiefly to the carbonising 
 of the fat. Before the fat has become fully burned, certain volatile 
 fatty acids are liberated which have a very disagreeable odour, and 
 various products are developed which are not only of no value for 
 nutrition, but which may be positively irritating to the alimentary 
 canal. According to Yeo, for beef, mutton, and game, a tempera- 
 ture of 130 F. is sufficient for proper cooking, and the meat is 
 " rare " or " underdone," retaining a good deal of its reddish colour ; 
 but veal and poultry should be cooked at a higher temperature — at 
 
COOKING 267 
 
 from 158 to 160° F. These temperatures are lower than those 
 often used, and apply rather to the degree of heat which is to be 
 maintained after the meat is first placed in position for roasting, 
 when, as previously stated, the temperature may be much higher. 
 
 Game or meat which is " high " or somewhat tainted is extremely 
 repulsive if cooked by boiling or stewing, when it disintegrates more 
 or less and the elements of decomposition pass into and flavour the 
 whole mass. Such meat, however, is sometimes palatable, and is 
 not necessarily unwholesome if cooked by roasting, when the ex- 
 ternal layers which have first commenced to decompose are thor- 
 oughly browned and thereby disinfected. Some persons prefer that 
 a leg of mutton should be hung until it becomes slightly odorous 
 before it is roasted, but it must be fresh tor boiling. 
 
 5. Frying. — Frying is a process of cooking by which the heat is 
 transmitted by the contact of the food with melted fat, butter, or oil, 
 and not by radiation, as in the case of broiling or roasting. As ex- 
 plained by Williams, the fat does not necessarily boil, for the food, 
 as well as the fatty material itself, may contain a considerable pro- 
 portion of water which, by being suddenly vaporised, produces the 
 familiar spluttering which accompanies the process of frying. 
 
 The boiling point of fats is very much above that of water, and 
 the vaporisation of the latter is complete at 212 F. Between 300 
 and 500 F. may be required to vaporise the so-called volatile oils, 
 but fats and oils used in cooking do not apply to this class, and 
 when heated above 400 F. they turn dark brown or black and emit a 
 disagreeable odour and smoke, leaving a non-volatile carbon residue. 
 
 The process of frying bears somewhat the same relation to boil- 
 ing that the broiling of meat does, in that the heat employed is 
 considerably greater. It is suddenly applied, and as a result the 
 external surface of the food mass is coagulated and hardened before 
 the juices in the interior have time to escape. For this reason, deli- 
 cate fish, like the trout, is much more highly flavoured and palatable 
 when fried than boiled. More or less butyric acid is developed from 
 fat in frying. 
 
 The popular idea in regard to frying is that the fat used, whether 
 butter, lard, or drippings, is simply for the purpose of preventing 
 food from adhering to the frying pan, but, from the explanation of 
 the process quoted above, it is seen that this is not the case, and the 
 best frying is done by immersing the food completely in a bath of 
 fat or oil. Even olive or sperm oil may be used for this purpose, 
 and the fish or other food is lowered in an open wire basket or net- 
 ting into a deep pan which contains the fat, in which it is completely 
 submerged. There is no danger of the fat soaking into the food if 
 it is sufficiently hot and if the process is not too long continued, for, 
 as stated by Williams, " the water amid the fibres of the fish is boil- 
 ing and driving out steam so rapidly that no fat can enter if the 
 
268 FOOD PREPARATION AND PRESERVATION 
 
 heat is well maintained to the last moment." Fritters cooked in 
 this way are light and puffy from the sudden expansion of the water 
 which they contain into large bubbles of steam, and are consequently 
 decidedly more digestible. Bacon fries in its own fat. 
 
 Frying is less perfectly understood by cooks than almost any 
 other method of preparing meat, and the process as usually carried 
 out results in very unwholesome products. The pans used are too 
 shallow, and the food and fat are apt to become scorched. 
 
 When the meat or other material is dipped into hot melted oil or 
 fat, more or less of it clings to the surface of the food, and for this 
 reason may render it unfit for persons with feeble digestive powers. 
 In the case of fish cooked in this manner with their scales, the fat 
 which adheres to them may be easily removed when eaten, and the 
 meat within will be found to be quite digestible ; but meat, such as 
 steak, cooked by frying is notoriously indigestible. Salt meat may 
 be cooked first by boiling before frying, as in the case of hams, 
 although the latter may be subsequently roasted instead of fried. 
 Such meats always require prolonged cooking. According to Yeo, 
 the addition of a little vinegar tends to make them more tender. 
 
 6. Braising. — Braising is a method of cooking meat by which it 
 is immersed in a solution of vegetable and animal juices called 
 " braise," contained in a covered vessel, in which it is exposed to a 
 strong but not boiling temperature. It is of value especially for 
 cooking tough meat of any sort or meat which is too fresh or young. 
 The cover of the kettle is so arranged as to prevent evaporation 
 from occurring to any extent ; the meat becomes permeated in the 
 long cooking with the juices of fresh vegetables and herbs, and is 
 kept from drying. 
 
 Towards the end of the process cooking-sherry or spices may be 
 added, such as cloves or mace, or thin slices of bacon. The amount 
 of fluid used should be but barely sufficient to cover the meat, and 
 in this way the surrounding broth is kept very concentrated. Some- 
 times the meat which is braised is partially roasted. 
 
 7. Baking. — Baked meat is prepared by cooking in a confined 
 space, which prevents the volatile products which are driven off in 
 roasting from escaping, and consequently the meat has a somewhat 
 stronger and less delicate flavour than when roasted ; it is also richer, 
 and disagrees with dyspeptics. It becomes saturated with empyreu- 
 matic oils unless its surface is protected by a pie crust, but even that 
 does not add to its digestibility. 
 
 The baking of bread is described on page 137. 
 
 8. Steaming. — Cooking by steaming is a method but little used, 
 and is mainly applied to cereals, puddings, etc. 
 
 Soups. — Meat soups are made by continued boiling, which con- 
 verts the connective tissue of meat fibres into gelatin, which is grad- 
 ually dissolved into the water. The soup thus becomes an aqueous 
 
COOKING 269 
 
 solution of gelatin, with some of the extracts of the meat for flavour- 
 ing. Whatever albumin is dissolved and what little fat may be 
 melted forms a scum on the surface. The insoluble albumin be- 
 comes coagulated and floats about in small particles, which are 
 strained away if the soup is to be clear, but this process makes it 
 less nutritious for invalids. If a really rich soup or nutritious broth 
 is to be made from any piece of meat, so much of the latter is dis- 
 solved into the water that the residue is tasteless, tough, and so 
 indigestible that it is practically useless. On the other hand, there 
 are many scraps of meat or parts which are unsightly or less useful 
 for food from which very nutritious broth may be made, and the 
 inedible bones are utilised in the same manner. 
 
 The extent to which soups and broths may be made nutritious 
 depends largely upon the character of the meat used, and Parkes 
 placed meats in the following order in regard to the nutritive value 
 of their broths, commencing with the strongest : Chicken, mutton, 
 and beef. He said that the best broth made from beef contains 150 
 grains of nitrogenous nutriment to the pint and 90 grains of salts, 
 for nearly all of the salts of the beef, chiefly chlorides and phos- 
 phates, dissolve out into the surrounding water. 
 
 When a few drops of dilute hydrochloric acid are added to minced 
 meat immersed in water, the acid converts the muscle albumin into 
 syntonin, which is soluble in cold water, and after soaking in it for 
 several hours a moderately nutritious broth can be obtained. Such 
 broth may be heated to 130 F. without coagulation, when it will be 
 found to contain nearly 50 per cent of the meat albumin (Parkes). 
 (See Receipts for Beef Tea.) 
 
 Cooking of Fish. — Fish may be cooked by boiling, grilling, 
 baking, frying, or stewing. Of these several methods, boiling is 
 decidedly the most advantageous for persons with feeble digestions, 
 and next in order is broiling. When fish is boiled without the 
 addition of salt to the water it becomes soft and disintegrated, but if 
 boiled in sea water or artificially salted water it maintains its shape 
 and flavour. The quantity of salt present regulates the osmosis of 
 the juices of the fish into the water. As a rule, fish requires much 
 less time than meat for cooking. 
 
 If fried fish is to be eaten by dyspeptics, it should be cooked 
 whole, and the skin must be carefully removed subsequently. It is 
 never as digestible as boiled fish. 
 
 Cooking of Vegetables. — The object of cooking vegetables, as in 
 the case of cooking meat, is to render them more digestible, to give 
 variety, to modify their flavour, and in some cases to preserve them. 
 
 Some coarse vegetables, such as turnips, carrots, beats, and pota- 
 toes, while they make good raw food for animals, are unpalatable 
 and indigestible for man, and require softening and alteration by 
 prolonged boiling in soft water or by some other form of cooking. 
 
2/0 FOOD PREPARATION AND PRESERVATION 
 
 The cooking of vegetables macerates the cellular fibres or walls of 
 the cells and softens their contents, rendering the vegetable much 
 more easy of mastication, while the effect of the heat and moisture 
 is to cause swelling and rupture of the starch granules, in which con- 
 dition they are more easily and promptly acted upon by the starch- 
 digesting ferments contained in the saliva and pancreatic juice. 
 
 Many vegetables contain albuminous substances, besides sugars, 
 gums, and starches. The albuminous material is coagulated by ap- 
 propriate temperature and the other matters are more or less soluble 
 in water. 
 
 Most vegetables contain a very large percentage of water in their 
 natural state, but in many of the cooking processes to which they 
 are subjected, excepting perhaps in baking potatoes and the like, 
 water is always added in considerable quantity, either hot or cold. 
 
 FOOD CONCENTRATION-CONDENSED FOOD 
 
 The concentration of food is based upon the fact that many foods 
 contain a large percentage of free water, which can be driven off by 
 evaporation, thereby reducing the weight, and usually the bulk of 
 the food as well. Slight further condensation may be accomplished 
 by pressure through machinery which is capable of applying a force 
 of several tons to the square inch. 
 
 Drying. Desiccation. Extracts. — If the process of drying is not 
 carried beyond a partial evaporation, the food is called " condensed." 
 It may, however, be continued until the food is wholly dry, in which 
 case the substance may be either " desiccated " — i. e., torn into 
 shreds — or pulverised. Condensed and powdered foods may be 
 added to other foods in order to thicken them or add to their 
 nutritive power. 
 
 The nutritive principles of foods may be extracted by glycerin 
 or acid solutions and other materials, and the resulting extract is con- 
 densed by evaporation to the consistence of a paste or powder. Be- 
 yond this it is not possible to concentrate foods by chemical process, 
 for a definite bulk of food must be daily consumed from which to 
 derive the energy for the body and the substance needed for repair. 
 
 Drying is conducted either in the heat of the sun or by artificial 
 means. The class of dried foods embraces the various forms of 
 dried and desiccated meat and fish, dried milk, dried vegetables and 
 fruits, such as peas, beans, lentils, corn, okra, apples, peaches, cocoa- 
 nuts, grapes (raisins), figs, etc. The addition of sugar, flour, or salt 
 by abstracting moisture, aids the drying and helps to prevent decom- 
 position. (See Food Preservation by Drying, p. 274.) 
 
 Milk may be dried in vacuo and preserved by itself as a powder, 
 or mingled with other materials, such as malt and various starchy 
 foods. Condensed milk has been already described (p. 93). 
 
FOOD CONCENTRATION— CONDENSED FOOD 2J\ 
 
 Eggs may also be successfully dried ; they keep well, especially 
 when mixed with farinaceous materials (p. 106). 
 
 Froissart relates how the King of France in the invasion of 
 England in 1386 had the yolks of eggs packed and stored in bar- 
 rels to furnish rations for the troops. Egg albumin dries in the form 
 of thin scales which may be indefinitely preserved. 
 
 Meat. — The preservation of meat and fish by drying is probably 
 the oldest, as it is the most primitive, method in use. Meat drying 
 is practised extensively among savage tribes in almost all parts of 
 the worid, but especially where purity of the atmosphere combined 
 with intense heat and dryness of climate will cause the water to 
 evaporate from the meat so rapidly that germs do not have time to 
 decompose it. For this purpose only lean meat can be used, as the 
 fat does not part with its water with sufficient readiness. Dried 
 meat loses much in weight, becomes hard and tough, and in many 
 cases tasteless. It is therefore usually indigestible, and requires 
 prolonged cooking and proper seasoning. When prepared in this 
 way, the drying process may be applied very thoroughly, and the 
 food is more easily cooked and seasoned. Dried meat may be pre- 
 digested, evaporated, powdered, and made into a paste for broths, 
 or used to re-enforce various food preparations for invalids. Pow- 
 dered meat is sometimes mixed with sugar and salt, or pulverised 
 dried cooked vegetables, bread, etc. Meat extracts have been de- 
 scribed in detail on pp. in to 118. 
 
 Pemmican is a preparation of dried powdered meat, which has 
 been described on p. 197. 
 
 Dried vegetables keep even better than dried meats. Tea and 
 coffee are good examples of dried vegetable substances. They may 
 be extracted and then concentrated by evaporation. Potatoes are 
 concentrated by drying to less than one third of their original weight, 
 and they may be thus preserved in slices or in granular form. Many 
 other vegetables are prepared by drying, and, in addition, some are 
 compressed, as, for example, cabbage, cauliflower, carrots, etc. The 
 compression still further excludes air and moisture. As a rule, dried 
 vegetables are only serviceable for relieving monotony of diet when 
 fresh vegetables cannot be obtained. Desiccated vegetables have 
 been used with some success in the United States navy, but they 
 have less antiscorbutic property than fresh foods. 
 
 Bread may be preserved for a long time by drying, but it usually 
 becomes tasteless, and is useful in this condition only in emergencies, 
 or to make variety in the rations of sea biscuits, hard-tack, etc., 
 which are furnished to soldiers and sailors in active service. 
 
 Major Woodruff, Assistant Surgeon, U. S. A., writes of this 
 subject : " The Germans have been the first to take advantage of 
 drying and compressing processes in the manufacture of a dried, 
 compressed bread. The great difficulty in the use of bread for field 
 
272 FOOD PREPARATION AND PRESERVATION 
 
 service consists in the inability to supply it so that it will keep a long 
 time and be digestible. Hard-tack is ruinous to many soldiers, as 
 already pointed out. If baker's bread is compressed, it sinks into 
 a heavy dough. Only strong stomachs can digest it, and it is far 
 worse than the wet, soggy, hot breakfast bread with which we culti- 
 vate dyspepsia. If the bread is merely dried, it is too bulky for 
 transportation. By a new process, which probably consists in dry- 
 ing the bread and at the same time compressing it by improved 
 machinery, the Germans have secured a variety of field bread which 
 is spoken of in very high terms. Small bits of it thrown into soup 
 swell up like a dried sponge when thrown into hot water. The 
 soldiers are said to be very fond of it, and as far as known it is 
 entirely successful. . . . 
 
 " The French Department of Intendance has been experimenting 
 with dried bread, which is said to be superior for campaigning pur- 
 poses both to biscuit and ordinary bread. From the results of the 
 experiment, which are given in the Revue du Service de lTntendance 
 Militaire, it appears that this dried bread will absorb from five to six 
 times its own weight of water, milk, tea, coffee, or bouillon. Biscuit 
 absorbs hardly its own weight of liquid, although when thor- 
 oughly dried it contains only about 10 per cent of water, whereas 
 the bread contains from 12 to 14 per cent. It can be made in 
 cubes of convenient form." 
 
 Diet of Concentrated Foods 
 
 There are many complex dried foods in market prepared espe- 
 cially for invalid diet, and supposed to possess high nutritive value 
 with small bulk. As compared with fresh food, their lighter weight 
 and greater concentration make them valuable articles for temporary 
 invalid diet, but they cannot be said to possess any special advan- 
 tage over freshly made broths, scraped beef, etc., excepting in those 
 cases in which it is important to lessen the bulk and increase the 
 strength of the food. 
 
 Attempts have from time to time been made in the German army 
 and elsewhere to supply healthy men with a daily diet of concen- 
 trated foods. If this could be done, it would be of great economic 
 advantage for troops on the march, explorers in unknown countries, 
 sailors on long voyages, and for use in many ways, but after a few 
 days or a week of such treatment men lose in weight and deteriorate 
 in strength. It is not found practical to give food for any length 
 of time in which the total solid ingredients are concentrated to less 
 than twenty-two or twenty-three ounces for the day's ration, al- 
 though for a few days food may be used in which they have been 
 reduced to ten or twelve ounces (Parkes). Pea meal (p. 164) and 
 pemmican (p. 197) are the most noted rations of this class, to 
 
FOOD CONCENTRATION— CONDENSED FOOD 
 
 273 
 
 which bacon, hard-tack, concentrated meat extracts, coffee, and 
 chocolate are often added. 
 
 In a series of very instructive and important articles upon Mili- 
 tary Food, published in the Journal of the American Cavalry Asso- 
 ciation, Major Woodruff says : " Concentration only means the 
 exclusion of the indigestible portions and part of the water. Thus 
 the garrison ration gives to each man about five pounds of food, of 
 which only four pounds are eaten, and it is impossible to condense 
 this amount so that it will be much less than three pounds. All foods 
 that are compressed and dried still contain from 5 to 12 per cent of 
 water. The German soldier's war ration is equivalent to about two 
 pounds of water-free food in the above sense. This is not enough 
 for American soldiers during hard work, yet it is possible in an 
 emergency to give the soldier fairly good nourishment with these 
 improved foods, and not allow the weight to be over two pounds, 
 as seen in the following table, in which the analyses are only ap- 
 proximate : 
 
 
 GRAMMES. 
 
 Calories. 
 
 
 Articles. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 Weights. 
 
 3 cubes dried compressed 
 bread, J pound each 
 
 3 packages compressed soup, 
 6 ounces each 
 
 35 
 100 
 
 4 
 I50 
 
 250 
 200 
 
 450 
 
 2 
 
 28 
 
 1,233 
 2,625 
 
 f pound. 
 
 i " 
 
 3 tablets compressed tea or 
 coffee ready for use, possi- 
 bly a tablet of dried fruit. . 
 
 Total 
 
 135 
 
 154 
 
 30 
 
 3,858 
 
 * 2 pounds. 
 
 
 * Gross weight. 
 
 " The composition of the bread is assumed to be the same as 
 ordinary flour, and the tablets of soup can be manufactured of the 
 given composition. As usually made, the tablets do not contain so 
 much fat, which is here purposely increased in order to give the 
 necessary energy. Even with this increase they would not contain 
 as much as the first specimens of Erbswurst. 
 
 " For purposes of detached service the United States soldier has 
 been supplied, as seen in the following table : 
 
 I pound hard-tack. . . . , 
 
 -f pound bacon , 
 
 Coffee, sugar, and salt. , 
 
 Total 
 
 
 GRAMMES. 
 
 
 Calories. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 50 
 27 
 
 5 
 236 
 
 340 
 
 2i 
 
 J 9 
 
 1,644 
 2,310 
 
 77 
 
 241 
 
 340 
 
 30 
 
 3,954 
 
 Weights. 
 
 I pound. 
 
 2 pounds. 
 
274 FOOD PREPARATION AND PRESERVATION 
 
 Food Preservation 
 
 The different methods of food preservation have of late years 
 received much attention, for it is owing to them very largely that 
 it is possible to maintain large armies and navies in action and to 
 permit of the aggregation of men in communities away from all 
 immediate sources of food supply. 
 
 It was originally believed that contact with air was per se the 
 cause of the decomposition of food, but it is now known that the 
 great number of germs contained in even comparatively " pure " 
 atmospheric air are the agents of putrefaction rather than the air 
 itself, but the exclusion of the latter implies the exclusion of the 
 former. 
 
 The different methods of preserving foods are therefore all de- 
 pendent upon the principle of preventing fermentative changes which 
 are liable to occur when germs, derived either from the atmospheric 
 air or contamination with unclean substances, come in contact with 
 foods under favourable conditions of warmth and moisture. The 
 conditions which are inimical to the development of bacteria are 
 those which may be successfully adopted for the preservation of 
 food. 
 
 Ferments and putrefactive germs require for their activity a fair 
 degree of moisture, a moderately warm temperature, which for many 
 putrefactive germs ranges between 6o° and ioo° F., while certain 
 germs must, in addition, have free oxygen derived from the atmos- 
 pheric air. 
 
 The principal means employed for preserving food are included 
 under the following headings : 
 
 I. Drying. II. Smoking. III. Salting. IV. Freezing. V. Re- 
 frigeration. VI. Sterilisation. VII. Exclusion of Air — Canning. 
 VIII. Addition of Antiseptic and Preservative Substances. 
 
 I. Drying. — Drying in the sun or before a fire is probably the 
 oldest of methods of preserving food. At present it is used mainly 
 for fruits and vegetables, although in some excessively dry and clear 
 atmospheres, comparatively free from putrefactive bacteria, meat 
 also may be preserved in this way. " Jerked " meat is kept by 
 cutting it into thin slices and drying in the sun for several days. 
 Familiar instances of preservation by drying are found in raisins, 
 figs, dates, prunes, dried apples, peaches, desiccated cocoanut, etc. 
 Some vegetables are also preserved in this manner, such as Lima 
 beans, okra, corn, etc. Others are cut into slices and then dried, but 
 the latter are apt to become tough and tasteless. Fish, such as the 
 cod, is desiccated and preserved by drying, but with the addition of 
 salt. The desiccated meats and vegetables which are used for 
 making soups have the advantages of portability and permanency. 
 
FOOD CONCENTRATION— CONDENSED FOOD 275 
 
 They are nutritious, and may be added to strong beef tea to increase 
 its flavour and make it more palatable. 
 
 This subject is further discussed under the heading Food Con- 
 centration (p. 271). 
 
 II. Smoking. — Smoking is the preservation of meat or fish by 
 means of volatilised creosote and other substances developed from 
 wood or peat smoke, which have an antiseptic action. It is chiefly 
 applied to beef, tongue, ham, bacon, and fish. The meat or fish is 
 hung in a confined chamber and saturated with wood smoke for a 
 long time, so that it absorbs a small percentage of antiseptic mate- 
 rials, the fat is prevented from becoming rancid and the albumin 
 from putrefying. The smoking is commonly employed after salting 
 and in connection with drying. Painting the surface of meat with a 
 solution of wood creosote in vinegar has the same preservative 
 action. 
 
 The outer surface of meat, such as ham or bacon, preserved by 
 smoking becomes considerably drier and tougher than the interior, 
 but the latter is not made especially tough by the smoking if it was 
 originally tender. Well-smoked bacon cut thin and thoroughly 
 cooked is a digestible form of fatty food for tubercular patients, 
 and smoked beef may sometimes be eaten for the sake of variety 
 by patients who are placed upon a meat diet. The digestibility of 
 hams is enhanced by the smoking process to which they are sub- 
 jected. 
 
 /The process of smoking is applied to fish upon a very large 
 scale, and their digestibility and flavour cannot be said to be de- 
 stroyed by it in many cases ; in fact, in some instances, as in those 
 of smoked mackerel, herring, and salmon, while the flavour is 
 very different from that of the fresh fish, it is agreeable to many per- 
 sons, and these articles afford an important and appetising variety 
 of food. 
 
 III. Salting. — The process of salting is a primitive but still de- 
 sirable method of preserving meat and fish. Salted meat usually 
 becomes pale from the action of the salt upon the haemoglobin con- 
 tained in the blood vessels of the muscle fibre. The addition of a 
 little saltpetre helps to preserve the original reddish colour of salted 
 meat. Salt also absorbs moisture from the food, and thus dries it 
 while preserving it. 
 
 Brine, a strong solution of common salt, may be used to tem- 
 porarily preserve meat and other substances. The Chinese have 
 long practised the art of preserving fruits, roots, and flowers in it. 
 Corned beef is made by soaking the meat for some days in such a 
 solution. The brine acts upon the muscular tissues and toughens 
 it. Brine, concentrated by long-continued use, has been known to 
 acquire poisonous properties from changes in the organic matter 
 which has passed into it from the meat. The process of soak- 
 
276 FOOD PREPARATION AND PRESERVATION 
 
 ing in brine causes much of the extractives and natural salts of 
 the meat to osmose out from it, and the loss of organic mate- 
 rial and salts occurring in this way has been estimated by Liebig 
 and Parkes as equal to fully one third, for myosin itself is solu- 
 ble in strong salt solution. For these reasons salted meats, such 
 as corned beef, require prolonged cooking. Salt meat of all 
 kinds is drier, less digestible, and slightly less nutritious than 
 fresh meat. 
 
 IV. Freezing. — Food may be kept in a frozen condition almost 
 indefinitely. On being thawed, it must be cooked immediately, 
 otherwise decomposition may set in at once, and, omitting milk 
 and cream, food is not easily eaten in an actual frozen state, ex- 
 cepting by the northern Eskimos, who take their meat in that form 
 by preference. 
 
 Meat and fish may be kept for many days frozen in blocks of ice 
 without losing much in flavour, but vegetables are not as good when 
 cooked after freezing. 
 
 In 1867 Dr. Carl von Baer reported to the Royal Society of 
 London the discovery in arctic Siberia of the body of a frozen 
 mammoth, the meat of which was preserved. As this animal has 
 been extinct since the days of prehistoric man, it afforded an illus- 
 tration of the marvellous preservative power of intense cold. An- 
 other such animal was found, in 1799, being eaten by wolves in 
 Siberia. 
 
 In 1861 the entire bodies of three Swiss guides, who forty-one 
 years before had been buried by an avalanche over the Glacier de 
 Boissons, were found in a state of excellent preservation. With 
 these examples of the influence of cold, it is little wonder that meat 
 may be preserved for a few months in ice and yet be quite fit to 
 eat. In freezing meat for export it is subjected to a temperature 
 of about 20 F. below zero. When quite hard the carcass is 
 sewn in thin cotton cloth and placed in a refrigerating chamber on 
 shipboard, where it keeps in good condition throughout long 
 voyages. 
 
 Meat actually frozen should be cooked as soon as it is thawed, 
 and meat thus preserved is better cooked by roasting than boiling, 
 unless it has been imperfectly thawed, in which case the central 
 portion may remain frozen after the external layers have begun to 
 cook, and when the latter are thoroughly roasted, the inside may 
 still be found almost raw. Frozen meat loses 10 per cent of its 
 nutritive value in cooking. Such meat has been transported in fresh 
 condition as far as fifty miles inland in the Philippines. 
 
 V. Refrigeration. — The process of refrigeration does not involve 
 the actual freezing of meat or vegetables, but implies their preserva- 
 tion in chambers at a temperature which is maintained but a few 
 degrees above the freezing point. This causes less alteration in 
 
FOOD CONCENTRATION— CONDENSED FOOD 2JJ 
 
 flavour than freezing. The cold is artificially generated, and beef, 
 fish, fruits, and vegetables are now successfully transported for 
 thousands of miles in refrigerator cars and rooms fitted for the 
 purpose on steamships. 
 
 The refrigerating processes applied to the preservation of meat, 
 etc., are several. In most of them the actual reduction of tempera- 
 ture of the meat is maintained by cold air and not by contact 
 with ice. 
 
 One method consists in the adaptation of the principle that com- 
 pressed air on expanding derives the energy for its expansion from 
 heat, which it abstracts from all surrounding bodies. The liberation 
 of strongly compressed air, therefore, produces intense local cold in 
 its immediate vicinity. The air is originally compressed by a force 
 pump, and the heat which is developed by the compression is re- 
 moved by a circulating stream of cold water. The cooled com- 
 pressed air is then liberated with the effect described. Other 
 apparatus is constructed on the principle of ice machines, which 
 are operated by evaporating ammonia, which produces extreme 
 cold. 
 
 The keeping of meat by refrigeration is rapidly superseding the 
 canning process for this kind of food, over which it has many decided 
 advantages. Between 15 and 20 per cent of all the mutton eaten 
 in Great Britain is brought from New Zealand and the River Plate 
 in a refrigerated condition. 
 
 Major Woodruff, U. S. A., writes : " The French Government 
 is taking the initial step towards applying this new industry to the 
 purposes of war. They have succeeded in keeping dressed beef in 
 a perfect condition for three or four months with the present appli- 
 ances. 
 
 " A moment's thought will show what a revolution this matter 
 of cold storage can make in military practices. It will obviate all 
 necessity of keeping live cattle near the army, a system that so 
 often results in diseased animals and fatal epidemics among the 
 soldiers. It will help to wipe out of existence all the salt meats 
 formerly supplied, and will thus avoid that large list of diseases of 
 stomach, bowels, and nutrition that salt meats have been accused 
 of causing." 
 
 VI. Sterilisation. — By sterilisation of food is meant the process 
 of rendering it germ-free by heat, and it includes the preservation 
 of such food in sterilised vessels. Practically all thoroughly cooked 
 food is for the time being " sterilised," and overdone meat keeps 
 longer than underdone meat, for if the outer layers are firmly coag- 
 ulated and dried by the heat of boiling or roasting, they form an 
 envelope which is less pervious to the atmospheric air and germs. 
 (See Cooking, pp. 260, 261.) 
 
 Canned food (p. 278) is also sterilised, but the latter term is 
 
278 FOOD PREPARATION AND PRESERVATION 
 
 applied chiefly to milk which has been treated by the method de- 
 scribed on p. 84. 
 
 VII. Exclusion of Air. — Exclusion of air from contact with food 
 is accomplished not only in the process of canning, but by such 
 means as varnishing or covering it with substances which are com- 
 paratively impermeable, as in the case of varnishing eggs, covering 
 fish with oil, or pate de foie gras with lard, etc. 
 
 Eggs undergo decomposition from the entrance of the atmos- 
 pheric air and germs through their shells, and this process may be 
 prevented, sometimes for several years, by covering fresh eggs with 
 almost any substance which is more impermeable than their shells, 
 such as gum, fat, butter, oil, beeswax, or fresh milk of lime. The 
 sawdust or salt in which eggs are commonly packed serves the 
 double purpose of insuring safety in transportation and excluding 
 to some degree the air. Similarly meat may be preserved by coating 
 it with paraffin, gelatin, collodion, or layers of powdered charcoal 
 or of lard after the manner of potted meats. Beef has been sent in 
 good condition from Australia to England by merely dipping it into 
 hogsheads of melted fat, in which it was allowed to remain after the 
 fat cooled and solidified. The preservation of meats in air-tight 
 skins, like sausages, has long been practised. 
 
 When food is preserved by any of these methods care must be 
 exercised to have it perfectly fresh at the start and to drive off by 
 heat or otherwise any air which may be present in the food itself or 
 in its containing vessel. 
 
 Canning. — The original idea of the preservation of foods by can- 
 ning was that the exclusion of air was the sole object necessary of 
 accomplishment. It is now known, however, that many putrefactive 
 bacteria are anaerobic, and that the food must be thoroughly steril- 
 ised before the can is closed. This should be done by heat, but 
 since it can also be accomplished by the addition of antiseptics, the 
 introduction of the latter is practised by some unscrupulous manu- 
 facturers to the detriment of the public health. 
 
 The process of canning meat or vegetables is conducted as fol- 
 lows : The food is placed in clean new tin cans, filling them as com- 
 pletely as possible. Lids are then tightly soldered on the cans, 
 leaving a minute pinhole opening only for the escape of air and 
 steam. The cans are then immersed in a bath of boiling fluid, such 
 as zinc-chloride solution, having a higher boiling point than the 
 water within the cans. The latter boils, expels at first air, then 
 steam, and thoroughly cooks the food, making it aseptic by killing 
 all germs. Before the cans cool, their minute openings are soldered, 
 and they are then ready for storage. 
 
 The long boiling of meat in this manner toughens its fibres by 
 hardening the syntonin. Such meat is apparently tender, but in 
 reality it is not very digestible (Williams). 
 
FOOD CONCENTRATION— CONDENSED FOOD 279 
 
 To avoid the necessity of cooking food at a high temperature 
 in order to exclude the air, various modifications in the process of 
 canning are employed. One of these — McCalFs — is based on the 
 disinfection of the air by sodium sulphite. In another process sul- 
 phurous acid and nitrogen are used to replace the air. 
 
 H. W. Wiley, who has made an exhaustive study of canned 
 foods, says, in an instructive report on Foods and Food Adulter- 
 ants, made by him for the United States Department of Agriculture 
 (Bull. No. 13, Part VIII): 
 
 " All manner of food is canned, and that at prices which place it 
 within the reach of the humblest pockets. Preserved food has been 
 a great democratic factor, and has nearly obliterated one of the 
 old lines of demarcation between the poor and the wealthy. Vege- 
 tables out of season are no longer a luxury of the rich. ... In the 
 American grocery pineapples from Singapore, salmon from British 
 Columbia, fruit from California, peas from France, okra from Louisi- 
 ana, sweet corn from New York, string beans from Scotland, mut- 
 ton from Australia, sardines from Italy, stand side by side on the 
 shelves."' 
 
 Much light is thrown by Wiley upon the economic value of the 
 substances under consideration in the following important state- 
 ments from the report above quoted : 
 
 " The quantity of dry food material in canned goods varies within 
 wide limits. It is very low in such vegetables as string beans, aspara- 
 gus, etc., and quite high in such materials as canned corn, succo- 
 tash, and other bodies of that description. The lowest percentage 
 of dry matter in string beans of American origin was 4.17. In other 
 words, in buying one hundred pounds of such material the consumer 
 purchases 95.83 pounds of water. 
 
 " The price of the packages of string beans [bought in open 
 market] varied within wide limits, depending both upon the size of 
 the packages and the labels they bore. The highest price paid was 
 thirty-five cents, and the weight of the contents of the package was 
 a little over three pounds. The lowest price paid was ten cents, and 
 this was paid in many instances. The highest price paid, according 
 to the percentage of dry matter, was in sample 10,928, costing thirty 
 cents and containing only two hundred and fifty-four grammes of 
 string beans, 31. 1 grammes of dry matter, and 94.37 per cent of 
 water. The price of the dry matter in this package was nearly 
 one cent per gramme, which would be almost five dollars per 
 pound. The enormous cost of food in canned goods is illus- 
 trated to the fullest extent by this sample, showing in a striking 
 way that such food materials must be regarded in the light of 
 luxuries or condiments rather than as nutrients to support a 
 healthy organism. An expenditure of ten or fifteen cents for a 
 good article of flour or meal will procure as much nutriment for a 
 20 
 
28o FOOD PREPARATION AND PRESERVATION 
 
 family as the investment of three or four dollars in canned goods 
 would. 
 
 " A general view of the digestive experiments must lead to the 
 conviction that the process of canning, especially when preservatives 
 are employed, such as salicylic acid and sulphites, tends to diminish 
 the digestibility of the albuminoid and other bodies. The low per- 
 centage of digestible albuminoids will be remarked with some degree 
 of astonishment in all the analytical tables." 
 
 Of the dangers of poisoning from canned foods Wiley says : 
 '• Vegetables are usually canned in the fresh state, and if they are in 
 any degree spoiled at the time the fact is usually conspicuously evi- 
 dent to the taste, so that the canner cannot afford to use them. 
 Bacterial action seldom occurs in the can without bursting it or 
 rendering it unsalable. Ptomaines may, however, develop where 
 the canned food is allowed to stand for some time after open- 
 ing, though even then this is unlikely in the case of preserved 
 vegetables. 
 
 " It may be said, therefore, that the principal risks to health which 
 may arise from the use of canned foods are those due to the use of 
 preservatives, or to the presence of the heavy metals — copper, tin, 
 lead, and zinc. ... In this country there is no restriction whatever 
 in regard to the character of the tin employed, and as a result of this 
 the tin of some of the cans has been found to contain as high as 12 
 per cent of lead. . . . The analyses of numerous samples of solder 
 employed show that it contains fully 50 per cent of lead. In addi- 
 tion to this there is no care taken to prevent the solder from coming 
 in contact with the contents of the can. It is a rare thing to care- 
 fully examine the contents of a can without finding pellets of solder 
 somewhere therein. 
 
 " Another great source of danger from lead has been disclosed by 
 the analytical work, viz., in the use of glass vessels closed with lead 
 tops or with rubber pads, in which sulphate of lead is found to exist." 
 
 The frequency of poisoning by eating canned lobster, crabs, or 
 shellfish is due mainly to the rapidity with which they decompose 
 and develop ptomaines after the can has been opened. The contents 
 of such a can partially used should not be kept until the next day. 
 
 Canned beef is boiled and steamed under pressure at 250 F. 
 It loses most of its extractives and has the tastelessness, therefore, 
 of meat from which soup has been made. Vegetables may be added 
 to improve the taste, either in the canning process or subsequently 
 during cooking. 
 
 Canned beef should be eaten promptly after opening, for it is 
 liable to spoil within a few hours, especially in tropical climates. 
 Severe gastro-enteric disorders may arise from eating such spoiled 
 meat, and epidemics of such poisoning have been observed in a 
 French garrison at Tours (1898), among the British troops in South 
 
FOOD CONCENTRATION— CONDENSED FOOD 28 1 
 
 Africa (1900), and among our own troops in Cuba (1899). In the 
 latter case much public scandal arose in connection with this subject, 
 and from the further fact that manufacturers do not always resist 
 the temptation to can meats of inferior quality, or which may be 
 already partially decomposed, especially when hurried demands for 
 canned goods are made to meet the exigencies of warfare. At the 
 commencement of the Spanish-American War, in 1898, 7,000,000 
 pounds of canned roast beef were purchased by the commissary de- 
 partment for use by the United States soldiers. 
 
 VIII. Antiseptic and Preservative Substances. — A long list of 
 chemical substances have been used from time to time in the pres- 
 ervation of food, but most of them have been supplanted by the 
 safer process of canning, refrigeration, etc. 
 
 The use of various antiseptic or preservative fluids is designed to 
 prevent the activity of germs and fermentation. Sugar, like salt, in 
 strong solution possesses decided antiseptic powers, and hence the 
 employment of strong sirups for the preservation of fruits, and of 
 sugar itself in making candied fruits. Other harmless preservative 
 materials which are added are oils, chiefly serviceable for keeping 
 fish, and vinegar and spirits of wine for pickling such products as 
 chilies, tarragon, and shallot. 
 
 Vinegar is used to preserve oysters, lobsters, and other sea 
 food, as well as cucumbers, cauliflower, and other vegetables, as 
 " pickles." Spices, mustard, and similar condiments are usually 
 added. 
 
 " Soused " fish, such as mackerel, are immersed in mixtures of 
 cider vinegar flavoured with cloves, nutmeg, parsley, bay, onions, 
 etc. After being " soused " once or twice the food is heated in the 
 fluid to 140 F., flavouring substances are added, such as Worcester- 
 shire sauce, extract of anchovy, and lemons, and the whole is put in 
 air-tight jars (Clark). 
 
 Among the materials sometimes employed for preserving foods 
 may be mentioned the fumes of burning sulphur (sulphurous acid), 
 acetic acid, weak carbolic acid, bisulphite of calcium, and the injec- 
 tion into the blood vessels of meat of alum, chloride of aluminum, 
 etc. Borax, boric and salicylic acids, formaldehyde, and other mate- 
 rials have been extensively used in the preservation of milk, beer, 
 meats, etc. Sodium sulphite is added to preserve chopped meat 
 and Hamburger steak, and a mixture of borax, nitre, and salt is 
 used in sausages. 
 
 A new method of meat preservation has been introduced by 
 a Mr. Jones in England. It consists of injecting the animal the 
 moment after it is killed with a solution of borax, which is so 
 uniformly distributed through the circulation to all the fibres of 
 the meat that but a very small quantity of the antiseptic need be 
 employed. 
 
282 FOOD PREPARATION AND PRESERVATION 
 
 The use of borax and boric acid as food preservatives is so com- 
 mon that it is a matter of great* importance to determine the influ- 
 ence of these substances upon nutrition. This Prof. R. H. Chitten- 
 den and William J. Gies have done. (American Journal of Physiol- 
 ogy, No. I, 1898.) After elaborate experiments upon animals, these 
 authors conclude as follows : Doses of borax up to 5 grammes per 
 diem, continued for some time, do not disturb proteid metabolism or 
 general nutrition. In larger doses borax retards proteid and fat as- 
 similation and increases the weight of feces. Very large doses cause 
 nausea, vomiting, mucous diarrhoea, and lessen the urine secre- 
 tion (through which borax is eliminated). Boric acid in doses 
 amounting to 10 or 15 grains per diem does not affect nutrition 
 or proteid metabolism ; it does not affect the volume of urine or 
 irritate the alimentary canal. Neither drug controls intestinal pu- 
 trefaction. 
 
 " Embalmed beef." This term is applied to meat which has been 
 coated with a preservative antiseptic wash of some sort. A solution 
 of boric acid is sometimes employed, but formalin is used more 
 often. Flies avoid the coating and do not alight upon it. 
 
 Formaldehyde, or formalin, is a strong antiseptic. It is not espe- 
 cially harmful in moderate doses, but Halliburton, of London, has 
 shown that it is especially active in inhibiting the action of the normal 
 digestive ferments. It has proved highly injurious to infants when 
 added to their milk. 
 
 Glycerin has been used as a preservative, but it cannot be em- 
 ployed in any quantity on account of its aperient action. Carbonate 
 of sodium and sugar added to milk will preserve it for ten or twelve 
 days (Yeo). 
 
 It is true of practically all of these latter substances that food 
 preserved by them if used in excess or for any length of time is apt 
 to endanger the normal digestive functions, besides being somewhat 
 less nutritious and more tasteless than other preparations. The use 
 of many of them has been suppressed by law on account of their 
 injurious properties, and the addition of salicylic acid to beer, milk, 
 and other forms of animal food is everywhere condemned. 
 
 Substitutes for Food 
 
 Men are often placed under conditions in which, from poverty or 
 exposure, sufficient quantities of food cannot be obtained. Under 
 these circumstances, the craving of hunger may be diminished and 
 the actual tissue waste may be retarded by the substitution of cer- 
 tain mild stimulants and beverages. Tea, coffee, and tobacco all 
 possess moderate action in this respect, and alcohol, under such 
 conditions, is both a stimulant and a food. The natives of various 
 barbarous or semicivilised countries, while performing long feats 
 
FOOD CONCENTRATION— CONDENSED FOOD 283 
 
 of marching, being often unable to obtain sufficient food with regu- 
 larity, make use of a variety of different substances for the purpose 
 above indicated. Among these may be mentioned betel nut, kola 
 nut, Siberian fungus, the cocoa leaf, and pepperwort, which are 
 chewed from time to time ; hasheesh and opium, which are both 
 eaten and smoked ; mate, and various forms of alcoholic fermented 
 drinks. All these substances are used to enable men to prolong 
 periods of fasting. 
 
 Quantity of Food Required 
 
 The quantity of food required to maintain the body in vigour 
 depends upon the following conditions : 
 
 1. External temperature. 2. Climate and season. 3. Clothing. 
 4. Occupation, work, and exercise. 5. The state of individual health. 
 6. Age. 7. Sex. 
 
 In civilised communities, where cooking is a fine art, the num- 
 ber and variety of food preparations is so great that the appetite is 
 often stimulated beyond the requirements of the system, and conse- 
 quently more food is eaten than is necessary or desirable to maintain 
 the best standard of bodily health and vigour. 
 
 Persons in this country who live in comfortable circumstances 
 often eat a dozen or fifteen ounces of solid food at breakfast, and 
 again at luncheon, and perhaps thirty ounces more at dinner, making 
 a total of, say, fifty-five or sixty ounces, to which are added only 
 fifty or fifty-five ounces of fluids. This is about a third more than 
 the amount of solids actually needed, forty ounces of solid food 
 (which equals twenty-three ounces of water-free food) being a fair 
 average for the daily necessities of most persons, one fourth of which 
 should be animal and three fourths vegetable food. They eat too 
 much and drink too little fluid in proportion. (See Water, p. 19.) 
 
 Gluttony results in overdevelopment and overwork of the digest- 
 ive apparatus. The stomach and bowels become enlarged, the liver 
 is engorged, and a predisposition is established to degenerative 
 changes, fatty heart, etc. (See Overeating.) 
 
 The most northern Eskimos, for example, who often eat but one 
 meal a day and then gorge themselves with tough meat, develop big 
 jaws and distended abdomens (Cooke). Hayes described Eskimos 
 who ate daily from twelve to fifteen pounds of food, about one third 
 of which was fat, and the rest mostly meat ; and Captain Hall, when 
 on his arctic expedition, declares that he saw a native consume 
 twenty pounds of raw meat and drink a quart of train oil within 
 twenty-four hours. 
 
 It is stated by competent students of dietetics that more disease 
 arises from abuse of food in regard to both quantity and quality than 
 from abuse of drink. 
 
284 FOOD PREPARATION AND PRESERVATION 
 
 Sir Henry Thompson says (Diet in Relation to Age and Activ- 
 ity) : " More mischief in the form of actual disease, of impaired 
 vigour, and of shortened life accrues to civilised man, so far as I have 
 observed in our own country and throughout western and cen- 
 tral Europe, from erroneous habits in eating than from the habit- 
 ual use of alcoholic drink, considerable as I know the evil of that 
 to be." 
 
 1. The external temperature increases the rate of oxidation pro- 
 cesses in the body as it becomes colder by stimulating- the respira- 
 tion and circulation, and there is a consequent increased demand 
 for food. 
 
 2. Climate and season influence the quantity of food eaten. Cold, 
 bracing atmosphere stimulates the appetite, tempts one to exercise 
 vigorously, and hence demands a larger consumption of fuel or food. 
 A hot climate or season, with enervating, moist air, disposes man 
 to languor and inactivity, and diminishes the appetite as well as the 
 need for food. 
 
 3. Abundant clothing in a cold climate conserves the body heat, 
 and less food is therefore required to maintain life than if the body 
 is but scantily clad. 
 
 4. Exercise and muscular work also promote oxidation in the 
 tissues and augment waste production from the muscles. This waste 
 must be replaced, and energy must be supplied for work by addi- 
 tional consumption of food. Outdoor work demands more food 
 than indoor work, and mental labour less than physical. Where 
 men are fed upon a carefully regulated diet — as in prisons — it is' 
 found that those who are performing hard labour require about one 
 fifth more solid food than the others. The hard-labour prison diet- 
 ary in England comprises fifty ounces of solid food, chiefly bread 
 and vegetables. (See Diet in Prisons.) 
 
 5. The state of health of the individual greatly modifies the 
 amount of food required both indirectly, through influencing exer- 
 cise and work, and directly, by the local condition of the digestive 
 system. 
 
 Feeble and inactive persons may live on a third or less of the 
 ordinary ration. Patients having chronic, purulent discharges, such 
 as come from old sinuses, empyema, and tubercular abscesses, need 
 large quantities of food — if they can digest it — to maintain their 
 strength against the constant drain on their systems. 
 
 The nursing mother should have abundant food, for she must 
 eat for two. 
 
 6. The age of the individual not only modifies the absolute 
 amount of food required, but also the relative quantity in proportion 
 to body weight. In the first year of life the infant grows six or 
 eight inches, and at the end of a twelvemonth it should weigh two 
 or three times as much again as at birth. This rapid growth necessi- 
 
FOOD CONCENTRATION— CONDENSED FOOD 285 
 
 tates a relatively larger consumption of food than at any other period 
 of life, and hence the child is fed at first once every two hours, and 
 later every three hours. During the second year the proportionate 
 growth is half that of the first year, and during the third year it is 
 one third that of the first. After the third year the weight and growth 
 increase more uniformly, but the child must still have a large relative 
 quantity of food, a great proportion of which must be tissue-forming 
 — i. e., nitrogenous. 
 
 The following table is given by Prof. Arthur Goss (U. S. De- 
 partment of Agriculture, Bulletin No. 54) : 
 
 One meal of boy 14 to 16 years of age, inclusive, equivalent to 0.8 meal of man. 
 One meal of girl 14 to 16 years of age, inclusive, equivalent to 0.7 meal of man. 
 One meal of child 10 to 13 years of age, inclusive, equivalent to 0.6 meal of man. 
 One meal of child 6 to 9 years of age, inclusive, equivalent to 0.5 meal of man. 
 One meal of child 2 to 5 years of age, inclusive, equivalent to 0.4 meal of man. 
 One meal of child under 2 years of age equivalent to 0.3 meal of man. 
 
 The rapidly growing, active boy often eats more animal food than 
 the adult, and the middle-aged man eats more than the aged. A 
 man of seventy years may preserve good health on a quantity of 
 food which would soon starve his grandson. 
 
 7. Sex influences to a considerable extent the quantity of food 
 consumed, but allowance must be made for totally different habits 
 of life. There are many women w T ho eat as much as men, but the 
 majority require less food, even when doing the same work. Under 
 equal conditions in penal institutions men require about one fifth 
 more solid food than women. Female factory operatives eat from 
 •one tenth to one fifth less food than men. Prof. Arthur Goss gives 
 the equivalent that one meal of woman averages 0.8 meal of man 
 at moderate muscular labour. 
 
 Mrs. E. H. Richards, as the result of observations (Food as a 
 Factor in Student Life) upon 130 young women students at the 
 University of Chicago, whose average weight was 120 pounds, gives 
 the following table of food consumption in grammes per diem : 
 
 Protein 120 
 
 Fat 161 
 
 Carbohydrates 4 02 
 
 Total 659 
 
 Potential energy in calories 3.3S3 
 
 Women, on the average, weigh less than men, take less exercise, 
 work less, and live less in the open air, and hence require less food. 
 As a consequence of their habits of life they are more liable to dys- 
 pepsia and constipation, which are also factors in reducing the quan- 
 tity of their food below the standards for men. There are naturally 
 many exceptions to all these general statements. 
 
 It is ordinarily impossible or impracticable to definitely weigh the 
 
286 
 
 FOOD PREPARATION AND PRESERVATION 
 
 _ 
 
 food for individual consumption, but where large numbers of men 
 are being fed by contract in institutions, or as sailors or soldiers, or 
 on exploring expeditions, it becomes necessary to estimate carefully 
 the quantity of food required per diem to maintain normal health and 
 vigour. To facilitate such estimates, tables have been carefully com- 
 puted based upon the nutrient value of different foods. 
 
 Quite exceptionally, persons are observed who subsist in good 
 health upon an abnormally small quantity of food. They usually do 
 but little work, and they are often, but not always, advanced in 
 years. (See Food in Old Age, p. 308.) 
 
 Fothergill referred to the case of one Wood, a miller of Billericay, 
 who for eighteen years subsisted solely upon a daily allowance of 
 sixteen ounces of flour, which he ate as sea biscuit made into a pud- 
 ding. By this diet he reduced his figure from extreme corpulency 
 to normal size, and maintained good bodily vigour. 
 
 In the preparation of food to be eaten it is customary to allow 
 10 per cent of waste in calculating the gross quantity for dietaries 
 of institutions, army rations, etc. Mrs. E. H. Richards found that 
 this percentage is somewhat too low. 
 
 In computing the quantity of food needed for daily consumption 
 its composition must be taken into account. The estimates of differ- 
 ent authors vary somewhat in regard to the necessary quantity of 
 different kinds of food in a mixed diet, but notwithstanding this 
 there is a general correspondence between them. The chief dis- 
 crepancy concerns the amount of fat to be eaten, and it will be 
 noticed in the following tables that, as a rule, when the fat is cut 
 down the carbohydrate estimate is correspondingly increased. 
 
 Standard Daily Diet for an Adult Male at Ordinary Work 
 Computed in grammes. 
 
 Albuminates 
 
 Fats 
 
 Carbohydrates 
 
 Salts 
 
 Total water-free food.. . 
 
 Mole- 
 
 Pettenkofer 
 
 schott. 
 
 and Voit. 
 
 130 
 
 137 
 
 84 
 
 117 
 
 404 
 
 352 
 
 30 
 
 30 
 
 648 
 
 636 
 
 Ranke. 
 
 465 
 
 Play- 
 fair. 
 
 IOO Ilg 
 
 IOO 51 
 
 24O ; 530 
 
 25 
 
 700 
 
 Foster. 
 
 Lan- 
 dois. 
 
 133 
 
 95 
 422 
 
 I20 
 
 90 
 
 330 
 
 650 
 
 540 
 
 Dujardin- 
 Beaumetz. 
 
 124 
 
 55 
 430 
 
 609 
 
 Healthy Adult Man, Abundant Diet and Rest (Bauer) 
 
 
 Taken in. 
 
 Consumed. 
 
 Stored up. 
 
 Albumin 
 
 137 
 117 
 
 352 
 
 137 
 
 52 
 352 
 
 
 Fat 
 
 65 
 
 Carbohydrates 
 
 
 
FOOD CONCENTRATION— CONDENSED FOOD 
 
 287 
 
 An Ideal Ration of Solid Food (Mrs. E. H. Richards) 
 
 Material. 
 
 AMOUNT. 
 
 PROTEID. 
 
 FAT. 
 
 CARBOHYDRATES. 
 
 Calories. 
 
 Grms. 
 
 Oz. 
 
 Grms. 
 
 Oz. 
 
 Grms. 
 
 Oz. 
 
 Grms. 
 
 Oz. 
 
 Bread 
 
 453-6 
 
 226.8 
 
 226.8 
 
 28.3 
 
 113- 4 
 453-6 
 28.3 
 14.17 
 
 16 
 
 8 
 8 
 1 
 
 4 
 16 
 
 1 
 * 
 
 31-75 
 34- 02 
 12.52 
 6.60 
 3.63 
 18.14 
 
 0.14 
 
 1. 12 
 I.20 
 O.44 
 O.23 
 O.I3 
 O.64 
 
 2.26 
 
 H-34 
 2.04 
 7.50 
 4-42 
 
 18.14 
 
 12.27 
 
 0.08 
 0.40 
 0.07 
 0.26 
 0.16 
 0.64 
 
 257-28 
 
 9.60 
 
 4.88 
 
 90.72 
 
 27.36 
 
 4.04 
 
 0-34 
 O.I7 
 3.20 
 O.96 
 
 1,206.82 
 
 Meat 
 
 243-72 
 70.OI 
 135.42 
 75-55 
 613.21 
 112. 17 
 118.62 
 
 Oysters 
 
 Breakfast cocoa. 
 Milk 
 
 Broth 
 
 Sugar 
 
 Butter 
 
 
 
 Total 
 
 
 
 106 . 80 
 
 
 57-97 
 
 
 389.84 
 
 
 2,574.60 
 
 An Ideal Ration of Liquid Food (Mrs. E. H. Richards) 
 
 Material. 
 
 Beef broth or consomme" 
 
 To which has been added one 
 
 large egg, minus shell 
 
 Dried fruit soup 
 
 Lemon jelly 
 
 Whole milk 
 
 Rice or arrowroot 
 
 Grape sugar, or some one of the 
 
 prepared foods (dry) 
 
 Total. 
 
 Amount. 
 
 Proteid. 
 
 Fat. 
 
 
 Grammes. 
 
 Gr amines. 
 
 I pint. 
 
 20.5 
 
 0-5 
 
 2 oz. 
 
 7.1 
 
 6.8 
 
 1 quart. 
 
 £ pint. 
 
 1 quart. 
 
 3 oz. (dry). 
 
 "b.'s 
 
 34.0 
 
 6.3 
 
 36.0 
 o-3 
 
 4 oz. (dry). 
 
 2-5 
 
 
 2.5 quarts to 
 3.0 quarts.* 
 
 76.9 
 
 43-6 
 
 Carbo- 
 hydrates. 
 
 Grai 
 
 IOO. O 
 
 12-5 
 44.O 
 67.2 
 
 100.0 
 
 Calories. 
 
 323-7 
 
 9I.67 
 4IO.OO 
 
 77.90 
 65I.OO 
 304.II 
 
 420.25 
 
 2,043.63 
 
 * According to how the rice is given. 
 A Common Invalid Ration too Low in Proteid (Mrs. E. H. Richards) 
 
 1 pint of beef broth or consomme" 
 
 1 pint of dried fruit soup 
 
 1 pint of lemon whey 
 
 1 pint of Imperial Granum, containing 3 oz. 
 
 2 quarts of liquid. Total 
 
 Proteid. 
 
 Fat. 
 
 Carbo- 
 hydrates. 
 
 Grammes. 
 
 Grammes. 
 
 Gramtnes. 
 
 20.5 
 
 0.5 
 
 50 
 
 6.8 
 
 21.5 
 O.4 
 
 79 
 64 
 
 27-3 
 
 22.4 
 
 193 
 
 Calories. 
 
 88.7 
 205.O 
 
 521.7 
 294.O 
 
 1,109.4 
 
 A Ration Rich in Proteid— 
 
 -after Acute Disease (Mrs. E 
 
 . H. Richards) 
 
 Material. 
 
 Amount. 
 
 Proteid. 
 
 Fat. 
 
 Carbo- 
 hydrates. 
 
 Calories. 
 
 
 Grms. Oz. 
 453.6 16 
 453.6 16 
 453.6 16 
 453-6 16 
 
 I4-I7 i 
 56.7 2 
 
 Grammes. 
 
 31-75 
 
 64.04 
 
 29.02 
 
 4.60 
 
 O.14 
 
 Grammes. 
 2.26 
 22.68 
 18.OO 
 
 3-25 
 12.27 
 
 58.46 
 5-84 
 
 Grammes. 
 
 257.28 
 
 39-00 
 1. 14 
 
 54-72 
 352.14 
 
 35-21 
 316.93 
 
 I,205.8l 
 
 Meat 
 
 487.62 
 
 
 444 • 48 
 
 
 53-43 
 
 Butter 
 
 118.62 
 
 Sugar 
 
 224-35 
 
 
 
 
 
 129-55 
 12.95 
 
 2,746.12 
 
 Less 10 per cent for indigestibility 
 
 
 274.61 
 
 Total 
 
 
 II6.60 
 
 52.62 
 
 2,534.31 
 
 
 
 
288 
 
 FOOD PREPARATION AND PRESERVATION 
 
 Table compiled by Mrs. E. H. Richards and Miss Marion Talbot 
 One day's food, at the University of Chicago, calculated to determine the amounts 
 and proportions of the various constituents and their comparison with the general 
 average. 
 
 Pounds. 
 
 
 Per cent 
 proteid. 
 
 Per cent 
 fat. 
 
 Per cent 
 
 carbo- 
 hydrate. 
 
 Pounds 
 
 protein 
 
 net. 
 
 Pounds 
 fat net. 
 
 Pounds 
 carbo- 
 hydrate 
 net. 
 
 Calo- 
 ries. 
 
 50.O 
 9O.O 
 
 45 .0 
 
 4.0 
 
 77.0 
 
 3.o 
 
 192.0 
 
 13.0 
 
 15.0 
 
 15.0 
 
 6.0 
 
 Stew and cold meat. 
 
 White potatoes 
 
 Sweet potatoes 
 
 2I.O 
 
 1.8 
 
 i-5 
 
 34.o 
 
 ii-5 
 1.3 
 
 3-5 
 3-o 
 2.0 
 
 8.0 
 0.2 
 O.4 
 
 7-5 
 
 1.8 
 
 3-7 
 12.0 
 
 83.0 
 
 19. I 
 26.O 
 
 70.0 
 83.O 
 
 4-7 
 
 3-0 
 
 0.5 
 
 96-5 
 
 65.0 
 
 11. 
 
 19.7 
 
 IO.5 
 1.6 
 0.7 
 1-4 
 
 8.9 
 
 4.0 
 
 O.I8 
 
 0.2 
 
 0.3 
 1.4 
 
 
 
 17.2 
 
 11. 7 
 
 
 Flour and grain. . . . 
 
 53-9 
 2-5 
 9.0 
 0.4 
 
 
 Milk 
 
 6.8 
 0.4 
 0.3 
 
 7-i 
 
 1.6 
 
 12.5 
 
 
 Cream 
 
 
 Butter 
 
 
 
 14.5 
 
 Prunes 
 
 3-5 
 1.0 
 
 4.85 
 12.5 
 20.0 
 19.0 
 15.0 
 
 12.0 
 
 15.0 
 
 5-o 
 
 22.0 
 
 0.2 
 
 
 4.0 
 0.8 
 5.o 
 
 
 9.0 
 
 Oranges, less 20 per 
 cent waste 
 
 Bananas, less 50 per 
 cent waste 
 
 
 50.0 
 
 7.2 
 41.0 
 26.0 
 
 1-3 
 
 0.9 
 8.2 
 5.0 
 2.1 
 
 ' ' 0.8 ' ' 
 6.2 
 i-3 
 3-i 
 
 
 
 
 
 
 
 
 14.0 
 
 Steak 
 
 
 
 
 
 
 657.2 
 
 
 
 
 
 48.3 
 7-9 
 
 38.68 
 2.06 
 
 119. 
 23.6 
 
 
 76.0 
 
 (Less turkey, lamb, 
 and bread left over) 
 
 
 
 
 
 
 
 
 
 
 581.2 
 
 Divided by 130. . . . 
 
 
 
 
 40.4 
 
 36.62 
 
 Q5 -4 
 
 
 
 
 
 
 
 4.4 Per nerson. nutrients. 
 
 
 
 
 0.310 
 
 Grammes. 
 I26.5 
 
 0.281 
 
 Grammes. 
 
 114. 7 
 
 O.733 
 
 
 
 
 
 
 Grammes. 
 332.0 
 
 2,946 
 2,953 
 
 
 Daily average for the 
 6 months, nutrients 
 
 
 
 
 108.0 
 
 102.0 
 
 381.0 
 
 
 
 ! 
 
 Average Daily Dietary for an Adult Man (Dujardin-Beaumetz) 
 
 Albuminates 124 grammes. 
 
 Carbohydrates 430 " 
 
 Fat 55 " 
 
 This would correspond with a bread-and-meat ration of — 
 
 White bread , 819 grammes (about 28 oz.). 
 
 Meat 259 " (about 9 oz.). 
 
 As a fair average for computation it may be said that 300 grains 
 of nitrogen and 4,800 grains of carbon are daily required. 
 
 In order to obtain the nitrogen necessary for the system from a 
 diet composed exclusively of starchy food — as, for example, pota- 
 toes — it would be necessary to eat ten pounds. If bread alone is 
 eaten, four pounds would be required, and this contains more than 
 
FOOD CONCENTRATION— CONDENSED FOOD 
 
 289 
 
 twice the amount of carbon needed. About fifteen pounds of cab- 
 bage would have to be eaten for the same purpose. On the other 
 hand, to obtain sufficient carbon from an exclusive meat diet at least 
 six pounds of beef must be consumed. If eggs were used exclu- 
 sively, about twenty-three pounds would have to be eaten. An 
 ordinary lump of sugar is the food equivalent of an ounce of potato. 
 A quart of milk, three fourths of a pound of beef, and five ounces 
 of bread are all approximately equal in nutrient value. 
 
 Years of age 
 
 4 8 12 16 20 24 28 32 36 40 44 48 52 56 
 
 64 68 72 76 
 
 ;340 
 
 .£260 
 
 £220 
 
 £ 
 
 140 
 
 
 
 
 
 
 
 ^s 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 */ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 } 
 
 y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 tf 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 tf 
 
 y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 fg£ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 // 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Approximate quantity, in grammes, of different classes of foods consumed in twenty- 
 four hours, computed according to age. (Mrs. E. H. Richards.) 
 
 The following table from Landois and Stirling is arranged to 
 show the total quantity of each single food which it would be neces- 
 sary to eat in order to obtain the requisite protein on the one hand 
 (column A) and the requisite carbohydrates on the other (column B). 
 For the purpose of comparison these authors estimate the necessary 
 daily amount of carbohydrates at 448 grammes and the necessary 
 proteids at 130 grammes: 
 
 Rice 
 
 Wheat bread 
 
 Lentils 
 
 Peas 
 
 E gg s 
 
 Rye bread. . . 
 
 Cheese 
 
 Potatoes.. . . , 
 Beef 
 
 2,562 grammes. 
 
 572 grammes. 
 
 1,444 
 
 625 
 
 491 
 
 806 
 
 582 
 
 819 
 
 968 
 
 902 " 
 
 2,875 
 
 930 " 
 
 388 
 
 2,011 " 
 
 10,000 " 
 
 2,039 " 
 
 614 " 
 
 2,261 " 
 
29O FOOD PREPARATION AND PRESERVATION 
 
 If a man doing hard labour were to attempt to live upon milk 
 alone he would require fully ten pints a day to obtain the carbon 
 necessary. Either of these quantities of food greatly overtaxes the 
 digestive system. In fact, it would be wholly impossible for most 
 people to eat meals of this character. The food would be too heavy ; 
 it would take too long a time to consume it, and it would be too 
 monotonous. It becomes absolutely essential, therefore, for man to 
 so regulate the composition of his diet as to properly balance its 
 necessary chemical elements. This balance is best secured by a diet 
 in which nitrogen bears the relation to carbon of 1 to 3.5 or 4. In 
 bread the proportion of carbon to nitrogen is 3.0 to 1, and in meat it 
 is reversed, and stands 1 to 3.5. Munk and Ufflemann state that the 
 ratio between animal and plant albumin in the diet should be 3 to 7. 
 
 It is also more economical for the workingman to have fats and 
 sugar in his diet and not to live exclusively on meat. The con- 
 tractor soon learns that ill-fed men do poor and insufficient work. 
 The force must be developed out of the latent energy of matter 
 whether bricks are to be carried to the top of a building by a man 
 or a hoisting machine. The carbon of coal is oxidised to develop 
 force for lifting through the engine. The carbon in all the forms 
 of fats, starches, and sugars is utilised in the body of man to enable 
 him to do the same work. The labourer does right therefore when 
 he eats bacon with his cabbage and treacle with his oatmeal. There 
 is one fallacy in the above comparison that must not be overlooked, 
 which is that the more fuel the machine consumes, the more work 
 it does ; this applies to man only within narrow limits, and too large 
 a quantity of food promptly brings him into trouble with his digestive 
 organs. (See Overeating.) 
 
 The amount of nutrient material required per diem by a healthy 
 adult male doing moderate manual labour is summed up as follows : 
 
 Protein 
 Fat 
 
 Atwater. 
 
 125 grammes. 
 125 
 
 Carbohydrates 500 " 450 
 
 This proportion is represented by Billings as follows : 
 
 . Lean meat 20 ounces. 
 
 Bread 22 " 
 
 Potatoes 10 " 
 
 Three 'or four cups of coffee. 
 
 According to Chambers, the average adult at ordinary labour 
 obtains enough food in a day if he eats one pound of meat and two 
 pounds of bread or its equivalent, provided no peculiarities of size, 
 health, or climate are to be accounted for. 
 
FOOD CONCENTRATION— CONDENSED FOOD 29 1 
 
 The average percentage of water in bread is 37 per cent ; in 
 cooked meat, 54 per cent ; in vegetables, 70 per cent or more 
 (Letheby). 
 
 " Assuming the food average as 23 water-free ounces daily and 
 the mean body weight 150 pounds, the body receives yj-g- of its own 
 weight in water-free solids. The range in different persons is -^ to 
 y^o of the body weight " (Parkes). 
 
 This problem may be differently stated, reckoning in the water 
 with the solid food as follows : 
 
 A robust man weighing 144 pounds may consume j% of his body 
 weight, or 6 pounds, in nourishment per diem, divided as follows : 
 
 Inorganic food — i. e., water and salts — 3.5 pounds. 
 
 Organic food (animal food, 1 pound; vegetable food, 1.5 pound), 
 2.5 pounds. 
 
 It is usually better, unless active exercise is being taken, to eat a 
 little less meat and more vegetable food, as previously stated, and 
 to drink a little more fluid. 
 
 The average amount of dry food by weight required for breakfast 
 may be put at 8 ounces, for luncheon 6 ounces, for dinner 9 ounces. 
 The " middle diet " at Guy's Hospital, which is supplied to the ma- 
 jority of the patients, furnishes 29.5 ounces of solid food per diem 
 in addition to liquids. Of course such persons are taking no active 
 exercise. This is equivalent to 17 ounces of dry or water-free food. 
 It consists of 4 ounces of meat (cooked), 12 ounces of bread, 8 ounces 
 of potatoes, 1 ounce of butter, 0.75 ounce of sugar, 0.25 ounce of 
 tea. and 2.5 ounces of milk. 
 
 Nitrogenous material should constitute " one fifth of the water- 
 free food, or from 4 to 5 ounces for active life. The ordinary meat 
 rations for soldiers is 12 ounces per diem, of which 20 per cent, or 2.4 
 ounces, is deducted for waste of bone, tendon, etc. For inactive life, 
 from 3 to 3.5 ounces " (Pavy). This diet will completely replace 
 the nitrogen eliminated from the body. " Two pounds of bread and 
 three fourths of a pound of uncooked beef contain as nearly as possi- 
 ble the right proportion of carbon and nitrogen." This makes 44 
 ounces of solid food. Water-free meat contains about 0.20 per cent 
 nitrogen. 
 
 Fat added to the daily diet in the proportion of about one ounce 
 of butter not only supplies necessary force and tissue elements, but 
 acts favourably in promoting the proper assimilation of the other 
 classes of food and diminishing to a great extent the wear and tear 
 of the tissues. With active work, especially in a cold atmosphere, 
 more than double this amount is consumed with advantage, and even 
 2.5 ounces form an average allowance for many classes of workmen. 
 
 The carbohydrates are required in quantities between 14 and 22 
 ounces, their main use being to convey energy for heat and mechan- 
 ical work. 
 
292 FOOD PREPARATION AND PRESERVATION 
 
 The quantity of salts required for daily use varies from 0.5 to 1 T ^ 
 ounce. This quantity is less affected by conditions of temperature 
 and exercise than are other food constituents. Chaumont estimates 
 that a man of 150 pounds can do an average day's work upon a diet 
 of albuminoids, 4.5 ounces ; fats, 3.75 ounces ; carbohydrates, 18 
 ounces; and salts, iy 1 ^ ounce. These estimates are of water-free 
 constituents. 
 
 Water. — The amount of water drunk per diem is usually less than 
 should be taken. Many persons believe that it is injurious to drink 
 much fluid with their meals and forget to take any between, and 
 as a result not enough water is consumed to thoroughly dissolve and 
 eliminate the waste matter of the system. The average quantity of 
 urine voided is 52 ounces, 10 ounces more are lost from the surface 
 of the lungs, and 18 ounces from the skin. This total of 80 ounces 
 must be daily replaced to maintain the equilibrium of the body. 
 The solid food of a mixed diet has been shown above to contain 
 on the average 50 or 60 per cent of water, so that about 25 ounces 
 of water are taken into the system daily as an integral part of the 
 food. In addition, at least 55 ounces or more should be drunk either 
 as plain water or in various beverages. 
 
 Another way of stating the above facts is that the average quan- 
 tity of solid food (not water-free) which is required by adults is 
 between 40 and 45 ounces per diem, and the total amount of food, 
 including all fluids, should be from 95 to 120 ounces, of which three 
 fifths or four fifths is composed of water, and the remaining one 
 or two fifths of water-free substance. These estimates are only 
 intended for general application, and there are necessarily many 
 exceptions. 
 
 The ratio of solid to liquid food varies in health with the greater 
 or less preponderance of fluids, the solid being more constant. It is 
 commonly nearly 1 to 2, but many persons reduce it to 1 to 1.5, or 
 even 1 to 1. 
 
 Muscular exertion demands an increase in both solid and fluid 
 food, but the former is more essential than the latter, if the exertion 
 be prolonged. 
 
 When a man does increasing work, unless his food be proportion- 
 ately increased, he begins to consume his own tissues until their loss 
 so weakens him that he is obliged to desist from a part, at least, of 
 his labour. Should the disproportion between output and income 
 continue, he becomes so enfeebled as to be liable to the inroads of 
 hardship in various forms — especially those of cold and zymotic 
 diseases. 
 
 It is estimated that in each twenty-four hours a man of normal 
 health and physique absorbs, including the respiratory oxygen and 
 water, about 7.25 pounds of material, which he eliminates in a corre- 
 sponding quantity of waste, about three fifths of which is water. 
 
FOOD CONCENTRATION— CONDENSED FOOD 293 
 
 One of the best means of determining the proper amount of food 
 to sustain a man in good health is derived from a study of the ex- 
 periences of arctic explorers. Their men are subjected to great 
 hardships and feats of endurance, as well as to intense cold. From 
 the nature of the expeditions no superfluous food can be carried, and 
 yet the chief factor in success is the maintenance of good bodily 
 vigour. For these reasons the rations for arctic travellers have been 
 most carefully established, and a brief review of them will throw 
 much light upon this interesting subject. 
 
 The Peary expedition to the north pole in 1887 used 19 ounces 
 of solid food as the ration for the sledging expedition, but this soon 
 proved to be inadequate in the cold of the arctic regions. Dr. Ray 
 used 29 ounces, which also proved insufficient, and later 34 ounces 
 of solid food. Various other expeditions have used 32 ounces 
 of solid food, consisting wholly of pemmican, which has been 
 sufficient. 
 
 Molintock, another arctic sledge traveller, used 40 to 48 ounces 
 of food daily. Captain Neary's expedition used 38 ounces of 
 solid food, proportioned as follows : Meat, 20 ounces ; biscuits, 
 14 ounces; potatoes, 2 ounces; sugar, 2 ounces. To this were 
 added chocolate, 1 ounce; rum, 2 ounces; and 1.5 ounce each 
 of tea and tobacco with condiments, making in all 44 ounces of 
 supplies. 
 
 De Long quotes from the physician to his arctic expedition that 
 " alcohol proves a great advantage, keeps off the craving for food, 
 preventing gnawing at the stomach, and has kept up the strength 
 of the men as given — 3 ounces per day." (This was during starva- 
 tion, but, as stated on p. 233, alcohol is injurious to the mainte- 
 nance of robust health in cold climates.) 
 
 While performing active exercise in the cold a diet of 1.5 pound 
 of stewed deer's meat did not prevent hunger, but 1.5 pound of 
 pemmican per diem, with one half ounce of tea and one half ounce 
 of Liebig's extract of meat, supported life for some time. On leaving 
 the ship and starting on their long sledge expedition, the following 
 daily ration was allowed each man by Lieutenant De Long : 
 
 Breakfast 
 
 Pemmican 4 ounces. 
 
 Ham 1 ounce. 
 
 Bread 3 " pieces." 
 
 Coffee 2 ounces. 
 
 Sugar $ ounce. 
 
 Dinner 
 
 Pemmican 8 ounces. 
 
 Liebig's extract , 1 ounce. 
 
 Tea i " 
 
 Sugar $■ " 
 
294 FOOD PREPARATION AND PRESERVATION 
 
 Supper 
 
 Pemmican 4 ounces. 
 
 Tongue 1 ounce. 
 
 Tea \ " 
 
 Sugar £ " 
 
 Lime juice 1 " 
 
 Bread 4 ounces. 
 
 While held fast in the ice, and still on the steamer, the average 
 allowance of food per day was about four pounds, but some com- 
 plained of being hungry on this ration. Several men suffered 
 severely from lead poisoning from the solder used in canning toma- 
 toes, traces of lead being found on examining the contents of the 
 can. The acid of the tomato acts upon the solder, forming a soluble 
 lead salt. The cans, however, had been kept for a period of two 
 years before their contents were eaten (De Long). (See Canning, 
 p. 280.) 
 
 In the voyage of the Jeannette to the arctic zone in the polar 
 expedition of 1879-81 a very liberal diet was allowed the sailors on 
 entering the arctic regions, the average quantity of food allotted per 
 man per diem being a ration of 5.5 pounds. Meat was furnished 
 three times a day. Fat was supplied in the form of pork and butter, 
 and bread and potatoes made the bulk of the starchy diet, constitut- 
 ing about two thirds of the whole amount of food. The diet at first 
 included large quantities of condensed milk, butter, eggs, oatmeal, 
 cheese, and macaroni, together with a great variety of canned fruits 
 and vegetables and dried fruits, such as apples, peaches, dates, figs, 
 prunes, and raisins. 
 
 In Lieutenant A. W. Greely's account of the expedition (Three 
 Years of Arctic Service) he says : " The amount of food per man 
 each day actually eaten in over two years at Fort Conger was as 
 follows : 
 
 Meat 26 . 8 ounces. 
 
 Canned vegetables 10 . o 
 
 Sugar and sirup 5.3 
 
 Farinaceous articles 13.6 
 
 Canned fruits 4.7 
 
 Dried fruits, preserves, fruit, butter, and pickles 2.9 
 
 " This aggregate of 64.3 ounces would doubtless be increased 
 by coffee, chocolate, tea, spices, condiments, etc., to nearly seventy 
 ounces. This amount may reasonably be assumed as the quantity 
 of food necessary for the maintenance of a man's health in a lati- 
 tude such as Conger (81 ° 44' N.), where the actual temperature is 
 4 F. (20° C.)." He adds that tomatoes proved to be the most serv- 
 iceable vegetable, and apples and peaches the best fruits. The bev- 
 erages consisted of coffee, tea, chocolate, cider, and a small quantity 
 of rum, the latter averaging two gills weekly for each man, which he 
 
FOOD CONCENTRATION— CONDENSED FOOD 295 
 
 regarded as beneficial from the effect it had upon the cheerfulness 
 and good humour of the men. Meat in the above table included fat, 
 in the shape of pemmican (four ounces), butter, lard, pork, and 
 bacon. 
 
 The hours for meals were as follows : Breakfast, 7 A. m. Dinner, 
 4 p. m., and two lunches. The latter consisted of hard bread and 
 butter, tea and coffee. The typical menu was as follows : 
 
 Breakfast. — Corn beef, oatmeal, fresh bread, chocolate, or 
 coffee. 
 
 Dinner. — Vegetable soup, baked pork and beans, corn bread, 
 stewed peaches, and coffee. 
 
 On sledging expeditions it was important to reduce the weight 
 and bulk of the food to a minimum ; accordingly in the Greely ex- 
 pedition of 1882 the daily allowance for sledging expeditions was 
 thirty-nine ounces, to which was added an ounce of lime juice. The 
 lime juice was carried solidified in the form of small squares, in 
 which form it proved refreshing and invigorating to the exhausted 
 men. This constituted the ration of the first year, 1882. Greely 
 writes ; z 
 
 " On the above ration of 1882 parties kept the field for forty 
 days in a mean temperature below zero 17.8 C, and returned in 
 health and strength." 
 
 In 1883 the experience of the previous year led him to modify 
 the ration by replacing part of the bread with butter and meat. This 
 modified ration consisted of — 
 
 Meat 22 ounces. 
 
 Butter 2 " 
 
 Vegetables 4 " 
 
 Bread 10 " 
 
 Sugar 2 .. " 
 
 Milk \ ounce. 
 
 Tea or chocolate 1 " 
 
 Salt , i " . 
 
 Pepper uV " 
 
 with an allowance of six ounces of alcohol for cooking the food of 
 a party of three or four people ; therefore the ration contained 
 40.5 ounces besides beverages. Greely says again : " Three fourths 
 of the ration were about equal quantities of pemmican, bacon, and 
 frozen musk-ox meat, while the balance was made up of canned sau- 
 sages and corned beef in about equal quantities " (Three Years of 
 Arctic Service, vol. i, pp. 202, 203). He suggests as a still further 
 improvement that the vegetable ration should consist of three ounces 
 of preserved potatoes, the remaining ounce being replaced by half 
 an ounce each of milk and extract of beef tea, which is the best 
 drink for the arctic regions. It should be chiefly used in the field 
 in the form of an extract. A little coffee is preferable to chocolate. 
 21 
 
296 FOOD PREPARATION AND PRESERVATION 
 
 The latter was found to induce thirst during the day. Tea should 
 be compressed or used as an extract. Curry paste and other power- 
 ful condiments were also found serviceable. Alcohol was not con- 
 sidered necessary as a food. 
 
 During the third winter of his arctic expedition, from November 
 1, 1883, to June 23, 1884, Greely's per capita ration for his entire 
 party was : 
 
 Meat 4.0 ounces. 
 
 Beef extract o . 26 ounce. 
 
 Evaporated potato 0.4 " 
 
 Soup 0.6 " 
 
 Tomatoes 0.3 " 
 
 Butter 0.5 ounce. 
 
 Lard 0.26 " 
 
 Rice 0.1 " 
 
 Raisins o. 16 " 
 
 Tea, compressed 0.3 " 
 
 Peas 0.2 •' I Extract of coffee o . 44 
 
 Corn 0.2 " 
 
 Carrots o. 1 " 
 
 Bread 6.0 ounces. 
 
 Dog biscuit 0.8 ounce. 
 
 Extract of chocolate 0.3 
 
 Milk 0.2 
 
 Mulberries 0.2 
 
 It is noticeable that alcohol is omitted from this ration. C. E. 
 Borchgrevink (First on the Antarctic Continent, 1898-1900) made 
 extensive use of dried vegetables, and such articles as ham, bacon, 
 curry and rice, cheese, dried fish, sardines, jam, marmalade, and 
 cocoa. 
 
 The usual estimate for the total quantity of all food material, 
 including solids, water, and respiratory oxygen as well, which is 
 consumed by a healthy adult male per annum is one and a half ton. 
 
 Following is the estimate of total food supply for eighteen 
 months for one man in the Yukon region. The total weight, about 
 one ton, is considerably less than that of food ordinarily eaten, owing 
 to the fact that fruit and vegetables must be carried in an evaporated 
 condition. 
 
 " The chief items are 600 pounds of flour, 300 pounds of bacon, 
 150 pounds each of beans and sugar, 75 pounds each of rolled oats 
 or other mush material and cornmeal, 50 pounds of rice, six dozen 
 cans of condensed milk, 35 pounds of butter in sealed cans, 150 
 pounds of evaporated vegetables, 100 pounds of evaporated fruit, 
 50 pounds of prunes and raisins, 30 pounds of dried fish, 40 pounds 
 of coffee, with baking powder, soda, salt, pepper, ginger, mustard, 
 yeast cakes, tea, soap, matches, lime juice (very important), dried 
 beef, extract of beef, soups in tins, sausage, tobacco, etc., as desired, 
 bearing in mind always that variety of food promotes health. There 
 has been more or less said in the newspapers about various con- 
 centrated foods, but, with the exception of evaporated vegetables 
 and fruit, condensed preserves, condensed milk, and beef extract, 
 nothing yet has been brought forward which has been proved de- 
 sirable. One cannot afford to experiment with his stomach in 
 Alaska." (New York Evening Post, July 6, 1898.) 
 
FOOD CONCENTRATION— CONDENSED FOOD 297 
 
 Men eat about two thirds of all the meat, and women one third. 
 Men consume about four fifths of all the alcoholic beverages, and 
 women one fifth. The latter consume much more tea than men. 
 
 Soyer has computed tables of the total quantity of foods con- 
 sumed by a man during his lifetime. He estimates that a man during 
 sixty years of life after early childhood eats 33J tons of meat, vege- 
 tables, and farinaceous food, and that an ordinary man by the time 
 he has attained to seventy years has consumed 30 oxen, 200 sheep, 
 100 calves, 200 lambs, 50 pigs, 1,200 fowls, 300 turkeys, 24,000 eggs, 
 4.5 tons of bread, and 3,000 gallons of tea and coffee. 
 
 Starvation and Inanition 
 
 Starvation, or asitia, is a term which technically applies rather to 
 the lack of sufficient food for the maintenance of the body, while 
 inanition means the lack of assimilation of food by the tissues. 
 Where there is defective absorption, food may be furnished to the 
 system in abundant quantity, but inanition results from lack of abil- 
 ity to absorb and develop force and nutriment from it. The interval 
 through which different persons can subsist without food depends 
 upon: 1, External conditions of temperature and moisture; 2, the 
 amount of work being performed ; and 3, the existing condition of 
 the body. 
 
 1. The maintenance of a uniform warm external temperature 
 prolongs the period through which man can endure abstinence from 
 food. Exposure to cold accelerates starvation symptoms by reduc- 
 ing the vitality of the body and the resistance of the system. Mois- 
 ture in the air, by preventing evaporation from the surface of the 
 body, prolongs the period of starvation which can be endured. 
 
 2. Persons who refrain completely from exercise can live far 
 longer without food than when undergoing active work. Self-for- 
 getfulness in times of famine, by diverting the mind from the suf- 
 ferings of the body, tends to prolong life. 
 
 3. Well-nourished persons can endure longer intervals of absti- 
 nence from food than the weak or diseased. The distress of deliri- 
 ous or apparently insensible persons may be augmented by lack of 
 sufficient food. Sex has no influence with the effects of starvation, 
 but they are most keenly felt at the extremes of age, by young 
 children, and senile subjects. 
 
 Those who have the most fat stored in their tissues call upon this 
 supply to maintain the energy of the body in the absence of food, 
 and, having a larger supply than thin or emaciated persons, they can 
 endure starvation much longer, although they may complain more 
 bitterly of the pangs of hunger than invalids, who are accustomed 
 to a low diet. Chossat's experiments with starving animals proved 
 that while they lost 40 per cent of body weight, the loss of fat alone 
 
298 FOOD PREPARATION AND PRESERVATION 
 
 reached 90 per cent, being greatly in excess of that of any other 
 substance. Anselmier fed starved dogs upon their own blood, and 
 succeeded in thus prolonging their lives for three or four days be- 
 yond the usual limit, and life lasted until 60 instead of 40 per cent 
 of their body weight had been lost. 
 
 When food is wholly withheld, life cannot be prolonged beyond 
 six to ten days in the majority of instances. During the winter of 
 i876-'77 an accident occurred in a colliery in South Wales by which 
 four men and a boy became imprisoned for ten days without food. 
 At the expiration of this period they were found alive, and, although 
 very feeble, they were able to walk when released. They had had 
 a supply of water, and the atmosphere in which they were confined 
 was moist. At another colliery accident in Wales a number of 
 men were confined in a mine for six days without food, and, al- 
 though their sufferings were extreme, nearly all were able to walk 
 out on being rescued. As a result of an earthquake in Calabria, 
 Sicily, in 1783, several persons were imprisoned in falling ruins. A 
 girl of eleven years survived, having been six days without food, 
 and another girl of sixteen years survived after eleven days of star- 
 vation. 
 
 The lack of food may be endured with far less torture if water is 
 applied in abundance to the system. When water is withheld in 
 addition the body loses weight much more rapidly, the tissues be- 
 come dry, the thirst excessive, the secretions are suppressed, and 
 the suffering is greatly intensified. 
 
 VOLUNTARY FASTING 
 
 Of late years several persons have attempted prolonged feats of 
 starvation, tempted by love of notoriety or desire of gain, by ex- 
 hibiting themselves for the gratification of public curiosity. In sev- 
 eral instances they have been carefully watched by medical experts 
 and there is every reason to believe that the fast has been conducted 
 with honesty. In at least two of these authenticated instances, those 
 of Tanner and Succi, the complete starvation period has been pro- 
 longed' for over forty days. In both cases fluids were allowed, and 
 one of the men relieved intense epigastric pain and food craving by 
 condensed medication. 
 
 Succi was an Italian who, in 1890, undertook an absolute fast of 
 forty-five days, during which period he lost 42J pounds and drank 
 1,154 ounces of water, or an average of about 25^ ounces per diem. 
 This he took in the forms of plain water, mineral water, and ice. 
 He became alarmingly emaciated during the fast, but even on the 
 last day had strength to walk about the room. He resumed eating 
 by first taking cocoa, and subsequently bouillon and other light 
 articles', and made a complete recovery. His mind remained clear 
 
FOOD CONCENTRATION— CONDENSED FOOD 299 
 
 throughout. He took occasional doses of a few drops of an elixir 
 supposed to contain opium. 
 
 There have been a number of cases from time to time recorded 
 of " fasting girls." They are usually of nervous hysterical tempera- 
 ment. On reaching the age of puberty they become dyspeptic and 
 grow shy and disinclined to eat what is good for them, although 
 they may gratify abnormal cravings surreptitiously. They are very 
 apt to be at the same time strongly impressed by religious beliefs, 
 and in their disordered mental condition to acquire the delusion 
 that it is sinful to eat. This delusion becomes fixed, and they then 
 are regarded as " freaks " and achieve much newspaper advertising. 
 They should be treated as ordinary cases of hysteria simply, and be 
 removed from oversympathetic friends and dealt with kindly but 
 firmly. Hydrotherapy yields excellent results, and even a good 
 spanking may not be amiss in awaking the patient to a realising 
 sense of her errors. The claim sometimes made in such cases as 
 those just described, that they lose no weight, is nonsensical, for 
 the body must diminish in weight continually by evaporation of 
 water from the lungs and skin and its passage from the kidneys and 
 by the exhalation of carbon. Edward Smith estimates that the 
 quantity of carbon exhaled in one day of fasting is equivalent to 
 that contained in twenty ounces of bread. 
 
 When either voluntary or forced starvation takes place very 
 gradually, especially in elderly people, their systems become slowly 
 accustomed to very small quantities of food. 
 
 Luigi Cornaro was a Venetian gentleman who advocated a very 
 abstemious diet, and whose own case is often cited in illustration of 
 the smallest quantity of food which may support life. He was born 
 in 1463 ; after a reckless and intemperate youth he reformed, and 
 by careful dieting prolonged his life to one hundred and three years. 
 He published a Treatise on a Temperate Life, and for the last forty- 
 eight years of his own existence he subsisted on a daily allowance 
 of twelve ounces of vegetable food with fourteen ounces of light 
 wine. He occasionally ate eggs, but rarely took any other form 
 of animal food. 
 
 There is much wisdom in some of his doctrines, but, unfortu- 
 nately, no one else who has attempted to practise his rules has met 
 with similar success in prolonging life. The majority of mankind 
 would undoubtedly prefer to live fewer years for the pleasure of 
 being less abstemious. 
 
 Periods of voluntary fasting of greater or less duration are rec- 
 ommended and practised by devotees of many religious sects. Such 
 fasting was formerly carried to a greater extent by ascetics than at 
 the present time. As a means of mental discipline or cultivation of 
 will power, fasting may in some instances be defended, but fasting 
 " to be useful must be voluntary " (Chambers), otherwise it is apt 
 
300 FOOD PREPARATION AND PRESERVATION 
 
 to cause irritability of temper, and it may even lead to deception to 
 obtain food. Such fasting may be carried to an excessive and in- 
 jurious degree unless it be definitely limited and supervised. It is 
 more powerful in its effect, moreover, if it is but seldom undertaken. 
 If a man so reduces himself by fasting that he cannot use his in- 
 tellectual faculties with accustomed vigour he may be sure that he 
 is doing himself injury. Better than complete fasting for purposes 
 of mental discipline or religious motives is the temporary elimination 
 from the diet of accustomed luxuries, or giving up such articles of 
 daily use as butter, sugar, salt, wine, tobacco, etc. This, in fact, is 
 a custom practised by many persons during the Lenten season. 
 
 The day has long since passed when lasting can be regarded as 
 favouring either clearness of intellect, muscular strength, or en- 
 durance, and, as Gerland has said, " the ethnologist can trace the 
 physical and mental decay of whole nations to a long course of insuf- 
 ficient food." 
 
 Dr. Denis, of Brussels University, presented an interesting report 
 at the International Congress of Anthropology for 1892, showing 
 striking parallelism in the curves of famine and crime, and of mar- 
 riages as inversely related to the price of wheat. 
 
 Symptoms. — The symptoms which result from complete starva- 
 tion are characteristic. If food is suddenly withheld, the sensation 
 of hunger gradually increases at first, becomes extreme, lasts for two 
 or three days, and slowly disappears. It is accompanied by a gnaw- 
 ing pain in the epigastrium, which is relieved on pressure. The pain 
 may disappear with the hunger, but it is followed by a sensation of 
 extreme weakness or faintness, which is both local in the stomach 
 and general throughout the body. The sensation of thirst, on the 
 contrary, when all fluid is withheld, persists until death or until the 
 subject becomes insane or unconscious. 
 
 When food is gradually withheld, urgent hunger may not be felt 
 at all, but the longer and more severe the fast, the more difficult 
 does digestion become. The circulation grows feeble, the heart 
 action rapid, the respiration shallow and possibly slow and irregular. 
 There is apt to be some thirst, even though water be supplied. If 
 it be withheld, the torture becomes unbearable. Constipation may 
 be succeeded by diarrhoea, but it more often remains complete. The 
 facies are typical, the expression is anxious and staring, the orbital 
 fat disappears, and the eyes are greatly sunken and finally become 
 glassy. Corneal ulceration may be present. General bodily ema- 
 ciation ensues, the muscles are soft and reduced in size by more 
 than one half, and the abdominal viscera to a similar degree, the 
 skin becomes pale, loose, and, from change in the secretion of per- 
 spiration, emits a peculiar fcetor and acquires a clay-like colour. 
 The feet and ankles may swell, owing to the enfeebled circulation. 
 
 The victims become so ravenous that all sense of taste gives place 
 
FOOD CONCENTRATION— CONDENSED FOOD 3OI 
 
 to the intense hunger. Upon one of the recent unfortunate arctic 
 expeditions, on one occasion, the tea being accidentally omitted from 
 the kettle, dirty water was drunk by the starving men without rec- 
 ognising the difference. The secretions are altered, and become 
 inactive. The urea excretion falls to one fourth the normal. The 
 total volume of blood is diminished, and anaemia is extreme. 
 
 The body temperature begins to fall in the first day of the period 
 of starvation, and continues falling, so that a loss of ten or more 
 degrees below the normal of 98.6 F. may occur. 
 
 In extreme cases muscular action is no longer possible ; there 
 are vertigo and faintness on raising the head, the voice is lost, and 
 gradually the nervous system succumbs to languor and general 
 prostration ; the mind becomes more and more dull, listless, and 
 even idiotic, the victim being unable to describe his condition or 
 express his wants. He may have hallucinations, insomnia, and 
 dreams, in which are often pictured scenes of plenty. 
 
 The sufferings produced by slow starvation distract the mind 
 and render connected thought difficult. If long continued, the mind 
 becomes unbalanced, and men who have been shipwrecked and left 
 to wander in the open sea in rowboats for a long time without food 
 usually become delirious, or even maniacal, within four or five days. 
 
 In 1874 three men and two boys were castaway for twenty-two 
 days in an open boat. They had at first ten days' provisions, and 
 subsequently nothing but old boots and jellyfish, and they fought 
 violently with each other in the delirium which ensued (Chambers). 
 
 During prolonged starvation the most important organs of the 
 body are nourished at the expense of others, especially of the skeletal 
 muscles. For example, in an animal starved for thirteen consecutive 
 days it was found that while the muscles lost 30 per cent in weight, 
 the brain lost but 3 per cent and the heart but 2.5 per cent. 
 
 The ultimate effects of starvation are identical whether the pro- 
 cess be gradual or rapid, occupying days or years, and death results 
 when the body has lost six tenths of its weight. It may occur while 
 the victim is in stupor or coma from cardiac failure or, possibly, in 
 convulsion. The actual cause of death has by many been attributed 
 to the loss of body heat. While this is undoubtedly a contributing 
 factor, it is more reasonable to suppose that it is due to the general 
 inanition of the muscles and nerves and the progressive enfeeble- 
 ment of the heart action. The heart muscle not infrequently will 
 be found to have undergone fatty degeneration. It is, however, true 
 that in animals kept warm by artificial means the advent of death 
 from starvation may be considerably postponed. 
 
 While undergoing starvation the blood is reduced in volume pro- 
 portionately with the loss in body weight, but it nevertheless main- 
 tains the balance of its normal average composition (Panum and 
 Voit). 
 
302 FOOD PREPARATION AND PRESERVATION 
 
 Hunger is not always a reliable guide as to the need of the sys- 
 tem for food. Some dyspeptics are always hungry and eat more 
 than they can digest. Hunger begets a habit of too rapid eating, 
 and more food may be taken than is necessary, because it has not 
 had time to be absorbed and reach the tissues before the meal is 
 over. Moreover, hunger may be temporarily appeased by eating 
 other substances than food, like bits of old leather, for example, 
 which appear to act mechanically in the stomach. For this purpose 
 men rendered insane by hunger will sometimes swallow all manner 
 of useless and harmful substances, such as buttons, pieces of metal, 
 pebbles, etc. 
 
 No more graphic and pathetic account of the miseries of starva- 
 tion exists than is found in the journal of Lieutenant De Long, 
 commanding the expedition of the Jeannette, which visited the arctic 
 regions in i879~ , 8i (The Voyage of the Jeannette, Journals of 
 George W. De Long, 1883). After leaving their sinking vessel the 
 members of the expedition were exposed, at first in open boats, and 
 later in their long sledge journey, to the most exhausting work and 
 to intense suffering from cold and wet. They frequently dragged 
 their sleds in severe storms for ten or twelve miles a day, while 
 subsisting solely upon half a pound of stewed deer meat, with a 
 little tea three times a day. This food being exhausted, they were 
 obliged to consume the meat of their fast remaining dog, which they 
 ate fried. They subsisted upon this food exclusively for four days 
 longer, having an allowance of but half a pound a day, and finally 
 their last journey of twenty-five miles was performed with no other 
 nourishment than a few ounces of alcohol and an infusion made 
 from some old tea leaves. During this time their intense suffering 
 from hunger was partially alleviated by chewing scraps of deer 
 skin, which, from its bulk in the stomach, seemed to afford slight 
 relief. 
 
 The alcohol being exhausted, they lived for another day upon 
 a teaspoonful of olive oil, with a breakfast composed of an infusion 
 made from the arctic willow (containing really no nourishment) 
 and " two old boots." After this the men, becoming weaker and 
 weaker, -were unable to proceed farther on their journey, being 
 driven back by intense cold and the difficulty of crossing the par- 
 tially unfrozen rivers. Their feebleness gradually overcame them, 
 until one by one they died of inanition. Four men survived for 
 sixteen days upon absolutely no food whatever, and possibly their 
 sufferings were even further prolonged, but the journal of their gal- 
 lant and heroic commander ceased at this point, for he, too, died. 
 
 In the starvation which overtook the members of the Greely 
 party on the Lady Franklin Bay Expedition, and caused the death 
 of a large number of the company, attempts were made, as in the 
 case of the Jeannette expedition, to relieve the agonies of hunger 
 
FOOD CONCENTRATION— CONDENSED FOOD 303 
 
 by filling the stomach with indigestible material of various kinds. 
 The skin sleeping bags were roasted or boiled and eaten, and even 
 oil-tanned skin was consumed, while the sufferings of the men were 
 aggravated by the presence of game in sight but out of reach. A 
 few shrimp and lichens were obtained and stewed with seal skin. At 
 this time, although it was summer, the temperature was occasionallv 
 below the freezing point, but during part of the two years spent in 
 the vicinity of Fort Conger it was sometimes — 40 or even — 6o° F. 
 
 During the siege of Paris in 1871, when thousands of the in- 
 habitants were reduced to starvation, it was found that a diet which 
 was barely sufficient to support life consisted of ten ounces of bread 
 with one ounce of meat. 
 
 In prisons the diet limit has often been reduced too low. It 
 may be sufficient to maintain life, but if hard labour be inflicted, 
 weakness, sickness, and death will inevitably follow. In an over- 
 crowded prison a daily ration of twenty-eight ounces of unbolted 
 meal and five ounces of bacon has been known to cause death by 
 slow starvation. As a means of discipline a starvation diet is some- 
 times enforced in penal institutions for a few days, and it is usually 
 quite as efficacious as corporal punishment. A diet which is de- 
 signed to effect its aim by monotony as well as reduction in quan- 
 tity, but without reaching the limit of cruelty, is the following, 
 which has been used at the United States military prison at Fort 
 Leavenworth : 
 
 Breakfast. — Hash or stew, 8 ounces ; bread, 7.5 ounces. 
 
 Dinner. — Soup, 8 ounces ; bread, 7.5 ounces. 
 
 After twenty continuous days of this diet eight ounces of bread 
 are allowed for supper. This diet has been found to make the most 
 refractory men soon manageable. (See Diet in Prisons.) 
 
 Treatment. — The treatment of persons rescued from starvation 
 must be conducted with the utmost care. The digestive system is 
 so enfeebled that to allow them to yield to the cravings of returning 
 appetite is to insure immediate death by overburdening the stomach 
 and circulation. The body should be kept warm and in absolute 
 rest, and warm fluid nourishment in minute quantities — half tea- 
 spoonful doses of beef peptones or meat juice — may be given at 
 intervals of fifteen minutes or half an hour. If no vomiting or evil 
 symptom results, small quantities of peptonised milk may be tried 
 at half-hour intervals. Alcoholic stimulants in any quantity are to 
 be avoided, but a few drops of brandy or whisky may be given from 
 time to time in water. If the stomach is irritable, nutrient enemata 
 should be employed. The following day the quantity of food may 
 be slightly increased, but if emaciation is extreme and enfeeblement 
 is pronounced, the patient must be kept upon a fluid diet for ten 
 days or more. Easily digested forms of starchy food may then be 
 added, such as dry bread, arrowroot, gruel, and the like. 
 
304 FOOD PREPARATION AND PRESERVATION 
 
 FAMINE 
 
 When starvation occurs upon a large scale, affecting a commu- 
 nity with famine, pestilence is sure to accompany it. Disease has 
 always been rampant in Ireland when the potato crops have failed, 
 and in India when the grain supply has given out. Much of the ill- 
 ness which occurred in the early history of the Crimea was due to 
 insufficient food, and in the Middle Ages the ravages of pestilential 
 diseases, such as typhus, smallpox, the plague, etc., were always 
 worst in times of general starvation. The history of epochs of 
 famine in siege or otherwise is always accompanied by outbreaks 
 of violence, for hunger begets ill-temper, vice, and crime. This has 
 occurred of late years, notably in Athens, Florence, and London, 
 and in Paris during the Commune. 
 
 Nothing predisposes man so much to all forms of infectious 
 disease as starvation and inanition. This is so well known that 
 physicians and nurses in charge of contagious cases are particularly 
 cautioned to eat well and not expose themselves to infection while 
 suffering from fatigue and lack of food. 
 
 Improperly Balanced Ingredients of Diet 
 
 Improper diet is often quite as injurious as slow starvation, for a 
 person who eats a large bulk of food of one class, to the exclusion 
 of other classes, may delude himself by thinking that he is taking 
 nourishment enough on account of the degree of satiety which he 
 derives from his diet. " The outward appearance of such persons is 
 to a certain extent characteristic, marked generally by a pale and 
 puffy aspect, due partly to a general excess of water in the tissues 
 and partly to an abnormal deposition of fat " (Bauer). The evil 
 result of such diet is very apparent among infants and growing 
 children who have been fed upon a large bulk of farinaceous food to 
 the exclusion of milk, meat juice, etc., and in them the foundation 
 may be laid for the development of scurvy, or scrofula, or tuberculo- 
 sis, and sometimes also the stomach and bowels become permanently 
 distended. (See Diet for Infants and Children.) 
 
 The effects above described are commonly produced by excessive 
 ingestion of starchy and saccharine foods to the exclusion of pro- 
 tein, and, on account of the cheaper cost, the children of the poor 
 are more apt to be injured in this manner than the rich, among 
 whom the opposite diet — an excess of nitrogenous aliments — is more 
 common. The latter sometimes gives rise to circulatory disturb- 
 ances, overworks the kidneys, and produces nervous irritability. 
 
 It has often been observed by dietists that proportionately more 
 fat is consumed in the United States than in Europe, and some are 
 inclined to attribute to this form of food some influence upon the 
 
FOOD CONCENTRATION— CONDENSED FOOD 
 
 305 
 
 greater activity which characterises Americans. It is extremely 
 doubtful whether this has as much to do with it as climatic and 
 other conditions of environment. 
 
 Taken by themselves, carbohydrates have little or no effect in 
 deferring death from starvation, but with albuminates they act as 
 tissue sparers. (See Force-producing Value of Foods, p. 21.) 
 
 Mrs. Richards gives the following useful comparisons of food 
 composition, showing particularly the inefficiency of fluid diets other 
 than milk to support life : 
 
 Three quarts of milk 
 
 Three quarts of beef broth or consommi 
 
 Soup of Munich Hospital 
 
 Rations recommended in certain invalid re- 
 ceipt books 
 
 Rations recommended in another receipt book 
 
 Prausnitz's estimate of normal ration for man 
 
 Prausnitz's estimate of normal ration for 
 woman 
 
 Estimated life ration 
 
 Maximum work ration 
 
 Minimum work ration 
 
 Proteid. 
 
 I02.0 
 
 I23.O 
 
 21.6 
 
 24.5 
 66.5 
 
 IIO.O 
 IOO. o 
 
 75.0 
 
 125.0 
 
 IIO.O 
 
 Common invalid ration too low in protein . 
 1 pint beef juice, containing 7 per cent. . . . 
 1 pint whole milk 
 
 1 quart flour gruel, made with whole milk. 
 
 2 quarts of liquid. Total 
 
 31.5 
 17.0 
 
 18.2 
 
 66.7 
 
 Fat. 
 
 I08.0 
 
 3.0 
 
 21.6 
 
 28.5 
 
 23-5 
 50.0 
 
 50.0 
 
 40.0 
 
 125.0 
 
 90.0 
 
 18.0 
 
 18.2 
 
 36.2 
 
 Carbo- 
 hydrate. 
 
 I32.O 
 
 I08.O 
 
 65.6 
 
 83.5 
 
 350-400 
 
 3OO-350 
 325-0 
 450.0 
 420.0 
 
 22.0 
 38.0 
 
 60.O 
 
 Calories. 
 
 1,953.0 
 
 532.0 
 730.0 
 
 631.O 
 
 83I.O 
 2,350.0 
 
 2,100.0 
 2,000 . 
 
 3,500.0 
 3,000.0 
 
 I29.O 
 
 325-5 
 397-9 
 
 852.4 
 
PART IV 
 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 AGE AND FOOD. 
 INDIVIDUAL SIZE AND FOOD. 
 BODY WEIGHT AND FOOD. 
 SEX AND FOOD. 
 
 DIET AND HEREDITY. 
 DIET AND RACE. 
 CLIMATE AND SEASON 
 FOOD. 
 
 an: 
 
 AGE AND FOOD 
 
 Food in Childhood 
 
 A child at three or four years of age actually consumes nearly 
 one fourth as much food as it requires at adult life, for during this 
 process tissue growth is very rapid, and if the child be in health, 
 the bodily activity is relatively very great. An active child at twelve 
 or fifteen years of age who is growing fast and who is freely exer- 
 cising may require and assimilate as much food as a man past middle 
 age, and insufficient food and food of defective quality and composi- 
 tion work proportionately far more harm during the growing age. 
 
 Inquiries made in this country in regard to the diet of older 
 children and young adults demonstrate that it contains a propor- 
 tionately large quantity of fatty food — much more than is custom- 
 arily consumed in European countries. This is in great part owing 
 to the habit of eating considerable butter, which, generally speaking, 
 the better circumstances of Americans enable them to obtain. 
 
 The following table from the investigations of the Munich School 
 gives : 
 
 The Minimum Amount of Food Necessary for Different Ages 
 
 Age. 
 
 Infant until one and a half year 
 Child from six to fifteen years. . 
 
 Man (moderate work) 
 
 Woman 
 
 Aged man 
 
 Aged woman 
 
 306 
 
 Nitrogenous 
 substances. 
 
 Grammes. 
 
 20-36 
 
 70-80 
 
 Il8 
 
 92 
 
 IOO 
 
 80 
 
 Fats. 
 
 Grammes. 
 
 30-45 
 
 37-50 
 
 56 
 
 44 
 68 
 50 
 
 Carbohydrates. 
 
 Grammes. 
 
 60-90 
 250-4OO 
 
 500 
 
 400 
 
 350 
 
 260 
 
AGE AND FOOD 307 
 
 The special diet regulations for infancy and childhood are de- 
 scribed at length under the headings Diet in Infancy and Diet in 
 Childhood. 
 
 Food in Adult Life 
 
 The nature and quality of the diet appropriate for adults must 
 depend somewhat upon individual constitution, occupation, habits 
 of life, and to some extent upon the climate in which they live. 
 
 The full adult weight is not usually attained before the twenty- 
 fifth year, although in some cases it is reached earlier. In many 
 instances adults after the age of forty or forty-five years increase 
 considerably in weight. In men the bones continue to solidify until 
 about the thirtieth year ; in women this condition is usually reached 
 a few years earlier. When the final growth of the body and develop- 
 ment of the vital organs is completed the use of food consists simply 
 in maintaining the proper equilibrium of the tissues by replacing 
 waste with new material and in furnishing fuel for the development 
 of force, the food being no longer required for growth. Many per- 
 sons eat more than is required for these purposes. 
 
 As men advance in life, become prosperous, and acquire more 
 and more luxurious habits of living or become absorbed in various 
 occupations, they are apt to take less exercise, while the number of 
 luxuries of the table which their means enable them to command 
 constantly tempt them to indulge in food which is not needed and 
 which is imperfectly consumed in the body. 
 
 Sir H. Thompson writes (Diet in Relation to Age and Activity) : 
 
 " More than one half of the disease which embitters the middle 
 and latter part of life among the middle and upper classes of the 
 population is due to avoidable errors in diet." 
 
 It is often difficult for a man between the ages of twenty and 
 thirty years who has led an exceptionally active and vigorous or 
 perhaps even an athletic life to realise, as he grows older and passes 
 on towards forty-five or fifty years of age, that he requires less food 
 to maintain his organic equilibrium than formerly, and his habits of 
 eating acquired at a more impressionable period of life cling with 
 great pertinacity. It may prove an advantage sometimes in such 
 cases to lessen the appetite for dinner by a late lunch, or to try 
 other simple means of restriction. 
 
 These observations fail of application to the poor, whose means 
 do not allow them to gratify their appetites, and in the case of those 
 whose diet is established for them. There is quite as much, if not 
 more, ill arising from deficient feeding as from overfeeding; in either 
 case the difficulty is only made serious by long continuance, and 
 occasional great indulgence in overeating as in overdrinking is less 
 productive of harm than habitual indiscretions of a lesser degree. 
 So much is due to habit in the different organs of the body in 
 
308 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 relation to food that the stomach and intestine will usually reject 
 undigested the contents of an occasional excessive meal, whereas 
 with habitual overeating they become accustomed to appropriating 
 very large quantities of food, which are absorbed, but which are not 
 eliminated without straining the excretory organs, or which may be 
 stored in the body in the form of incompletely oxidised material, 
 which accumulates until the system rebels and a violent bilious 
 attack by vomiting and purging relieves the overburdened body. 
 There are persons who have so little restraint over their appetites 
 that they persistently indulge themselves in this way. 
 
 Food in Old Age 
 
 In old age there are inevitable changes which slowly occur in 
 the circulatory and digestive organs of the body. Although the 
 general health may still be unimpaired, the circulation is less vigor- 
 ous, and the nervous system less active to external stimulation. 
 There are degenerations in the secreting organs with a tendency 
 to deposition in the tissues of phosphate and carbonate of lime, 
 derived from the food. Absorption is less active, and there is 
 diminished adaptability of the whole system to alterations in environ- 
 ment, and much less ability to meet the requirements of emergen- 
 cies, such as sudden calls for the use of muscles or mental strain. 
 The muscular tone of the intestine is apt to deteriorate and produce 
 constipation and a relaxed condition resulting in its dilatation. The 
 circulation through the mesenteric vessels and those of the portal 
 system becomes inactive, with a consequent reduction in the rate 
 of absorption, and a diminished and altered gland secretion in the 
 liver, pancreas, etc. 
 
 For these reasons the digestive powers are less vigorous, but, 
 on the other hand, there is not so much demand for fuel in the body 
 as in earlier years. The vital processes conducted by the circulation, 
 respiration, and metabolic changes in the tissues are very inactive, 
 and there is a correspondingly restricted expenditure of energy. 
 
 Persons of very advanced age — those who are past eighty years 
 or more — can sometimes live comfortably on an astonishingly small 
 quantity of food. J. Forster examined the food of the inmates of an 
 institution for elderly widows and found that many of the old women 
 subsisted very comfortably upon a diet containing, in grammes, al- 
 bumin, 67; fat, 38; and carbohydrates, 266. 
 
 Much depends, however, upon the rapidity with which the 
 changes above described have developed, and dietetic rules for such 
 cases are not to be based upon a definite period of years so much 
 as upon the degree of senility which is present in individual cases. 
 
 Sir Henry Thompson (Diet in Relation to Age and Activity), 
 in commenting upon the progressing diminution with advancing 
 
AGE AND FOOD 309 
 
 years of physical energy and of the power to eliminate waste material 
 from the body, and the consequent harm of overeating, says that if a 
 man past his half century of life " continues to consume the same 
 abundant breakfasts, substantial lunches, and heavy dinners which at 
 the summit of his power he could dispose of almost with impunity, 
 he will in time either certainly accumulate fat or become acquainted 
 with gout or rheumatism, or show signs of unhealthy deposit of some 
 kind in some part of the body — processes which must inevitably 
 empoison, undermine, or shorten his remaining term of life. . . . 
 The typical man of eighty or ninety years is lean and spare, and lives 
 on slender rations." 
 
 In the dietetic treatment of cases of extreme old age the rules 
 which are naturally suggested are : 
 
 1. To diminish the total quantity of food ingested. 
 
 2. To give food at frequent intervals in small amount. 
 
 3. To give only easily digestible food, which does not produce 
 too large a residue of waste matter, either in the intestinal canal or 
 in the form of excrementitious material in the blood. 
 
 It is an undoubted fact that, having reached an advanced age, a 
 man may often prolong his life and greatly add to the comfort of his 
 remaining years by adhering to these rules. Yet there are many 
 instances of those whose constitutional vigour is so great and whose 
 appetite for the good things of the table remains so keen that they 
 are unable or unwilling to listen to the dictates of reason. I recol- 
 lect an instance of a gentleman who, in the enjoyment of almost 
 perfect health at the advanced age of ninety-four, suddenly termi- 
 nated his life by an uncontrollable indulgence in lobster salad. The 
 idea is prevalent with some people that the quantity of food and 
 stimulants should be increased pari passu with age, but this is as 
 wrong in theory as it is pernicious in practice, and the simple fact 
 that an article of particularly rich or hearty food has been enjoyed 
 with impunity for many years is no argument that it can be indefi- 
 nitely taken in the same degree, although this reasoning is very 
 often encountered. 
 
 In commenting upon Professor Humphrey's report upon cente- 
 narians, made for the British Medical Association, Dr. Yeo observes : 
 " Their habits in eating and drinking tended, as a rule, to great mod- 
 eration in both. ... Of animal food the majority took but little. 
 . . . The exact quantity is mentioned in nine instances : One took 
 \2 ounces, one 6, one 5, and six 4 ounces daily. In the use of 
 alcoholic drinks we also find evidence of great moderation." 
 
 Some more recent investigations of the dietetic habits of men 
 over one hundred years of age show considerable diversity ; thus, for 
 example, some were found who ate but one meal a day, while others 
 ate four or five ; some drank but little fluid, others took a great 
 deal ; some were total abstainers from alcohol, and others were not. 
 
3IO FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 Persons who attain to very advanced age are almost invariably 
 of spare habit, and the universal testimony in regard to centenarians 
 is that they have never abused food or drink, and that in the latter 
 years of life, at least, they have been very abstemious in the use of 
 meat. In fact, Nature usually furnishes a hint in this direction by 
 depriving them of their teeth, making it practically impossible to eat 
 animal food, which requires mastication, and, as Yeo suggests, " if 
 artificial teeth are used for the purpose of continuing a diet com- 
 posed of animal flesh, they will not prove an unqualified advantage." 
 
 Next in importance to diminishing the quantity of food in the 
 diet of the aged (especially the proportion of fats and proteid ma- 
 terial) should be considered the necessity of regularity in diet, both 
 in regard to the general character of the food taken and the times 
 of eating. 
 
 If the teeth are absent, tough vegetables and meats must be 
 avoided, yet the food should not be wholly fluid, for some mastica- 
 tion should be performed in order to maintain the salivary flow. 
 Plenty of time should be allowed for this purpose. 
 
 Any sudden changes in diet should be avoided, and the intervals 
 between the ingestion of food should not exceed six or eight hours. 
 
 It is very common for elderly people to awaken early in the morn- 
 ing at three or four o'clock and to be unable to drop off to sleep 
 again, but if they have some light form of nourishment at the bed- 
 side, such as a glass of milk or a little gruel, which they can take 
 at that time, they will often continue their sleep. 
 
 Malt liquors are very good for the aged, and a moderate amount 
 of alcohol acts as a tonic and supplies them with needed energy for 
 digestion and other functions. 
 
 Yeo gives the following suggestions in regard to the diet of the 
 aged, which are so useful that they will be quoted in full : 
 
 " Of animal foods best suited for this time of life the following 
 may be mentioned. When the organs of mastication are altogether 
 inefficient these foods should be minced or pounded into a paste or 
 otherwise finely subdivided : 
 
 ' Young and tender chicken and game and other tender meats. 
 
 " Potted chicken, game, and other meats, sweetbread. 
 
 " White fish, as soles, whiting, smelts, flounders, etc. Best when 
 boiled. 
 
 " Bacon, grilled ; eggs lightly cooked or beaten up with milk. 
 
 " Nutritious soups, such as chicken or fish, purees, beef tea, mut- 
 ton and chicken broths. 
 
 " Milk in all forms, when easily digested. 
 
 " Beef tea and milk supply the needed mineral substances, and 
 the former is an excellent stimulant. 
 
 " The addition to milk of an equal quantity of Vichy water, warm, 
 or of warm water, will often help to make it agree. 
 
INDIVIDUAL SIZE AND FOOD 311 
 
 " Of vegetable foods the following are all suitable : 
 
 " Bread and milk made with the crumb of stale bread and with- 
 out any lumps. 
 
 " Porridge and oatmeal gruel. 
 
 " Puddings of ground rice, tapioca, arrowroot, sago, macaroni 
 with milk or eggs and flavoured with some warm spices, or served 
 with fruit juice or jelly; bread and butter, at least a day old; rusks 
 for soaking in tea, or milk, or water. 
 
 " Artificial foods, consisting of predigested starches. The diges- 
 tive ferments are scantily provided by the digestive organs at this 
 age, and soluble carbohydrates are valuable for maintaining the body 
 heat. 
 
 " All farinaceous foods should be submitted to a high tempera- 
 ture for some time, so as to render the starch granules more easy 
 of digestion. 
 
 " Vegetable purees of all kinds may be taken in moderation — 
 e. g., potatoes, carrots, spinach, and other succulent vegetables. 
 
 " It is important that the use of potatoes and fresh vegetables 
 should not be neglected; otherwise a scorbutic state of the body 
 may be engendered. . ' ' 
 
 " Stewed celery and stewed Spanish or Portugal onions. 
 
 " Stewed or baked fruits and fruit jellies and the pulp of per- 
 fectly ripe raw fruits in small quantity. 
 
 " The acidity of certain stewed fruits may be advantageously 
 neutralised by the addition of a little bicarbonate of soda so as to 
 avoid the use of a large quantity of cane sugar to sweeten it, as this 
 is apt to cause gastric fermentation and acidity. In stewing fruit, 
 about as much soda as will cover a shilling should be added to each 
 pound of fruit. 
 
 " Aged persons often require their foods to be accompanied with 
 some kind of condiment, which promotes their digestion arid pre- 
 vents flatulence. 
 
 " Caviare and the roes of smoked and salted herrings are of this 
 nature. 
 
 " For sweetening food, milk sugar is much less prone to excite 
 acid fermentation than cane sugar. 
 
 " A very digestible form of fat — when it is needed — is cream, 
 mixed with an equal quantity of hot water and about ten drops of 
 sal volatile to each fluid ounce." 
 
 INDIVIDUAL SIZE AND FOOD 
 
 The size of the body has more influence than its weight upon the 
 
 quantity of food consumed. In infant feeding the relationship is 
 
 made the subject of careful study (see Infant Feeding), but in adults 
 
 there is more variation. As a general rule, persons of large frame 
 
 22 
 
312 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 eat in proportion to their size, and vice versa, but there are many 
 exceptions familiar to all, and some very corpulent persons are very 
 abstemious at the table. Because most persons eat more than they 
 really need, a man of large frame can often eat less than one of small 
 size, and yet have plenty. 
 
 Attempts have been made to demonstrate that a preponderance 
 of animal or vegetable food respectively, or of some particular sys- 
 tem of diet, influences the stature of men. Of course, children who 
 receive insufficient food or food poor in quality may be half grown, 
 but beyond that fact theories as to the specific influence of different 
 classes of food upon the development of the body are founded upon 
 ignorance of the natural history of the different races of man. The 
 diet of Bushmen, Australians, and Fuegians presents instructive ex- 
 amples of tribes with large or small bodies, demonstrating that " it 
 is not quality or monotony of food, but its quantity that affects devel- 
 opment " (Gerland). 
 
 BODY WEIGHT AND FOOD 
 
 The question as to how far gain or loss in the body weight may 
 be taken as an indication of the appropriateness of diet is important. 
 In prescribing systems of diet for many diseases, such as dyspepsia, 
 obesity, diabetes, phthisis, etc., it is very desirable to have the pa- 
 tient weighed systematically at least once a week, and good scales 
 are very useful in the physician's office. Care should, of course, be 
 observed that changes in clothing are not allowed to interfere with 
 the accuracy of the observations. Loss of weight, under some con- 
 ditions, may be much more rapid than gain ever is. The latter at 
 best does not usually proceed at a rate of more than two or three 
 pounds in a week, even during convalescence from such an illness 
 as typhoid fever ; but in diseases like cholera, for example, in which 
 emaciation is extremely rapid, the loss of weight may amount to two 
 or three pounds a day, or possibly more. 
 
 In some diseases a fallacy arises in comparing food consumption 
 with body weight. In fevers there is usually loss of weight, but this 
 is not always the case. Sometimes in aseptic fevers the weight may 
 remain uniform ; and in phthisis there is sometimes uninterrupted 
 gain during a moderate hectic. Leyden has found that in fever, 
 while the albuminous ingredients of the body are diminishing, there 
 may be more water stored in the tissues, and in cases of anasarca and 
 dropsical accumulations of rapid development it is quite possible for 
 the weight to increase, while in reality the body is rapidly wasting 
 away, and it would be a very grave mistake to deduce any conclu- 
 sions for feeding the patient from the weight alone. Another impor- 
 tant consideration is the rapidity of loss of waste food products from| 
 the body. 
 
SEX AND FOOD 313 
 
 The normal weight of faeces which should be voided each day is 
 five or six ounces — about one fourth of which is solid matter, the 
 rest water. Many persons do not pass over half this quantity for 
 days together, and thus go on accumulating waste material, which 
 adds to their weight. The same disproportion between food in- 
 gestion and the elimination of urea and different salts in the urine 
 may exist. Moreover, the loss of weight by excessive perspiration 
 may reach a pound or two a day. Athletes subjected to violent 
 physical strain and stokers working in great heat — sometimes of 
 120 F. — may lose two pounds in an hour in this manner. The 
 night sweats of phthisis cause considerable actual loss in weight, 
 besides the exhaustion which they occasion. The loss of weight 
 through the aqueous vapour and carbon dioxide in the lungs may 
 vary somewhat, although it is less changeable than might be sup- 
 posed. 
 
 For all these reasons it is necessary to be somewhat cautious in 
 accepting conclusions from the scales for application in ordering 
 more or less food, or altering its character. 
 
 The weighing of infants immediately before and after nursing at 
 the breast is an excellent and fairly accurate method of determining 
 how much food they are getting, and infants whose nutrition gives 
 any cause for anxiety should be frequently weighed, for in them, for 
 obvious reasons, the record of slight variations in weight can be 
 much more accurately utilised in regulating feeding. 
 
 SEX AND FOOD 
 
 The relation of sex in regard to food affects the quantity rather 
 than the quality, excepting among a few rude tribes where super- 
 stition is allowed full sway. The northern Eskimos, for instance, 
 have a belief that if women eat eggs they cannot become pregnant, 
 which is in curious contrast to the reputation for aphrodisiac effects 
 which this food has among civilised people ! Women eat less food 
 than men relatively because their average size is smaller, and also 
 absolutely because they do less work and lead a more indoor life. 
 The difference is slight, and when other conditions are equalised the 
 question of sex has very little influence upon the quantity of food 
 consumed. 
 
 Generally speaking, women's digestive processes are somewhat 
 less active than men's, and they have greater tendency to consti- 
 pation. The accepted standards for woman as compared with man 
 are as follows : The meal of a woman equals 0.8 of the meal of a 
 man ; a woman with little muscular work demands 80 grammes 
 protein, and a total food value of 2,400 calories ; at moderate mus- 
 cular work woman requires 90 grammes protein and 2,800 calories ; 
 man with little muscular work requires 112 grammes protein and 
 
314 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 3,000 calories, and at moderate muscular work 125 grammes pro- 
 tein and 3,500 calories. 
 
 About the only way in which sex affects the quality of food con- 
 sumed is in the somewhat greater fondness for sweets and confec- 
 tionery exhibited by females, but this can be shown to be due more 
 to other considerations of habit and custom than to sex. The use 
 of tobacco and alcohol by many men, for instance, . makes them 
 care less for such foods. 
 
 DIET AND HEREDITY 
 
 The influence of heredity upon diet is not very striking. Children 
 are sometimes supposed to inherit likes and dislikes for particular 
 foods, whereas they are merely acquired tastes from the circum- 
 stance that they have certain foods offered them at home to the 
 exclusion of others. The functions of the stomach and intestines 
 appear to be somewhat hereditary. Violent seasickness and a 
 tendency to biliousness and constipation in some persons and the 
 prompt vomiting of the contents of an overloaded stomach in others 
 is sometimes a family trait, running through three or four genera- 
 tions. So is occasionally the inability to digest special foods, such 
 as crustaceans, strawberries, etc., but such instances are rare. 
 
 Unfortunately, the abuse of alcohol is very strongly hereditary — 
 so much so that the children of inebriate parents should be protected 
 as long as possible from learning the taste of either beer, wine, or 
 spirits. 
 
 Heredity has some influence in disorders of food assimilation, 
 like gout and diabetes, and in such cases improper diet and careless 
 habits of eating may develop latent disease. 
 
 DIET AND RACE 
 
 The food of prehistoric man necessarily consisted of the simplest 
 elements, represented by fruits, berries, nuts, insects, and an occa- 
 sional piece of raw fish or meat. Such food is, in fact, the diet of 
 primitive tribes to-day. The Fuegian lives chiefly upon shellfish 
 and seaweeds, and the Central African dwarf upon plantains and 
 insects (see p. 33). The name " Eskimo " was first applied by 
 natives of eastern Canada in opprobrium, to signify " raw-fish 
 eater." 
 
 The history of the development of diets and of food cultivation 
 and preparation is practically a history of the progress of culture, 
 and most of our present foods were quite unknown to our earliest 
 progenitors. The discovery of the uses of fire greatly increased 
 the variety of available foods for man, for all the cereals which are 
 cultivated require its use to fit them for digestion. As Gerland has 
 
DIET AND RACE 31 5 
 
 said, men obtain their food from natural products, by cultivation, 
 or by barter and commercial exchange, according as nomadic or 
 fixed habits predominate, and " no mere hunting or fishing tribe can 
 be large and remain in one place," for it is estimated that in the 
 temperate zone to support one man by these means at least sixteen 
 square miles of territory are necessary. 
 
 Many a tribal, and even national war has been the more or less 
 direct outcome of the necessities of obtaining food supply from dis- 
 tant sources, and the economic, commercial, and social development 
 of all matters pertaining to food among civilised people to-day far 
 exceeds in importance all other practical questions. As man ad- 
 vanced in culture and began to live in communities where division 
 of labour became an important factor in development, preference 
 to some extent superseded necessity in the selection of diet, and as 
 food acquired a commercial value, more and more labour was be- 
 stowed upon its preparation and preservation, until at the present 
 time the rich are able to select their diet with almost total disregard 
 of season or climate, and even the common labourer finds it eco- 
 nomical to eat some foods which, like sugar or tea, may have been 
 transported many thousands of miles. 
 
 Following is a synopsis of an exceedingly interesting report 
 kindly written for me by Dr. Frederick A. Cook, the physician to 
 the Peary expedition to northwestern Greenland in iSgi-g2, which 
 is appended to illustrate the dietetic habits of a race which, for nearly 
 a thousand years, are believed to have been practically isolated from 
 commercial or social relations with any of their neighbours. There 
 is so little scientific information existing in regard to the dietetic 
 habits of the tribe of Eskimos which he studied, who live the farthest 
 north of any people in the world, that his statements will be found 
 of exceptional value. One cannot peruse the account without be- 
 ing impressed with the fact that generalisations in regard to the 
 influences of diet upon the system should be made with great caution 
 when applied to different races of man. For example, both scurvy 
 and rheumatism are sometimes attributed to an excessive meat diet, 
 yet the Eskimo has no starchy food at all and does not suffer from 
 these diseases, and, moreover, his bodily vigour and power of en- 
 durance compare favourably with that of any other race or class 
 of men, and in some respects it is greater than that possessed by 
 others. 
 
 Dr. Cook says in regard to the Eskimos of northwestern Green- 
 land : " They usually eat but one meal a day, which they take at 
 irregular times, being people without restrictions of any kind. They 
 can be seen eating and drinking whenever able to procure suste- 
 nance. Their diet consists almost exclusively of meat, composed 
 principally of the muscular tissues of the following animals, in the 
 order of their importance to the native's: Seal, walrus, norwhale, 
 
316 FOODS REQUIRED FOR SPECIAL CONDITIONS • 
 
 white whale, polar bear, reindeer, arctic hare, and sea fowls, such 
 as guillemots, gulls, eider ducks, etc. When food is scarce they 
 eat every part of the animal, including the stomach and intestines ; 
 indeed, the only vegetable food that the most northern Eskimo can 
 obtain consists of the contents of the stomach of the reindeer 
 (lichens), which he is only occasionally able to secure. The women 
 and children sometimes eat flowers of the arctic poppies and the 
 so-called scurvy grass, but never to any great extent. In times of 
 famine, in order to prevent wholesale starvation, the aged are turned 
 out to starve to death, and their bodies are then devoured by the 
 more vigorous members of the tribe. Occasionally, when the old 
 people are shrewd and active, the younger children are sacrificed 
 for this purpose. As a rule, the Eskimo will not eat dogs, but when 
 food is scarce dogs are first added to their larder, and when the 
 last dog has been eaten, human beings come next in order. 
 
 " One of the greatest delicacies is old seal. A native never wastes 
 the carcass of an animal ; if he should kill the seal fifty or a hundred 
 miles from home he will bring it to shore and cache it in such a 
 way that the foxes, bears, and birds cannot attack it. He then leaves 
 it, and may not return for two or three years, when he comes back 
 in anticipation of a great feast, for the old seal seems to him like 
 old cheese to us, and he enjoys it immensely, although a white man 
 could not endure the odour. I have known twenty individuals to 
 eat a seal of this character in less than two hours, leaving only 
 shreds of the skin after them. I have never been able to verify 
 the statement, so commonly quoted, ' that Eskimos can eat twenty 
 pounds of meat or blubber.' 
 
 " Fully two thirds of the Eskimo food is eaten raw, and one 
 half is consumed while in the frozen state. When an Eskimo woman 
 starts her blubber lamp and places over it a conlipsie (the name 
 applied to their primitive stew pot) she does so principally to obtain 
 the warm drink which the cooked meat affords. It cannot be said 
 that Eskimos cook their meat because they prefer it cooked, but 
 because when the meat is heated slowly, as it can only be heated 
 by their primitive method, the blood and fat ooze from the mus- 
 cular tissues and form a thick soup, which, aside from water, is 
 almost their only drink, and a cupful of this beverage is offered 
 to every guest. The natives may consume three or four hours in 
 eating one meal, and when they have thoroughly gorged themselves 
 they will lie down and sleep ; as they do this, however, they place 
 before themselves a dish full of cooked meat, and those who awake 
 from their sleep will finish their meal, but on rising no breakfast is 
 served, for the Eskimo who has a day's journey before him would 
 not think of eating before starting. He claims that this would 
 prevent his ability to travel, and this rule the Eskimos apply to 
 their dogs as well, who are often only fed every two days. These 
 
DIET AND RACE 317 
 
 Eskimos are as irregular in their habits of sleep as they are in regard 
 to their meals. During the four months of constant sunshine they 
 usually arise when the sun is in the south, but the Eskimo never 
 thinks of going to bed until he is sleepy, so that in time of excite- 
 ment, when there is a new arrival or in the pursuit of game, he will 
 often remain awake for forty-eight or seventy-two hours, and then 
 he will sleep ' until the spirit of sleep has left him,' as he ex- 
 presses it. 
 
 " The Eskimos endure fasting very well, and after a good, full 
 meal they can fast for two or three days, apparently without serious, 
 inconvenience. Indeed, when food is scarce — which usually happens 
 during the period of darkness — some thrive on about one meal a 
 week, but they appreciate the fact that he who is not well fed can- 
 not encounter fierce storms, and no one who has not had full rations 
 would think of venturing out in severe weather. During the tedious 
 night of four months these Eskimos appear to undergo a state of 
 hibernation, eating very little and sleeping a great deal ; their other- 
 wise lively spirits are more or less subdued, and while they try to 
 keep cheerful they are apt to become depressed and debilitated, and 
 they are not capable of great muscular exercise during this time. 
 When the sun returns their skins are somewhat jaundiced, and they 
 are very anaemic. This peculiar effect was also produced in the 
 members of our party in a more exaggerated form, although we 
 tried many methods of overcoming the depression, and though we 
 had no trace of scurvy our will powers were lessened, and our 
 ambition was, to some extent, lost, and our muscular power as well 
 was much reduced, so that a walk of a mile produced exhaustion. 
 All of the secretions were diminished, particularly those of the 
 digestive tract, and to stimulate these taxed my mental skill for the 
 greater part of the winter of i89i-'92, but with us, as with the 
 Eskimo, as soon as the sun returned our strength and ambition 
 came back, and we felt as if we had gained a new lease of life and 
 were ready to encounter any hardship. 
 
 " The Eskimo drinks very little while eating. He usually defers 
 that for some time afterwards, or perhaps until he arises next morn- 
 ing, when he drinks a great deal, and while I have not measured 
 the quantity of water consumed by any definite number of inches 
 in twenty-four hours, I have often given Eskimo men three pints 
 of water at one time, and nursing women two quarts. Before start- 
 ing upon a journey a native will fill up with water. It should be 
 remembered that these people use no free salt or condiments. 
 
 " I am not prepared to say that the food of these people bears 
 any relation to their stature, as other factors may influence their 
 height, but their large abdominal development is undoubtedly due 
 to the immense quantity of food and drink which they consume at 
 one time. Variation in diet does not seem to be a necessity to the 
 
318 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 Eskimo unless he is feeling ill, when he recognises the importance 
 of a change of food and surroundings. He will always hail with 
 pleasure the first bird, deer, or walrus of the season. 
 
 " The Eskimo's clothing is such a perfect non-conductor that the 
 temperature does not vary much around his body, and in summer it 
 is practically the same as in the coldest day of winter. For this 
 reason, the extreme cold of winter does not call for a large quantity 
 of food, but a native knows that his food is fuel for his body, and 
 that he must take it in sufficient quantity to develop muscular power 
 and animal heat. 
 
 " The Eskimo mother nurses her child until the next is born or 
 shortly before it, a period which varies in from one to eight or nine 
 years, but the average time is four years. Long before the mother 
 weans her child she masticates the food, opens the baby's mouth, 
 and transfers the food from her own mouth to the baby's, very much 
 as a pigeon does, and the child thus brought up would not think of 
 taking up pieces of meat or toys or anything else to put into its 
 mouth, for it will take nothing except from its mother. 
 
 " The members of our expedition took very few forced marches 
 in low temperatures. The one over the interior of Greenland was 
 undertaken at the time of year when the thermometer ranges from 
 5° F. below zero to 40 above. 
 
 " The quantity of food consumed per man every twenty-four 
 hours upon this expedition was as follows :: 
 
 Pemmican i£ pound. 
 
 Bacon, fat 6 ounces. 
 
 Powdered pea soup 2 
 
 Dry ship biscuits 12 ' ' : 
 
 Condensed milk 3 " 
 
 " A quart of tea with perhaps a pint of water was our only drink,. 
 but we had no drink through the day while on the march, and often 
 were unable to secure more fluid than two cups each morning and. 
 night. The pemmican was composed of dried beef and beef tallow, 
 half and half, a few currants, and a little sugar, but no salt. On 
 several expeditions during the spring of 1892, while the thermometer 
 ranged from 20 to 40 F. below zero, the members of the party 
 always consumed large quantities of food. This was not, however, 
 until they had been out two or three days, when the amount of 
 food which they could devour seemed almost unlimited. There 
 was no time that we craved for fat. We enjoyed the pemmican 
 immensely, but that was because we had nothing else. During the 
 extreme cold weather, while in the field, we took more kindly to 
 fats, but never in preference to other foods. Canned meats, for 
 some unexplained reason, were soon in disfavour,- for the variety 
 and character of the food seemed to be of very little consequence ;. 
 
DIET AND RACE 
 
 319 
 
 indeed, our appetites were such that we were ready to eat anything 
 and everything placed before us. We were, however, always liber- 
 ally supplied with hydrocarbons, and I believe had this not been 
 the case, a demand for them would soon have arisen, for the most 
 valuable food for a polar expedition is composed largely of hydro- 
 carbons. 
 
 44 The most important articles of diet for a polar expedition we 
 found to be pemmican, cranberry sauce, tea, coffee, chocolate, pre- 
 served milk, sugar, ham, cheese, bacon, oleomargarine, lard, pickles, 
 lime juice, dried fish, beef-soup tablets, wheat, corn, rye flour, rice, 
 hominy, oatmeal, dried vegetables, and a liberal supply of all kinds 
 of canned vegetables, particularly canned tomatoes, peas, beans, 
 corn, canned soups, and dried fruits. Lime juice was not served 
 regularly to the members of the expedition, and I think nothing is 
 to be gained by so doing. For some of the members of the party 
 it was decidedly injurious, but others called for it occasionally as 
 a refreshing drink. 
 
 " The average weight of these northern Eskimo men is one hun- 
 dred and thirty-five pounds, but that of the women one hundred 
 and eighty-eight pounds. Obesity is foreign to the Eskimo, and 
 leanness is equally rare." 
 
 Studies of negro diet have been made for the United States De- 
 partment of Agriculture (Bulletin No. 71, 1899) by H. B. Frissell 
 and Isabel Bevier, with the following result : 
 
 Cost, Nutrients, and Fuel Value of Food per Man per Day in Dietary 
 Studies in Virginia and Flsewhere 
 
 DIETARIES OF NEGROES IN ALABAMA 
 
 Dietary with minimum protein 
 
 Dietary with maximum protein 
 
 Dietary with minimum energy 
 
 Dietary with maximum energy 
 
 Average of 20 negro families in Alabama 
 
 Average of 19 negro families in Virginia 
 
 AVERAGES OF OTHER DIETARIES 
 Average of 4 Mexican families in New Mexico. 
 
 Average of 14 mechanics' families 
 
 Average of 10 farmers' families 
 
 Average of 14 professional men's families 
 
 Tentative standard for man at moderate work . 
 
 Cost. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Cents. 
 
 Grms. 
 
 Grms. 
 
 Grins. 
 
 4 
 
 26 
 
 83 
 
 225 
 
 11 
 
 99 
 
 252 
 
 666 
 
 5 
 
 3i 
 
 27 
 
 304 
 
 12 
 
 93 
 
 283 
 
 649 
 
 8 
 
 62 
 
 132 
 
 436 
 
 11 
 
 109 
 
 159 
 
 444 
 
 8 
 
 94 
 
 71 
 
 610 
 
 !9 
 
 103 
 
 I50 
 
 402 
 
 
 97 
 
 130 
 
 467 
 
 28 
 
 104 
 
 125 
 
 423 
 
 
 125 
 
 
 
 Fuel 
 value. 
 
 Calories. 
 1,800 
 5.480 
 1,625 
 5-670 
 3,270 
 
 3,745 
 
 3,55o 
 3,465 
 3,5i5 
 3,325 
 
 3,50o 
 
 The preponderance of protein in the diet of Virginia negroes 
 as compared with those investigated in Alabama is due to resi- 
 dence nearer the sea and large consumption of fish, especially salt 
 herring. 
 
320 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 Arthur Goss (Nutrition Investigations in New Mexico, U. S. 
 Department of Agriculture, Bulletin No. 54) gives the following 
 dietary of a Mexican living in New Mexico and an Alabama negro : 
 
 
 NUTRIENTS IN GRAMMES. 
 
 Fuel value in 
 calories. 
 
 
 Protein. 
 
 Fats. 
 
 Carbohydrates. 
 
 Mexican 
 
 68 
 62 
 
 73 
 132 
 
 572 
 436 
 
 3,320 
 
 Negro 
 
 3. 2 70 
 
 
 
 In this dietary the Mexican subsists upon but little more than 
 half of the standard requirement of protein, and the negro upon 
 less than one half. The Mexican eats chiefly flour and frijoles, with 
 little meat, and the negro subsists upon bacon, fish, and cornmeal. 
 
 CLIMATE AND SEASON AND FOOD 
 
 ,Much has been written about the need of man changing his 
 diet when he removes from one climate to another, in the belief that 
 the natives always eat the kind of food best adapted to the climate 
 in which they live. This is superficial reasoning, and too much im- 
 portance is attached to the relations of climate to diet per se. As a 
 matter of fact, the natives of a country eat what they can obtain 
 easiest, or what their habits and mode of life have accustomed them 
 to in the struggle for the survival of the fittest. " Climate affects 
 diet mainly by the supply it affords " (Chambers). 
 
 " The national dietary is determined largely by the climate and 
 nature of the available soil, and among civilised communities it is 
 largely modified as facilities for commerce and interchange of food 
 products are increased. 
 
 " Maritime people naturally derive much nitrogenous food from 
 the sea, as fish, molluscs, crustaceans, etc. Among the residents 
 of the far North albuminous and fatty diet predominates, and the 
 coarser cereals — barley, rye, oats, etc. — being more hardy, predomi- 
 nate in their food. Barley grows the farthest north of all the cere- 
 als " (Clark). 
 
 The Hindu subsists mainly upon rice, one of the simplest types 
 of farinaceous food, and he derives his nitrogen from corn and len- 
 tils. He must consequently eat a large bulk of food in order to 
 obtain sufficient nitrogen for the needs of the system ; his digestive 
 organs enlarge, and he finds the means of stimulating them by the 
 free use of condiments of various sorts. Bulky and fibrous vege- 
 table food distends the alimentary canal. The natives of very hot 
 countries live mainly upon vegetable and starchy foods, eating cere- 
 als, green vegetables, and pulpy fruits which contain water, salts, 
 and acids in abundance, which are cooling and refreshing. As a 
 
CLIMATE AND SEASON AND FOOD 321 
 
 rule, they eat less animal food than do the natives of temperate and 
 arctic regions, nor do they require fats in excess, although they take 
 some fats and oils. 
 
 While these statements apply to a majority of mankind, they are 
 by no means without exception, and it must not be argued that 
 because a tribe eats the only food which Nature has provided, they 
 could not live equally well in their own climate upon other food, 
 if they could obtain it. Far from depending solely upon vege- 
 table food, most savage tribes living in the torrid zone eat meat 
 ravenously when they can get it, and often prefer it in an advanced 
 stage of decomposition. 
 
 The New Zealander and South Sea Islander choose a varied diet 
 of fish, eggs, roots, seeds, berries, seaweeds, and meat if obtainable 
 (see p. 32). 
 
 As pointed out by Chambers, the Pampas, who eat flesh and 
 drink water only, thrive on hot arid plains, and so do the Nubian 
 Arabs, while the peasants of northern Norway and southern Spain 
 live alike almost wholly on breadstuffs without meat. He says that 
 " the immediate transition from a purely animal to a purely vege- 
 table diet, though borne by the individual, is fatal to the race," and 
 " the best diet in the abstract is a mixed diet, and mixed in the 
 proportion selected by the experience of most civilised nations, and 
 it is also best for the individual who is accustomed to it to adhere 
 to under whatever sky he may be wandering." In changing resi- 
 dence from one extreme of climate to another it is not advisable to 
 alter the diet too suddenly, and more must depend upon the previous 
 habits and occupation of the individual than upon external tem- 
 perature. Meat eaters find it easier to adopt quickly another form 
 of diet than vegetarians. The Dominican friars deteriorated so much 
 in health in the British climate that they were obliged while resident 
 in England to obtain special dispensation allowing them to eat meat 
 four times a week. 
 
 The English soldiers transported to India or Africa are not re- 
 quired to become exclusive vegetarians ; and the French in Africa 
 or Panama have done best upon a mixed diet. In the United States 
 Surgeon General's report for 1900 the statement is made that " ex- 
 perience in the Philippines has shown that though it is undoubt- 
 edly true that while leading quiet lives men eat less in a tropical 
 climate than in a temperate or cold climate, and particularly of 
 meat or fatty substances, our soldiers during the active operations 
 of last year have shown no marked tendency to lessen the quan- 
 tity of fresh meat eaten. Exhausting labours and fatigues with 
 corresponding wear and tear of the muscular system require a 
 liberal meat issue, which the soldier uses with satisfaction and ad- 
 vantage." 
 
 " Well-clad and sheltered soldiers require less rations than poorly 
 
322 FOODS REQUIRED FOR SPECIAL CONDITIONS 
 
 clad men exposed to the weather — a good thing to know in times 
 of great privation " (Woodruff). 
 
 Men often become involuntary vegetarians while travelling in 
 hot climates from inability to procure meat, and may partially starve 
 themselves from lack of appetite for monotonous food, variety being 
 unobtainable. This leads them to resort to strong condiments, 
 spices, curry, etc., to stimulate the appetite. 
 
 Many persons, especially those past middle life and people with 
 a tendency to corpulency, find that during the heat of the summer 
 season, and especially during the prevalence of " heat waves," they 
 are in much better health when they abstain from hot soups, fat, 
 and meat, and take but little animal food of any kind. The total 
 quantity of food eaten may advantageously be reduced at this time 
 of the year as much as one sixth, or even one fourth. Most persons 
 find this out as a matter of individual experience ; but there are 
 others who should be especially directed in the matter, and the rule 
 applies to infants as well as adults. The diet in winter should com- 
 prise both more nitrogen and more carbon than in summer. 
 
 The breakfast hour is often made half an hour or an hour earlier 
 in summer than in winter to advantage. 
 
 The thirst engendered by living in hot climates is conducive to 
 excessive drinking, and as the water is often bad, an additional ex- 
 cuse is often made for drinking too much liquor. By these means 
 the foundations for hepatic and renal troubles, cirrhosis, and Bright's 
 disease are often laid. On this account, in very hot climates strong 
 alcoholic drinks ought especially to be avoided. In India they uni- 
 formly disagree, and lighter beverages, such as beer and wines, must 
 be taken very sparingly ; but there is no objection to tea, coffee, and 
 chocolate. 
 
PART V 
 
 FOOD DIGESTION.— CONDITIONS WHICH ESPE- 
 CIALLY AFFECT DIGESTION 
 
 HOURS FOR MEALS AND ORDER OF TAKING FOOD 
 
 The hours for taking meals which are commonly selected are 
 those which are best adapted to the varying needs of the system at 
 different times in the day, and experience teaches that they must be 
 varied considerably with occupation. In the larger American cities 
 where commerce is active, and many men are subjected during the 
 day to excitement, hurry, and strain, an evening dinner hour often 
 best meets the needs of the system as well as the requirements of 
 personal convenience. In the rural districts, however, and in many 
 countries where life is less hurried and active than under the condi- 
 tions of the extraordinarily rapid growth and development of the 
 United States, it is found that taking the heaviest meal at noon 
 agrees better with the wants of most persons. The hours for infant 
 feeding are described under the heading Infant Feeding. 
 
 Children should always dine early in the day. There are in gen- 
 eral three systems for adults in regard to the number of meals 
 and hours for taking them which are in common use, in which two, 
 three, and four meals, respectively, are eaten in the twenty-four 
 hours. 
 
 The first system, which is in vogue in France and, to a less extent, 
 elsewhere, is that of eating but two substantial meals a day. On 
 first rising in the morning, a cup of hot coffee or chocolate is taken 
 with a roll or some other simple form of bread. This enables two or 
 three hours of moderate work to be accomplished before the first 
 real meal, which is a breakfast eaten in the late morning, usually 
 at or before twelve o'clock. This meal is substantial, consisting of 
 several courses of solid food. The second meal, which is the dinner, 
 is usually eaten between six and seven o'clock. This system is in 
 use among workingmen as well as with the leisure classes, and is 
 found well adapted to their habits of life. Americans travelling 
 abroad, who are accustomed to eat a heavier meal for breakfast, often 
 
 323 
 
324 FOOD DIGESTION 
 
 find some difficulty in adapting themselves to the French custom, 
 but many learn to like it, and as the travelling public are commonly 
 for the time being, a leisure class, it is less difficult to adapt them- 
 selves to new customs abroad than to introduce them at home. 
 
 The Germans also usually take a cup of coffee or other light 
 beverage and a roll or Butter-brod soon after rising, but they dine 
 very early, often at half-past twelve, taking a heavy, deliberate meal 
 at this hour, which they are apt to follow with beer and tobacco. 
 Their offices and banks open early, and are often closed from noon 
 until three o'clock, when they are reopened until five, whereas in 
 most cities in this country the most active business hours are in 
 the middle of the day, and it would be practically impossible for 
 many men to give up two or three hours at this time to eating and 
 social converse. The Germans usually take a supper with meat at 
 a somewhat late hour — between half-past seven and eight o'clock. 
 In many German towns it is customary to open the theatres as early 
 as six o'clock, so that the performance is closed in time for a supper 
 at nine. The habit of eating between meals and of taking occa- 
 sional light lunches in the afternoon seems to be more prevalent 
 there than elsewhere. 
 
 In England it is a very common custom for the better classes 
 to breakfast at eight or nine o'clock, lunch or dine between one and 
 two, take a cup of tea and perhaps a biscuit at four or five, and 
 dine or sup at eight o'clock. 
 
 In the United States, where there are theoretically no class dis- 
 tinctions, they practically do exist very strikingly in regard to the 
 hours for taking meals, and the hard-working labouring class, 
 whether employed in the city or country, almost universally dine 
 at noon. It is mainly the mercantile and professional classes in large 
 cities who dine between 6 and 7 p. m., while the more fashionable or 
 leisure classes dine even later — sometimes at eight o'clock. Most 
 of the latter, however, on going to the country for a summer holi- 
 day, are accustomed to reverse their habits and dine at the usual 
 country hour — at one o'clock, taking supper at half-past six or seven. 
 In the Southern cities it is quite common to dine in the neighbour- 
 hood of half-past two or three o'clock. Many persons in cities who 
 habitually dine late on week days from long-continued custom, on 
 Sundays dine shortly after noon, taking supper in the evening. This 
 is an old custom handed down from days in which less exacting 
 occupations favoured noon dining throughout the week, but due in 
 part also to economical reasons, and a desire to make the work for 
 servants as light as possible on Sunday afternoon. While those in 
 good health with active digestion suffer no inconvenience from thus 
 changing the hour for meals on one day in the week, there are others 
 who find that it disagrees with them and disturbs their digestion. 
 A hearty meal at noon following a very light breakfast, consisting 
 
HOURS FOR MEALS AND ORDER OF TAKING FOOD 325 
 
 of a roll and cup of coffee or tea, may be perfectly digested for 
 years, yet reversing the order of the meals may entirely disorder 
 the digestion. 
 
 For professional and other classes of men in the United States 
 who are not occupied in physical labour or outdoor pursuits the 
 following system is found to possess decided advantages : A break- 
 fast is taken soon after rising, at half-past seven to half-past eight, 
 which consists of fresh fruit, porridge or oatmeal, or other varieties 
 of cereals, poached eggs or omelet, and a little bacon or fresh or 
 salt fish, bread and butter, tea or coffee. The lunch, eaten between 
 one and two o'clock, may consist of a lean chop, or a piece of cold 
 ham, or a slice of rare beef with some stewed or baked potatoes, 
 with a simple lettuce salad, or perhaps a little cheese for dessert. 
 If a heavy meal is taken at this hour by persons unaccustomed to 
 it, and who have had a breakfast of solid food, they often feel dull 
 and sleepy for an hour or two thereafter, and are consequently 
 incapacitated from active mental exercise. The dinner should be 
 from half-past six to half-past seven, after the principal labours of 
 the day are over, and at an hour early enough to allow of the com- 
 plete digestion of the heaviest meal of the day before retiring. This 
 may consist of several courses, which are conventionally arranged 
 in the order which appears to be most rational and physiological — 
 namely, soup, fish or an entree, a steak or joint with potatoes and 
 one or two fresh vegetables, a salad, and a light pudding or cooked 
 fruit. 
 
 A clear soup at the commencement of a meal does not interfere 
 with digestion, but favours it. The fluid, if taken in a quantity not 
 exceeding eight or ten ounces, is, for the greater part, promptly 
 absorbed in the stomach, and its warmth and the sustenance it con- 
 tains act favourably upon the circulation, stimulate the secretion of 
 gastric juice, and satisfy temporarily the cravings of hunger which 
 are not met by the taking of solid food until after it has been 
 digested for some time. The fish or entree is then eaten in the 
 earlier stage of gastric secretion when the gastric juice has not yet 
 attained its full strength and quantity. This is followed by the eat- 
 ing of meat, which is destined to remain in the stomach for several 
 hours, and requires all the energies of its digestive processes. The 
 saccharine or farinaceous food, which does not undergo digestion 
 in the stomach, is taken towards the end of the meal, when it remains 
 a less time in the stomach than animal food. 
 
 The discussion of more elaborate dinners, consisting, as they 
 do very often, of a dozen or more separate courses, w r ould be out 
 of place in this volume. Such dinners can only be indulged in for 
 any length of time by those whose digestion is robust and whose 
 leisure and comparative freedom from care and anxiety allow them 
 to devote abundant time and physical energy to their meals and to 
 
326 FOOD DIGESTION 
 
 secure sufficient holidays and trips to noted spas to enable them 
 to periodically relieve the digestive system of the strain put upon 
 it. Persons who rise late and dine early should eat but a small 
 breakfast and a hearty supper. If the noon dinner is replaced by 
 a light luncheon, a substantial breakfast should be eaten. 
 
 Undoubtedly it is usually best to so order one's occupation that 
 neither severe mental nor physical labour need be undertaken imme- 
 diately after eating. Yet much depends upon the age and strength 
 of the individual. 
 
 At one of the largest colleges for girls in New England the pupils 
 dine at one o'clock, and many of them commence to study imme- 
 diately thereafter, or at 2 p. m. ; yet cases of indigestion are com- 
 paratively infrequent among them ; and the ordinary day labourer 
 begins his work again without detriment almost immediately after 
 a hearty noon meal, and continues it while gastric and intestinal 
 digestion are still necessarily incompleted. 
 
 Invalids often require modification in the accustomed hours for 
 meals, and Balfour says that " all invalids should have their impor- 
 tant meal in the middle of the day." 
 
 Between four and five hours, on the average, must be regarded 
 as necessary for complete digestion of a mixed meal. 
 
 The intervals between meals should be regulated with reference 
 to individual peculiarities. As a general rule, convalescents or per- 
 sons with feeble digestive powers and poor appetites, who are unable 
 to eat a sufficient quantity of food at any one meal, should be fed 
 more frequently, perhaps four or five times — that is, in addition to 
 three ordinary meals, they should have light lunches in the middle 
 of the forenoon and afternoon, or possibly just before retiring. The 
 latter is particularly to be recommended, for if the food be light 
 and nutritious, such as a bowl of gruel and a glass of hot milk, or 
 a cup of cocoa with a biscuit, and possibly a glass of beer, sleep is 
 not interfered with, but is promoted, and the system is saved from 
 too long an interval of starvation between the hours of dinner or 
 supper and breakfast. On the other hand, dyspeptics and patients 
 with gastric catarrh may find it desirable to allow an interval of fully 
 seven hours between their meals, in order to give abundant time for 
 the digestion of one meal before that of the next is undertaken, and 
 they should stop eating short of repletion. 
 
 There are others whose digestion is good, but constitutionally 
 slow, and they are better with intervals of at least six hours between 
 their meals ; and there are some people who keep in better health 
 on only two meals a day, and occasionally, although it must be 
 regarded as an eccentricity, except in the case of some savages and 
 the Eskimos (see p. 315), there are persons who thrive upon but 
 one meal a day. 
 
 The monks of La Trappe eat but one meal daily, as a religious 
 
APPETITE 327 
 
 custom, at which they consume so much food that they become dull 
 and lethargic for several hours afterwards (Combe). 
 
 Many savages, like the Hottentots, have no regular times for 
 eating, but, like the carnivores, take their food whenever and how- 
 ever they can best obtain it. 
 
 The business or professional man when overworked sometimes 
 forms the habit of omitting his noon luncheon ; but this custom, 
 although it may benefit some forms of dyspepsia, is a pernicious 
 one in the majority of instances if long continued. 
 
 APPETITE 
 
 The term " appetite " in relation to dietetics usually means a 
 pleasurable desire for food or drink, whereas hunger and thirst im- 
 ply a craving for food and drink respectively, which has become 
 disagreeable or positively painful. There is, however, no distinct 
 line of demarcation to be drawn between these terms. 
 
 The appetite for food is a most capricious sensation, subject to 
 all manner of disturbing influences. It is to some extent appar- 
 ently under control of the will, in that it can be trained to recur at 
 certain intervals before taking food. In a normal state it is, there- 
 fore, rhythmical, and it may then be taken as an index of the need 
 of food, but when it becomes abnormal it is a very unreliable guide. 
 
 " As a general rule, though by no means without exception, sub- 
 stances pleasing to the palate are useful and not injurious to the 
 organism " (Brunton). 
 
 The appetite often appears with great suddenness, either inde- 
 pendently or as the result of directing the attention to matters of 
 food and eating. It may depart as suddenly, even without gratifi- 
 cation, or it may vanish after the first few mouthfuls of food are 
 eaten, although it was apparently vigorous a moment before. 
 
 The appetite is aroused by a variety of circumstances and con- 
 ditions, both physical and mental. Such are the smell, taste, and 
 sight of food, good hygienic surroundings, exercise, bathing, cold 
 or stimulating air, agreeable companionship, pleasurable mental 
 emotions, and the proper preparation and serving of food. It may 
 be stimulated by bitters, condiments, such salt foods as caviare or 
 herring, and in some cases by alcohol. Wine drunk between meals 
 is apt to spoil the appetite, but taken in moderation with meals it 
 may increase it. A substance known as orexine, in the form either 
 of a hydrochlorate, tannate, or simple basic condition, has been 
 recommended as having the special function of exciting the appe- 
 tite in convalescents. It does not, however, give uniform results, 
 and I have seen little or no benefit from its use. 
 
 To obtain the most complete satisfaction from the sense of taste 
 one should swallow the food, and not merely take it into the mouth. 
 23 
 
328 FOOD DIGESTION 
 
 The appetite is usually somewhat more keen in winter than in 
 summer, but many persons observe no difference. It is depressed 
 or destroyed by mental emotion, especially grief, anxiety, and worry ; 
 by the sight, smell, or taste of ill-prepared or improperly cooked 
 or badly served food ; foul air and poor hygienic surroundings ; 
 fatigue and exhaustion; many diseases, more particularly febrile 
 diseases and most gastric disorders ; nausea ; the abuse of strong 
 condiments, and of many drugs, notably opium and those which, 
 like potassium iodide, produce a continual offensive taste in the 
 mouth ; the abuse of alcohol ; eating irregularly and at too short 
 intervals. 
 
 In old age the appetite, especially for meats, usually becomes 
 less keen, and the absence of teeth contributes to the loss of desire 
 for this kind of food. There is often a dislike for cold fluids. 
 
 A voracious appetite sometimes occurs in children and youth. 
 
 Bulimia is the name given to this condition, which is by no means 
 an indication of vigour, and is often due, according to Beale, to an 
 irritable condition of the nerves of the stomach, and may be brought 
 about by eating at irregular intervals, which results in disturbance 
 of the gastric secretion. Such children are usually thin, and are 
 encouraged by ill-advised parents or attendants to gorge themselves 
 with food which they do not digest. It is a popular belief that the 
 presence of intestinal worms excites a ravenous appetite. In some 
 cases this may be true, especially of round worms {Ascaris lumbri- 
 coides), which are very active, and which may even throw a child 
 into convulsions by local irritation of the intestine. On the con- 
 trary, worms of any sort may be present in considerable number 
 without giving rise to symptoms. Persons whose appetites ex- 
 ceed their digestive strength do well to eat very slowly. By so 
 doing, the food eaten at the first part of a meal may become 
 partially absorbed and lessen the desire for more before the meal 
 is over. 
 
 The appetite is very dependent upon habit and upon the usual 
 order and arrangement of the meal. An attempt to eat a lump of 
 butter alone usually fails, but it is easily consumed if spread upon 
 bread. Reversing the customary order of the different foods served 
 at a dinner usually produces disgust, and may even excite nausea. 
 
 Abnormal Cravings 
 
 Instances of abnormal cravings for food are familiar to every 
 one. They sometimes take the form merely of an inordinate desire 
 for food which is in itself wholesome but which is poorly adapted 
 to an existing diseased condition. Such desire is apt to come in 
 the course of any protracted illness in which a very restricted diet 
 has been maintained for weeks. It is largely psychic, and does not 
 
VARIETY IN DIET 329 
 
 necessarily indicate an increased appetite. The dysenteric patient 
 may long for ham or pickles or vegetables, or the very obese will 
 beg for sweets, preserves, or farinaceous food. 
 
 In other cases the craving may be an indication of a positive 
 want in the system, as when a scorbutic patient hungers for fresh 
 fruit and vegetable acids. 
 
 In no disease is the craving for food of every kind more pro- 
 nounced than in convalescence from typhoid fever. In this case 
 the hunger can hardly be considered abnormal, for it is an expres- 
 sion of the need of wasted and exhausted tissue throughout the body 
 for nutriment. 
 
 Patients usually find it most difficult to give up the class of foods 
 which they well know does them most harm. The subject of flatu- 
 lent dyspepsia longs for saccharine, and perhaps amylaceous or fatty 
 foods — confectionery, pastry, and the like — and the diabetic some- 
 times has an inordinate craving for bread, which so far possesses 
 him as to cause a resort to any subterfuge to obtain it. 
 
 In disordered mental conditions, hysteria, hypochondriasis, mel- 
 ancholia, and in the peculiar periods of puberty, pregnancy, and the 
 menopause, cravings for wholly injurious articles may occur. Such 
 patients have been known to eat chalk, or sour food, or consume 
 large quantities of salt, sodium bicarbonate, etc. 
 
 With the exception of chronic alcoholism — if alcohol be regarded 
 as a food as well as a stimulant — there is no distinct food " habit," 
 in the sense that any particular food is likely to be long eaten to an 
 injurious excess. Those articles of diet which are oftenest abused 
 are condiments and confectionery. 
 
 VARIETY IN DIET 
 
 Monotony of diet is not incompatible with maintenance of life, 
 and even of health, when the food is restricted to two or three 
 articles only, but for the reasons given in discussing the force value 
 of different foods (p. 7) there is no single food, not even milk, 
 which will support man in ordinary health and vigour for long. 
 There are many primitive races and tribes of man who live comfort- 
 ably upon a diet so restricted that it would soon prove unbearable 
 for a European or an American. Much, therefore, depends upon 
 custom, and no doubt upon heredity. The Hindu eats boiled rice 
 and ghee, or melted butter, and the low-caste Chinese eats rice to 
 the almost, but not complete, exclusion of other food ; the Eskimo 
 lives upon one or two kinds of meat or fish, and a little fat; and 
 the Congo native subsists chiefly upon the plantain. The Central 
 American Indian lives almost entirely upon maize, and some of the 
 Polynesians eat bread-fruit alone for two thirds of the year. The 
 roving Indian of the North American plains originally subsisted 
 
330 FOOD DIGESTION 
 
 all winter upon a diet of salt meat, and the Scotch peasants formerly 
 lived for six days in the week upon oatmeal porridge. 
 
 Such a monotony of diet is, however, usually a question of en- 
 vironment and not of choice. The carnivorous Eskimo enjoys 
 canned vegetables when they are offered to him, and the vegetarian 
 African native gorges himself with meat when he can obtain it. As 
 a rule, the more civilised the tribe of man the greater is the variety 
 of his diet, and once accustomed to variety, it is very difficult to 
 subsist upon a too restricted regimen. It is the ability to subsist 
 upon a variety of foods which makes it possible for man to adapt 
 himself so well to his environment when he migrates from one 
 extreme of climate to another. 
 
 This adaptation is also possible because the elementary foods 
 possess general nutritive properties for all the organs of the body, 
 rather than special value for individual structures ; for example, 
 there is no " brain food " in distinction from food which nourishes 
 other organs as well. 
 
 An ideally perfect food combination if made upon purely theo- 
 retical considerations of the needs of the body for just so much 
 albumin, fat, starch, sugar, salts, and water would be a compound 
 which in a very short time would become too monotonous and 
 wearisome to be eaten. Even the domestic animals are kept in 
 better condition by occasional slight changes in diet — such, for in- 
 stance, as are afforded by change of pasturage or the variety which 
 the season of the year produces in their natural food ; and it is well 
 known that the flavour of the meat of fish and wild animals depends 
 upon the nature of their diet. For example, canvasback and redhead 
 ducks are much more palatable while feeding upon the wild celery 
 plant than when eating other food, domestic turkeys and capons 
 improve when fed upon grain, swine flesh is made better by feeding 
 the animal with corn than with skimmed milk, and salmon and 
 shad acquire a more delicate flavour when feeding in fresh-water 
 rivers. 
 
 In a report of digestion experiments made for the United States 
 Department of Agriculture (Bulletin No. 85, 1900) by Charles D. 
 Woods and L. H. Merrill, the statement is made that " it is a matter 
 of common observation that digestion experiments made with one 
 kind of food material do not give on the whole as reliable results 
 as those in which two or more food materials are used. In other 
 words, it appears that with a mixed diet the same person will digest 
 a larger proportion of nutrients than with a diet composed of a 
 single food material." 
 
 Among some peoples the variety of food is considerably re- 
 stricted by religious observances, custom, and associations. For 
 instance, there is the Buddhist prohibition of meat and the Jewish 
 prohibition of swine flesh. When a variety in food cannot be se- 
 
 ^ 
 
THE NERVOUS SYSTEM AND DIGESTION 33 1 
 
 cured the desired effect in stimulating the appetite and digestive 
 secretions may be obtained by altering the methods of cooking and 
 by modifying the taste and odour of food. On the other hand, too 
 great variety, as well as too elaborate cooking, becomes equally 
 tiresome. Those who eat constantly at restaurants and large hotels, 
 where the table is greatly diversified, often find that a change to 
 a simpler home table agrees with them better. 
 
 Woodruff attributes the decrease in drunkenness in the past few 
 years in the United States army to the advantages accruing from 
 a much greater variety in diet since fresh vegetables were made a 
 part of the ration, and since by a system of exchange the soldier has 
 been enabled to barter an excess of common ration food for a few 
 articles of luxury. He also says : " Variety is necessary in the army 
 for another reason : When the diet is very simple there is apt to 
 be constipation, and in the field this condition is sometimes quite 
 marked. It is recognised by physicians that chronic constipation 
 cannot be properly treated with drugs, and it must be rectified by 
 diet. The field ration, if possible, should overcome this tendency 
 to constipation. Sluggishness of the bowels quite commonly goes 
 along with discontent, homesickness among soldiers, and in such 
 conditions the soldier is not a reliable fighter — he is easily beaten." 
 
 THE NERVOUS SYSTEM AND DIGESTION 
 
 The influence of the nervous system on digestion is very com- 
 plex. In a general way, the peripheral nerves may affect the digest- 
 ive process (a) through the circulation, (b) through motion, (c) 
 through glandular action. The nerves chiefly concerned in these 
 processes are the branches of the sympathetic system and the vagus. 
 The latter, through its association with the cardiac, vasomotor, and 
 respiratory centres in the medulla oblongata, places the vital func- 
 tions of the body in very intimate connection with food stimu- 
 lation acting through the branches of the nerve in the alimentary 
 canal. 
 
 (a) Action through the Circulation. — The nerves influence diges- 
 tion through the circulation by their vasomotor control, regulating 
 the calibre of the vessels and quantity of blood supplied to the walls 
 of the alimentary canal, the local blood pressure, and the consequent 
 rate of absorption. 
 
 (b) Action through Motion. — The nerves influence the movements 
 of the entire alimentary canal, either accelerating or inhibiting them, 
 thus controlling the propulsion of the food, its admixture with secre- 
 tions, and its contact with absorbing surfaces. 
 
 (c) Action through the Glands. — The nerve supply of the digestive 
 glands is distributed to their blood vessels, and also probably to 
 some extent to the cells of the gland parenchyma. This latter dis- 
 
332 FOOD DIGESTION 
 
 tribution is not always demonstrable histologically in man, but the 
 influence is unquestionable. 
 
 Under normal conditions, the nerves act mainly in connection 
 with the digestion through reflex stimulation produced by mechan- 
 ical irritation of food and by the chemical irritation of its different 
 ingredients as they undergo absorption. But, in addition, nerve cur- 
 rents from the central nervous system or from a remote peripheral 
 origin may interfere with the normal nerve functions. Every one is 
 familiar with examples of acute indigestion produced by fatigue of 
 the nervous system, undue mental excitement, emotion, etc. For 
 any given phase of digestion, disturbance of normal nerve function 
 will retard the process more in its earlier stages by checking or alter- 
 ing gland secretion. In its later stages the effect of the nervous 
 system will be more pronounced in controlling or inhibiting absorp- 
 tion. Overstimulation of the local nerves of the alimentary tract 
 may excite an increased watery secretion and exaggerate peristaltic 
 movement of the intestines, thereby hastening the passage of the 
 food through them before there is time for digestion or absorption, 
 and giving rise to diarrhoea. 
 
 CIRCULATION AND DIGESTION 
 
 The influence of the circulatory system upon digestion appears 
 in the composition of the blood and in its rate of supply to the 
 digestive glands. Vigorous active circulation accompanies good 
 digestion and maintains a normal local reaction and temperature, 
 and feeble, sluggish circulation produces local congestion of the 
 viscera and interferes with gland secretion and absorption. When 
 the nerves of the salivary glands are experimentally stimulated in 
 animals by an electric current the blood vessels are altered in cali- 
 bre. If the chorda-tympani nerve is stimulated the vessels are dilated 
 and the rapidity of the blood flow is accelerated so that the venous 
 blood issuing from the gland is of a red arterial hue, it not having 
 lingered long enough to undergo the ordinary changes in regard 
 to its gases. The salivary secretion becomes watery and contains 
 a smaller percentage of solids. 
 
 On the other hand, when the sympathetic nerves are stimulated 
 exactly the reverse occurs. Hence the blood supply is shown to 
 alter the digestive power of a secretion by modifying its compo- 
 sition. 
 
 Blood which is impoverished in composition, watery, anaemic, 
 or deficient in albuminous ingredients, will furnish poor materials 
 for the manufacture of the digestive secretions, and, further, the 
 muscular walls of the alimentary canal will suffer from malnutrition 
 and peristaltic action will be diminished. 
 
TEMPERATURE AND DIGESTION 33, 
 
 TEMPERATURE AND DIGESTION 
 
 Both the external temperature and the internal body heat in- 
 fluence digestive processes. The effect upon the system of the 
 temperature of food and drink is also a matter of important con- 
 sideration. 
 
 Hot food and drinks in cold weather, cold food and beverages 
 in hot weather, are instinctively resorted to by almost every one, 
 although this is, no doubt, as much due to mental association and, 
 perhaps, a temporary agreeable sensation of the temperature in 
 swallowing as it is to any decided influence exerted over the body 
 temperature. 
 
 Sudden modifications in the external temperature of either exces- 
 sive heat or cold react upon the circulation, respiration, and the 
 nervous system in a variety of ways and indirectly affect the digest- 
 ive apparatus. The shock of sudden or, more particularly, of con- 
 tinued exposure to cold over the entire surface of the body tends 
 to constrict the peripheral blood vessels and produce congestion of 
 the visceral vessels, modifying secretion and absorption in conse- 
 quence. A local application of heat and of cold over the abdominal 
 wall during activity of the digestive organs has but limited influence. 
 Patients wearing a Leiter coil over the abdomen through which ice 
 water is continually passed for many hours do not necessarily suffer 
 from retarded digestion, nor do those who are having poultices con- 
 tinuously applied to the abdomen. In a series of experiments which 
 I have made to determine the extent of heat penetration through 
 the abdominal wall it has been shown that the application of heat 
 or of cold of such extremes as can be borne without discomfort has 
 little or no influence on the circulation in the stomach or the in- 
 testines or upon the temperature of those organs so long as the 
 subcutaneous circulation is vigorous. This is owing to the rapid 
 neutralisation of the heat or cold applied externally by the con- 
 stantly changing layer of blood flowing beneath the surface. In 
 dogs, a poultice of 140 F. or an ice coil with water at 34 F. placed 
 over one side of the abdominal wall does not raise the temperature 
 of a long-stemmed thermometer more than a quarter of a degree 
 when slipped beneath the abdominal wall through a perforation or 
 held immediately below the poultice or coil. If, however, the ani- 
 mal be killed, circulation ceases, and the temperature of the ther- 
 mometer will immediately be affected to the extent of fifteen or 
 twenty degrees. It is doubtful, therefore, whether enfeebled diges- 
 tion can be much influenced by the local application of warmth over 
 the abdominal wall. Many persons, however, who have a tendency 
 to intestinal indigestion find it both agreeable and salutary to wear 
 continuously a broad flannel bandage about the abdomen to favour 
 uniformity in temperature and prevent the liability of taking cold. 
 
334 FOOD DIGESTION 
 
 It is incompatible with life that the variations of body tempera- 
 ture between the highest fever and the lowest depression should 
 exceed the limits of temperature at which digestion is known to 
 proceed when artificially conducted, so that these alterations do not 
 of themselves alone destroy digestive power in the stomach. The 
 latter is usually diminished or lost during fever, but this may be 
 owing more to disturbances of the circulatory and nervous systems 
 than to increased warmth of the stomach. 
 
 Efforts to raise or lower the local temperature in the stomach 
 during digestion by swallowing, respectively, hot water or pounded 
 ice are not productive of very striking results. 
 
 It is customary, and no doubt best, to administer stimulants hot 
 in collapse from any cause. 
 
 Wunderlich, Fothergill, and others have laid considerable stress 
 upon the antipyretic value of giving all fluids very cold in fevers, 
 but I have yet to see any effect upon genuine pyrexia, as, for ex- 
 ample, in typhoid fever, depending upon whether milk or other fluids 
 were administered very hot or iced. I often prescribe hot boiled 
 milk in such cases if patients prefer it, because the quantity of heat 
 units which can be thus conveyed into the body is too small to 
 merit serious consideration. 
 
 It is a popular belief that rich wines and oils are " heating " 
 foods, and, conversely, " cooling drinks " have long been used in 
 fevers, but the use of iced fluids and of cracked ice itself for relief 
 of thirst in fevers is of comparatively recent date. It followed the 
 extended introduction of the clinical thermometer, and to this day 
 one occasionally meets with opposition from mothers to giving a 
 child with high fever anything really cold. 
 
 Hot fluids drunk also favour perspiration, and sometimes aid 
 expectoration, but this is because they are promptly absorbed and 
 added to the volume of the blood, not because they contribute many 
 heat units to the body. Winternitz endeavoured to show by sphyg- 
 mograms that the imbibition of cold fluids increases arterial tension, 
 and that of hot fluids lessens it. This may be true, but the sphyg- 
 mograph is not at all a reliable instrument, and certainly the clinical 
 application of this rule is not capable of substantiation, although in 
 giving hot-air baths to promote perspiration in Bright's disease hot 
 drinks are of undoubted service. 
 
 With practice one may learn to swallow water which is uncom- 
 fortably hot to the touch — at a temperature of 115 or 120 F. It 
 has been swallowed at even 132 F. The drinking of very hot water 
 before meals aids in cleansing the mucous membrane in cases of 
 gastric catarrh and acts as a diuretic. The rate of local digestion 
 in the stomach is comparatively little influenced by swallowing either 
 hot fluids, such as soups or broths, or hot solid foods, and similarly 
 it is not much retarded by taking such substances very cold, pro- 
 
TEMPERATURE AND DIGESTION 335 
 
 vicled in each case they are swallowed very slowly. Some food is 
 more digestible when eaten hot than cold, but with other food the 
 reverse is true. In either case it is not so much because of the 
 warming or cooling of the stomach, but because of the physical 
 condition of the food. For example, some persons who cannot 
 digest hot mutton fat can take it cold because it becomes friable 
 and mixes better with other food. Some persons with very sensitive 
 stomachs cannot take the fat of cold butter spread upon bread, but 
 can digest it if melted thoroughly into hot toast, which subdivides 
 the fat particles and keeps them from fusion. Hot boiled ham is 
 more indigestible than cold ham for many persons. Hot milk may 
 be more digestible for invalids than iced milk, yet the latter may be 
 better borne if vomiting be present. Much must depend upon habit 
 and individual peculiarities. One may begin a dinner with iced raw 
 oysters, then take hot soup, and later conclude the meal with ice 
 cream, followed by hot coffee, and yet throughout, the temperature 
 of the stomach contents does not vary so much as half a degree, 
 because the warm blood circulating so rapidly and abundantly within 
 its walls and those of the oesophagus maintains the necessary normal 
 average most favourable to digestion. Hot food is cooled and cold 
 food is warmed in swallowing, and it may be said the hotter or the 
 colder it is, the less likely it is to modify the rate of gastric digestion, 
 for these extremes of temperature necessitate slow swallowing. 
 Swallowing several tumblerfuls of iced water in quick succession 
 does cool the stomach and inhibit digestion by local reduction of 
 temperature, and also by shock to the gastric nerves ; but even this 
 effect is less than is commonly supposed. There are about fourteen 
 pounds of blood in the body, having an average temperature of very 
 nearly ioo° F., all of which in turn keeps circulating through the 
 digestive organs, and a single tumblerful of iced water poured into 
 such a volume of warm fluid would not lower the temperature of 
 the whole very much. This is why swallowing pounded ice is of 
 so little avail to control gastric haemorrhage, and much less pulmo- 
 nary haemorrhage, although it may relieve nausea somewhat. In 
 support of these statements are the results of many experiments 
 which I have made upon patients undergoing treatment by lavage, 
 to whom I have given fluids at different temperatures, which were 
 immediately siphoned out of the stomach, and tested for heat loss 
 or gain. Two tumblerfuls of ice water may be slowly swallowed, and 
 if siphoned out again in five minutes the temperature of the fluid 
 will be found to have risen to fully 95 F. 
 
 The question has often been raised as to whether the body tem- 
 perature can be permanently affected by alterations in the quality 
 of the diet. It may be definitely stated that so long as the diet is 
 abundant and nutritious it makes no difference whether man is car- 
 nivorous, a vegetarian, or lives upon mixed diet. Insufficient food 
 
336 FOOD DIGESTION 
 
 and starvation or inanition from improper food, it is well known, 
 reduce the body temperature to from one to three or more degrees 
 below normal. Excess of alcohol also reduces it. 
 
 Improper and indigestible food may cause temporary rise in tem- 
 perature, but this is usually caused by more or less gastritis or 
 gastro-enteritis, and is therefore independent of normal considera- 
 tions. The total daily variation in body temperature normally pro- 
 duced by the ingestion of food does not commonly exceed J° F., 
 but it may reach i° F. The vegetarian rabbit has as high a tem- 
 perature as a dog fed upon animal food alone. The grass-eating 
 cow has a temperature two or three degrees above man's and quite 
 equal to that of many strictly carnivorous animals. The graminiv- 
 orous pigeon has a temperature as high as that of the fish-eating 
 gull. Xo deductions can therefore be made in regard to any per- 
 manent influence of diet upon normal body temperature in healthy 
 animals or in man. 
 
 The loss of body heat consequent upon starvation and inanition 
 will be discussed under those headings. 
 
 EXERCISE AND DIGESTION 
 
 The influence of muscular exercise upon digestion is practically 
 exemplified by every one's personal experience. Violent exercise, 
 even by those of robust constitution, taken immediately after the 
 ingestion of food almost invariably retards the process if it does 
 not produce acute dyspeptic symptoms, and even vomiting. This 
 is due mainly to the modification in the distribution of the blood, 
 which during active exercise passes in large amount to the periphery 
 of the body, and in much less quantity to the abdominal organs. 
 There are also increased products of waste matter formed during 
 muscular activity which circulate in the blood, and it is possible, 
 though it cannot be definitely asserted, that they may temporarily 
 interfere with the digestive secretions. Young children between the 
 ages of four or five and ten or twelve suffer much less from the 
 influence upon digestion of violent exercise than do adults. It is a 
 common experience to see children romping and playing violent 
 games immediately after eating without necessarily provoking in- 
 digestion — a habit which would be very disastrous to adults. On 
 the other hand, exercise has a vejw important relation to diges- 
 tion when taken at proper times and in right amount. This influence 
 is to be attributed rather to the combined effect upon the circulation 
 and respiration and general functional activity of the tissues which 
 promotes their nutrition than to any special local action on the 
 stomach or intestines. Exercise of a certain kind compresses or 
 shakes the liver in such a manner as to favour the elimination of 
 bile from it and increase its functional activity. For this reason 
 
REST AND SLEEP AND DIGESTION 337 
 
 horseback riding is unquestionably the most useful form of exercise 
 for many varieties of dyspepsia and so-called " biliousness." Mus- 
 cular fatigue following activity retards digestion very much, prob- 
 ably for the reason above suggested in regard to accumulation of 
 waste matter as a result of exercise. 
 
 Moderate exercise may often be advantageously taken in the 
 morning on rising for ten or fifteen minutes in order to get into a 
 good perspiration before taking a cold bath. Such exercise with 
 dumb-bells, Indian clubs, or weights with pulleys does not harm the 
 appetite, and for some persons it is invigorating and beneficial. 
 Stronger exercise, such as bicycle riding or taking long walks before 
 breakfast, is not to be recommended unless the individual has been 
 greatly overfed the night before. In the early morning hours, with 
 an empty stomach, exposure to the influence of cold and damp, or 
 possibly to infectious diseases, is believed to be greater than at other 
 hours in the day. Physicians visiting cases of infectious diseases 
 do well to go only at a time of day when they have recently taken 
 a full meal and when they are not suffering from extreme fatigue. 
 
 Men differ greatly in the amount of exercise which they find 
 necessary to keep them in good health and maintain a normal appe- 
 tite. To keep a really vigorous man in the best bodily condition 
 he should take daily exercise amounting to one hundred and fifty 
 foot tons of work, or an equivalent of a walk on a level of about 
 nine miles ; but very few are able to accomplish this excepting day 
 labourers. 
 
 The influence of food upon muscular activity has been studied 
 by Hodge, who constructed a movable cage so arranged that any 
 movements of the animal which it contains are communicated to the 
 cage itself, and through it to a recording tambour and kymograph- 
 ion. In this manner the restless activity of the hungry animal seek- 
 ing for food about its cage is recorded, as well as the indolence pro- 
 duced by a satisfying fatty diet and the stimulating effect of nitroge- 
 nous food. For example, he demonstrated that a mouse well fed 
 on cornmeal alone may be active but a few minutes in the day. 
 whereas the same animal fed upon meat and cream alone will exer- 
 cise for ten hours out of the twenty-four. This is no doubt due to 
 combined effects of the influence of the feeling of satiety, exhilara- 
 tion, varying functional activity of different organs of digestion, and 
 of the circulation and nervous system. It is to be hoped that future 
 investigations will differentiate more clearlv between these factors. 
 
 REST AND SLEEP AND DIGESTION 
 
 The custom of spending half an hour in making a leisurely toilet 
 for dinner is beneficial in giving the rest to mind and body which 
 puts the latter into the most favourable conditions. Dyspeptics and 
 
338 FOOD DIGESTION 
 
 persons subject to an irritable or feeble digestive system can often 
 derive much benefit by observing the rule of not eating when suf- 
 fering from bodily or mental fatigue. They should lie down from 
 half an hour to one hour and quietly rest before each meal, which 
 may then be digested in comfort. Muscular fatigue and over- 
 exertion demand food for the replenishment of waste material, but 
 the immediate digestive process is much facilitated by an intervening 
 period of rest. It is often advisable for them to rest (but not sleep) 
 for a similar time after meals. The practice of sipping hot coffee 
 after dinner and of smoking a cigar is conducive to the rest which 
 should be taken, whenever possible, after the ingestion of a heavy 
 meal. 
 
 Sleep is often affected by the amount of food taken. Overeating 
 with lack of physical exercise combined with sedentary habits and 
 brain work, is very apt to produce sleepiness. 
 
 Sleep in Relation to Meals. — During profound sleep the different 
 functions of the body are all more or less reduced in activity, and 
 the motility of the stomach is lessened. The rate of circulation and 
 respiration becomes slower, and gland secretion and digestive pro- 
 cesses are retarded. For this reason, after eating a heavy meal at 
 night, it is unwise to retire for two or three hours until the stage 
 of gastric digestion is in part completed. It is true that many of 
 the lower animals, particularly the carnivorous, who eat very fre- 
 quently, are accustomed to lie down and sleep immediately after 
 taking their food, but their functions in so many ways differ from 
 those of man that but little is to be gained by a comparison with 
 them, and their sleep is usually light until digestion is accomplished. 
 On the other hand, in man, if profound sleep follows the eating of 
 a heavy meal, digestion is very apt to be disturbed. A large volume 
 of blood is kept in the abdominal vessels during digestion, and the 
 cerebral circulation must be modified in consequence. It is possible 
 also that the various products of nutrition which are being absorbed 
 into the blood may act in stimulating the central nervous system 
 in peculiar ways. Such sleep is restless, and is disturbed by dreams 
 and nightmares, and even feverishness. 
 
 On the other hand, a light doze, in cases of exhaustion and for 
 the aged, taken for half an hour after dinner, does certainly no harm, 
 and may promote digestion by allowing more blood to be diverted 
 to the digestive organs, none being required for other activities. 
 
 Persons whose health is below the average on account of disor- 
 ders of digestion and assimilation not infrequently find that they 
 become very sleepy after eating, more particularly after eating a 
 heavy meal at noon ; this condition is sometimes very annoying, and 
 always indicates a lack of balance between the income and output 
 of energy, which must be regulated by proper attention to diet and 
 exercise. Usually in such cases the difficulty consists in habitually 
 
REST AND SLEEP AND DIGESTION 339 
 
 eating more food than the system can appropriate, and cleansing 
 the body through the emunctories, with a temporary reduction in 
 the quantity of food eaten, will remove it. In other cases the trouble 
 arises from the exhaustion of the nervous system, which is unable 
 to properly conduct two functions at once — that is, to regulate diges- 
 tion and at the same time exercise the mind. Obviously, in such 
 cases, rest and tonic treatment are indicated. The food should be 
 given more often, but in small amount. 
 
 In England the custom is very prevalent among some classes of 
 people outside of the larger cities of taking four meals a day. A 
 breakfast at about eight o'clock and dinner from one to two, and 
 a heavy tea — that is, a lunch with tea and some solid food — between 
 five and six, which is followed by supper from eight to nine. This 
 practice is well adapted for some persons, especially young, growing 
 children at school (see Diet in Schools), but older children are apt 
 to overeat if they follow such a custom. An interval of from one 
 and a half to two hours should elapse between eating supper and 
 retiring, and from two to three hours between dinner and bedtime 
 if the alimentary canal is too empty ; sleep will be retarded on this 
 account, and the earlier stages of hunger before great exhaustion 
 has occurred may be accompanied by restlessness and insomnia. A 
 very little food taken into the stomach under these conditions will 
 often produce sleep promptly. The aged, whose systems are sus- 
 ceptible to slight changes in their condition or environment, are 
 liable to become sleepy after their meals, and they find it to their 
 advantage to take a brief nap after dinner ; but this sleep is not 
 usually profound, and if it is too prolonged it indicates exhaustion, 
 which should be met by more careful attention to the diet and stimu- 
 lation. 
 
 Hunger produces wakefulness and restlessness, and starvation 
 may cause persistent insomnia. Going to bed late without dinner 
 or supper results in restlessness and insomnia, which may often be 
 cured by taking a glass of hot milk, or a cup of chocolate and some 
 light farinaceous article, or a light sandwich and a bottle of beer. 
 In all ordinary cases of insomnia it is well to see what help can 
 be got from diet and regular habits before resorting to hypnotics. 
 (See Insomnia.) 
 
 In some diseases, notably diphtheria, it becomes a grave question 
 between nourishment and sleep as to which is the more important. 
 Vigorous local measures may be needed to control the spread of the 
 membrane in the throat, necessitating half-hourly applications day 
 and night, which of course interrupt sleep ; and yet the patient may 
 need to be wakened for such applications, and the giving of nourish- 
 ment and stimulants as well. Sleep is often more needful than food, 
 and it is the duty of the physician to see that there is a proper 
 balance between them. In general, in exhausting disease, protracted 
 
340 FOOD DIGESTION 
 
 typhoid or other fevers, etc., nourishment must be given once in two 
 hours day and night ; but if the patient does not fall asleep readily 
 at night after being aroused for food, the intervals may be made 
 three-hourly, and as strength returns, four-hourly. In such cases it 
 is sometimes well to relax the rule, and give the patient one good 
 night's rest of five hours without awakening him for food ; but the 
 degree of exhaustion and need of cardiac stimulants must be the 
 guide in each separate case. 
 
 MENTAL EMOTION AND DIGESTION 
 
 Strong mental emotion, such as fright, terror, or excessive ex- 
 citement of almost any kind, inhibits the digestive functions, espe- 
 cially in the stomach, but also in the intestines. Such emotion may 
 be accompanied by vascular disturbances which will react upon the 
 digestive organs, and in addition there seems to be a diversion of 
 nerve currents from their proper course. Pleasurable emotions, 
 however, affect digestion favourably, and the expression " laugh and 
 grow fat " is certainly not without physiological basis. 
 
 Hufeland wrote that " laughter is one of the greatest helps to 
 digestion with which I am acquainted, and the custom prevalent 
 among our forefathers of exciting it at table by jesters and buffoons 
 was founded upon true medical principles." 
 
 Prolonged anxiety and worry, in almost every instance, result in 
 more or less gastric indigestion and malassimilation, so that, al- 
 though the appetite may remain good, nervous dyspepsia, consti- 
 pation, and loss of weight result. 
 
 FOOD IN THE MOUTH 
 
 The proper care of the mouth in relation to diet is an important 
 subject which is frequently overlooked. In patients who are unable, 
 from weakness or the prostration of fever, to use solid food or to 
 cleanse the mouth themselves, lack of movement in the tongue and 
 buccal muscles prevents proper cleansing of the teeth, and particles 
 of food accumulate about the gums. In extreme weakness of the 
 facial muscles the jaw drops and mouth breathing results. The air 
 passing through the mouth evaporates the moisture present and 
 gives rise to dryness of the tongue, which may become so extreme 
 as to interfere with deglutition and articulation. 
 
 In such cases the mouth should be frequently moistened by the 
 nurse and swabbed out by some antiseptic, such as a saturated solu- 
 tion of boric acid or diluted Listerine. This topic will be more fully 
 treated under the heading Dietetic Treatment of Typhoid Fever. 
 
 Food which is allowed to collect in the cavities of decayed teeth 
 favours the development of bacteria, which on being swallowed may 
 
FOOD IN THE STOMACH 34 1 
 
 become a cause of dyspepsia by exciting malfermentation in the 
 stomach, especially of milk. Much bacterial filth accumulates be- 
 neath artificial teeth which are not frequently cleansed. 
 
 Imperfect or painful teeth, or swollen gums, interfere with the 
 proper mastication of food, and when such conditions are present 
 care should be exercised that all food eaten be soft and bland. This 
 applies particularly to young children, very old persons, and the in- 
 sane, who are incompetent to take care of their own mouths. 
 
 The digestion of non-nitrogenous food begins in the mouth, and 
 depends upon the activity of the salivary ferment ptyalin, which 
 converts starches into dextrin and maltose. In health this action 
 is prompt and vigorous, and much of the starchy food is digested 
 in the mouth, in its transit along the oesophagus, and also in the 
 stomach, until the gastric juice becomes so acid as to check the 
 process, for ptyalin is most active upon the alkaline side of the 
 neutral point, and strong acidity inhibits its power. Chittenden has 
 demonstrated that after neutralising saliva, ptyalin fermentation pro- 
 ceeds well in the presence of 0.005 P er cent °f hydrochloric acid, but 
 stops with 0.025 per cent. Dufresne is responsible for the state- 
 ment that ptyalin recovers its activity in the alkaline intestine, but 
 that diastase is completely destroyed by the gastric juice. 
 
 In feeble and ill-nourished persons the salivary digestion be- 
 comes much impaired, and consequently their farinaceous food 
 should be partially dextrinised artificially by diastase or by pro- 
 longed cooking. 
 
 An acid reaction in the mouth may be present because of fer- 
 mentation, not because the. saliva itself is acid. In rheumatism the 
 saliva is very often acid. This reaction causes a sensation of dry- 
 ness, lessens the taste for food, and gives rise to thirst. Saliva which 
 is rich in cells and mucus is too viscid, and does not moisten the 
 food properly during mastication. When salivation is present the 
 ptyalin becomes too dilute to have any digestive action upon starchy 
 foods. If swallowed, the too abundant saliva carries much air into 
 the stomach ; and if it is alkaline, it neutralises the gastric juice. A 
 dry diet (see Dry Diet) will sometimes improve this undesirable 
 condition. 
 
 FOOD IN THE STOMACH 
 
 Much controversy has arisen over the question as to how far the 
 stomach performs the essential work of digestion, and how far the 
 intestine is responsible for it. Some writers argue that the stomach 
 is a comparatively useless organ except as a receptacle, and that the 
 small intestine, with the different juices which are poured into it, 
 is abundantly capable of doing alone the digestive work for the 
 entire body. Ewald has said that the stomach is hardly to be re- 
 garded as having a mucous membrane, but rather as a gland. The 
 
342 FOOD DIGESTION 
 
 entire stomach has been excised from man in a number of instances, 
 and although the operation has been done for relief of malignant 
 disease (carcinoma), in several cases a fair measure of digestion has 
 been retained and the patient has lived for more than a year. In 
 these operations the oesophagus is united to the duodenum. Such 
 cases prove the ability of the intestine to completely digest all 
 classes of foods. 
 
 Of recent years analysis has shown that the digestive products 
 formed from the food in the stomach are by no means as complete 
 in all cases as was at first supposed. The only really important 
 action of this organ consists in digesting a single class of foods — 
 namely, proteids — and this process is not always finished, whereas 
 the intestine digests not only proteids, but fats, starches, and sugars. 
 The stomach serves to warm and macerate all the food, so that it 
 relieves the small intestine of much preliminary work. Gastric diges- 
 tion is hindered by either acids or alkalies used in excess, by metallic 
 salts, strong alcohol, and by regurgitation of bile from the intestine. 
 Gillespie has found as many as twenty-four varieties of bacteria in 
 the intestine, most of which are harmless. Many are introduced 
 with the food and drink. 
 
 Quantity of Gastric Juice and other Digestive Fluids 
 
 No reliable estimates of the exact quantity of gastric juice, or, 
 in fact, of any of the digestive fluids, are obtainable. At best, such 
 estimates vary greatly according to different authorities. An abun- 
 dant secretion is not necessarily an active one in ferment or acid, 
 and the constant reabsorption of the water makes it quite impossible 
 to say how much fluid has been secreted, for if the digestive juices 
 be drained off and measured, the natural conditions are disturbed. 
 Bile or pancreatic fluid allowed to drain off constantly through a 
 fistula soon becomes altered in quality and weakened in digestive 
 power. 
 
 The estimates of the total quantity of the digestive fluids secreted 
 per diem extend from three or four quarts to three gallons, and it 
 is almost impossible to make exact measurements. 
 
 Secretion of the Gastric Juice 
 
 When food enters the stomach it immediately excites the secre- 
 tion of the gastric juice. This it does at first through mechanical 
 action, either upon the nerves or the cells of the gastric tubules 
 themselves. The purely physical character of the food which is 
 taken into the stomach will therefore, to some extent, affect the rate 
 of secretion as well as the composition of the gastric juice, and 
 foods are often spoken of as being either bland or irritating. The 
 
FOOD IN THE STOMACH 343 
 
 former are those which are soft or in a fine state of subdivision, such 
 as well-cooked farinaceous articles. The latter are the coarser forms 
 of food and condiments, especially pepper, mustard, curry, pickles, 
 etc., which have a more specific influence in increasing the flow of 
 juice. This is probably due to reflex action through the nerves of 
 the gastric mucous membrane. 
 
 The gastric juice is secreted more abundantly in response to the 
 chemical stimulus of some substances than others, as, for example, 
 sodium chloride and carbonate and alcohol when taken in moderate 
 dilution. If, however, they are taken to excess they cause derange- 
 ment of the gastric function, and congestion ensues with secretion of 
 a neutral or alkaline mucoid juice instead of the true acid secretion. 
 
 Haidenhain has observed that the mechanical pressure of food 
 against the stomach wall may be comparatively local and circum- 
 scribed, whereas the chemical stimulation of the food as soon as it 
 begins to be felt, causes abundant secretion from the whole surface 
 of the stomach, which becomes red and turgescent from increased 
 vascularity. 
 
 The flow of juice commences almost immediately after the food 
 has entered the stomach, and it continues to be secreted in varying 
 quantity for two or three hours. After this period the secretion 
 gradually diminishes. If the food has not been properly digested 
 within a limit of three and a half hours, it may fail to pass on into 
 the intestine, and while remaining in the stomach it undergoes vari- 
 ous processes of malfermentation which are wholly different from 
 the normal. These processes will be more fully discussed under the 
 headings of the several forms of dyspepsia. By examining the in- 
 terior of the human stomach when a fistula has been made, it appears 
 that if the organ is empty, merely irritating the mucous membrane by 
 rubbing its surface gently with a glass rod provokes the secretion 
 of juice, which first appears in little clear drops at the site of irrita- 
 tion. These gradually coalesce and form tiny rivulets which run 
 over the mucous surface to the most dependent portion of the stom- 
 ach. At the same time the mucous membrane becomes somewhat 
 congested and of a pinkish hue, owing to the greater quantity of 
 blood which circulates through it. 
 
 Hydrochloric Acid 
 
 Hydrochloric acid exists in the human gastric juice in the aver- 
 age proportion of 0.2 per cent. Experimentally it is found that the 
 best proteolytic digestion results with 0.1 to 0.2 per cent of hydro- 
 chloric acid. The acidity is reduced upon a vegetable diet. 
 
 The acid is secreted during active digestion but not normally at 
 other times. It is often diminished in quantity, and less often it 
 may be abnormally increased. Its action upon proteid foods like 
 24 
 
344 FOOD DIGESTION 
 
 egg albumin, blood fibrin, and meat, is to cause them to swell and 
 become somewhat translucent. It contributes the necessary acid 
 reaction in which the ferment pepsin causes solution of these and 
 other proteids and converts them into albumoses. 
 
 The quantity of free acid obtainable from the stomach is not 
 great when much proteid food has been eaten, although its secretion 
 may have been considerable. The secretion of the acid begins 
 shortly after the ingestion of food, and reaches a maximum within 
 about an hour. After an hour or two longer, according to the nature 
 and quantity of the food present, it lessens and finally ceases. 
 
 According to the views of some writers, the first acid formed in 
 the stomach is lactic acid, which joins the alkali of chlorides in the 
 blood, and liberates chlorine to form hydrochloric acid. Maly has 
 advocated the theory that the hydrochloric acid was formed from 
 the action of phosphates in the blood serum, splitting up the chlo- 
 rides so that the highly diffusible hydrochloric acid passes readily 
 out upon the free surface. 
 
 Roberts furnishes the following table illustrating the effect of 
 varying quantities of hydrochloric acid on the speed of peptic di- 
 gestion : 
 
 2 grammes beef-fibre ; i c. c. glycerin extract of pepsin ; varying proportions of 
 hydrochloric acid ; water to ioo c. c. 
 
 Proportion of dry HC1 in the Time in which digestion 
 
 digesting mixture. was completed. 
 
 0.05 per cent 500 minutes, almost no digestion. 
 
 0.08 " " 200 
 
 0.1 " " 130 •' 
 
 0.15 " " 115 " 
 
 0.2 " " IOO " 
 
 0.3 •' " 115 
 
 0.4 " " 160 " 
 
 0.6 " " 350 minutes, embarrassed. 
 
 The acid has an antiseptic influence, preventing the decomposi- 
 tion of food, and even checking it if already begun. It is also be- 
 lieved to possess an influence over the formation of pepsin. Briicke 
 claims, contrary to many observers, that the acid of the stomach 
 makes starch more soluble, and that much of it is also converted by 
 lactic-acid fermentation in the stomach into erythrodextrin. 
 
 Pepsin. — According to Chittenden, pepsin is a hydrolytic ferment 
 which is found in the cells of the tubules of the gastric mucous 
 membrane, chiefly near the cardiac portion. It exists in these cells 
 in an antecedent form, or as a granular " proenzyme," which is called 
 pepsinogen or propepsin, and the agent which is believed to convert 
 the propepsin into true pepsin, the active ferment, is hydrochloric 
 acid. This theory assigns a new function to this acid. Lactic and 
 acetic acids derived from food possess the same power in lesser 
 
FOOD IN THE STOMACH 345 
 
 degree. Like the other digestive ferments, pepsin belongs to the 
 class of colloid or non-crystallisable, indiffusible substances. 
 
 Pepsin digests coagulated tgg albumin even better than fibrin, 
 gluten, casein, myosin, and gelatin, and hence this substance is com- 
 monly employed in making quantitative tests of the relative digestive 
 power of different preparations of the ferment. The standard of the 
 United States Pharmacopoeia requires that pepsin shall dissolve 
 three thousand times its own weight of coagulated disintegrated tgg 
 albumin. The rapidity of digestion is augmented only up to a cer- 
 tain point by increase in the quantity of pepsin, but beyond this limit 
 it has no accelerating influence — no influence at all, in fact. 
 
 Pepsin reaches its maximum activity at a temperature consider- 
 ably higher than that of the body — namely, 130 F. Its action is 
 suspended below 40 F., and destroyed between 160 and 170 F. 
 
 The secretion of both pepsin and the rennet ferment or rennin 
 which is often associated with it seems to rise and fall with that of 
 hydrochloric acid, but this is not always the case. 
 
 Rennin has been described on p. 71. 
 
 Albumoses, Peptones. — The final product of food digestion as 
 accomplished by pepsin with the hydrochloric acid of the gastric 
 juice is peptone. Kuhne showed that peptone is seldom, if ever, 
 pure in the stomach, but the substance produced is a mixture of 
 true peptone with proteoses or albumoses, which have reactions 
 that in many respects are similar. The albumoses are more highly 
 diffusible than peptones. Undoubtedly both peptones and albumoses 
 are formed during digestion, and both may be absorbed. 
 
 Albumoses, like peptone, give a violet colour when added to a 
 dilute Fehling solution of copper sulphate, and on boiling with 
 nitric acid they exhibit a yellow colour and a precipitate which 
 alternately falls on cooling and disappears upon warming. The 
 albumoses may be separated from peptones by complete precipita- 
 tion by saturation in aqueous solution with sulphate of ammonium. 
 Bauer states it as his belief (Dietary of the Sick) " that the peptones 
 do fulfil in the organism all the functions of the albuminous bodies, 
 since they are again turned into coagulable albumin " ; but dissolved 
 albuminates are not necessarily converted into peptones before they 
 are capable of absorption (Voit and Bauer). 
 
 Politzer, Gerlach, and others have demonstrated experimentally 
 that albumoses can support nutrition and even cause gain in weight 
 when given alone and free from peptones, and Hildebrandt found 
 that the nitrogen of albumoses artificially fed to animals was utilised 
 in the nutrition of the body to an even greater degree than the pep- 
 tones of meat. 
 
 An excess of proteids overworks the liver and produces, on 
 reaching the general vascular system, various nervous disorders, 
 and, it is believed by many, lithsemia and gout as well. 
 
 S 
 
346 FOOD DIGESTION 
 
 Peristalsis. — In addition to exciting secretion upon entering- the 
 stomach, the food, at first by mechanical action and subsequently 
 possibly through chemical stimulation, excites more or less rhyth- 
 mical peristaltic movement in the muscular coat of the stomach. The 
 object of this movement is fourfold: 1. To mingle the contents of 
 the food thoroughly with the gastric juice. 2. To cause moderate 
 trituration of the particles of food which are made to move in cur- 
 rents that proceed along the greater curvature and pass back to 
 the cardiac end along the lesser curvature. 3. To bring the food 
 in contact successively with different portions of the mucous mem- 
 brane, and to thus stimulate it and favour the absorption of such 
 ingredients as this division of the alimentary canal is capable of 
 taking up. 4. To favour the occasional emptying of a portion of the 
 contents of the stomach into the duodenum, the movement at this 
 time being accompanied by a relaxation of the pyloric orifice. 
 
 Peristaltic action is influenced by the nature and composition of 
 the food ingested, and it may be also stimulated in other ways, which 
 will be more fully described in connection with intestinal peristalsis 
 (see Diarrhoea and Constipation), for it may be said in general that 
 those stimuli which effect intestinal peristalsis also influence this 
 peculiar movement in the stomach. 
 
 DURATION OF GASTRIC DIGESTION OF DIFFERENT 
 
 FOODS 
 
 Bauer says : " By the digestibility of a food one can obviously 
 understand nothing more or less than the sum of the resistances 
 that it offers to the action of the gastric juice." 
 
 The time required for gastric digestion cannot be stated with 
 absolute accuracy. In general, the period for the full digestion of 
 a mixed meal consisting of bread, meat, and vegetables is three and 
 a half hours, but because some kinds of food are thoroughly di- 
 gested in the stomach, while others are acted upon but little if at 
 all, the preponderance of one or other article of food in a mixed 
 diet may affect somewhat the whole period of digestion. Tables 
 are sometimes given in text-books of physiology in which the time 
 required for digestion of various kinds of meat are stated in a very 
 definite manner, but all such statements should be received with 
 ample allowance for ordinary variations. If one considers for a 
 moment the different elements concerned in the process of gastric 
 digestion, it is obvious that the normal time required for com- 
 plete digestion will vary constantly, even in the same individual in 
 a state of health, for it depends upon the kind of food eaten as 
 well as the following conditions: 1. Its state of subdivision, its solu- 
 bility, complexity, and the process of its cooking. 2. The rapidity 
 with which it is swallowed. 3. The thoroughness with which it is 
 
DURATION OF GASTRIC DIGESTION OF DIFFERENT FOODS 347 
 
 masticated. 4. The activity of the stomach at the time. 5. The 
 interval which has elapsed since the previous meal. 6. The condi- 
 tion of the blood and nerve supply of the gastric glands. 7. The 
 activity of peristaltic movement, which may either retard or hurry 
 the rate of emptying the stomach. 8. The amount of fluid drunk 
 with which the gastric juice is diluted. 9. The strength of the im- 
 portant ingredients of this juice, its volume, and the effect upon it 
 of food itself, neutralising it or not. 10. The rate of absorption. 
 11. Habit. 12. Idiosyncrasy. 13. The presence of excess of fat 
 or other materials incapable of digestion in the stomach. 14. The 
 diversion of the nervous energy required for digestion to other 
 functions, such as mental or muscular work. 
 
 Such statements are often definitely made in articles upon die- 
 tetics as that boiled mutton requires three hours for stomach diges- 
 tion, while roasted mutton requires three hours and eighteen min- 
 utes ; that raw oysters require two hours and fifty-five minutes and 
 roasted oysters three hours and eleven minutes ; that boiled carrots 
 require three hours and sixteen minutes, and the like. These figures 
 may impress the lay mind as being of interest and accuracy, but when 
 the above considerations have been taken into account, it must 
 be seen that they are far from reliable. It is important, however, 
 to state, if possible, the approximate time required for the digestion 
 of certain general classes of food, and the following estimates are 
 probably as nearly correct as possible in view of the above state- 
 ments. 
 
 The average time required for meats cooked by broiling, roast- 
 ing, or boiling is fully three hours or three and a half hours for their 
 complete digestion. Gigglberger found, as a result of feeding pa- 
 tients with test meals and withdrawing the stomach contents through 
 a tube, that meat requires from two and a half to five and a half hours 
 for digestion, according to its quality, method of cooking, etc. 
 Stewed meats need less time than roasts. Pork and very fat meat 
 may require four or five or more hours for digestion, and veal needs 
 at least four hours. Fresh lamb may be digested in two and a half to 
 three hours. Chicken, capon, and turkey may be digested in from 
 two to two and a half hours, but the meat of many of the forms of 
 wild birds, such as ducks, may require four hours. Some of the vis- 
 cera of animals which are eaten as food, such as brains, tripe, liver, 
 and kidneys, are digested in less time — approximately two hours. 
 Fish and shellfish require from two and a half to three hours for their 
 digestion. Raw eggs are usually digested in less time than cooked 
 ones, and they may be ready for absorption in two hours, whereas 
 hard-boiled eggs require at least three and a half hours. Milk is usu- 
 ally digested somewhat sooner when boiled than if raw. Milk whey 
 is absorbed from the stomach, but the curds often pass on into the 
 duodenum. 
 
343 FOOD DIGESTION 
 
 The majority of the heavier vegetables, such as peas, beans, corn, 
 beets, turnips, etc., remain in the stomach between three and three 
 and a half hours, but potatoes, if baked and mealy, may remain but 
 two and a half hours. Raw vegetables, such as coleslaw or raw 
 cabbage and lettuce, etc., may remain two and a half hours or more 
 in the stomach, and the same is true of most raw fruits, such as 
 berries, apples, pears, peaches, etc. The more digestible cereals — 
 rice, sago, tapioca, etc. — should pass on from the stomach within 
 two hours. Fats and oils taken alone may remain in the stomach 
 only a few moments. Sugars may, to some extent at least, be ab- 
 sorbed from the stomach wall in the course of the first hour of 
 digestion. 
 
 Since gastric juice is fairly constant in composition, its effect in 
 health upon the duration of digestion of the same kind of food 
 may not vary in the same individual ; but persons differ from one 
 another very much in the rapidity of their digestive processes. In 
 some persons, even in health, stomach digestion may be uni- 
 formly an hour or more slower than it is in others. Variations 
 from the usual period of digestion are almost always upon the side 
 of its retardation. The quality, composition, and quantity of the 
 food all affect the rate of gastric digestion. 
 
 Coarse food, badly cooked starchy food, excess of fats, tough- 
 fibred meats, unripe fruits or vegetables, all retard digestion, and 
 may prove very irritant. 
 
 Among articles of diet, substances are sometimes eaten which 
 are purely refuse material, such as the skin of potatoes and of coarse 
 fruits, grape seeds, shells, soft-shell crabs, etc. 
 
 They may pass on unaltered into the intestine and cause diar- 
 rhoea, or they may sometimes linger for several days and excite 
 reflex irritation. I have known undigested capsules of cod-liver oil 
 to be retained in the stomach for three or four days before being 
 vomited. (See Cod-liver Oil, p. 202.) 
 
 The temperature of food and drink affecting gastric digestion is 
 discussed under the heading Temperature and Digestion (p. 333). 
 
 DIGESTION OF PROTEIDS IN THE STOMACH 
 
 The various albuminous foods are digested best, each with a 
 different degree of acidity, and it is probable that throughout a meal 
 the intensity of reaction of the gastric juice varies considerably, 
 becoming stronger as more food is absorbed or more juice is 
 formed, or weaker as more of it passes with the chyme into the 
 pylorus or as it is more diluted with additional food or drink. In 
 this manner the different proteids are all certain of a fair opportunity 
 for timely digestion. 
 
 The products of albuminoid digestion in the stomach have been 
 
ABNORMALITIES OF GASTRIC DIGESTION 349 
 
 carefully analysed by Kuhne and Chittenden, and are found to suc- 
 ceed each other in the following order: 
 
 1. Albuminoids or proteids. 
 
 2. Syntonin or acid albumin. 
 
 3. Albumoses or proteoses — proto-albumose, hetero-albumose, 
 deutero-albumose. The three latter form — 
 
 4. Peptones. 
 
 Raw meat in the stomach turns grey-brown and swells. It takes 
 longer to digest meat raw than when cooked, for the fibres are 
 penetrated less easily by the gastric juice. An exception to this 
 occurs when the raw meat is first scraped or made into a pulp. In 
 the digestion of meats Frerichs found that the connective tissue is 
 first broken down by the gastric juice, then the sarcolemma, and 
 finally the substance between the striae of the muscle fibres. 
 
 Vegetable albumin is digested in the stomach in a manner quite 
 similar to the digestion of animal proteids. 
 
 Gluten and vegetable casein are also dissolved by the gastric juice 
 when strongly acid. 
 
 Gelatin is one of the substances most easily dissolved in and 
 absorbed from the stomach. It is altered by the hydrochloric acid 
 of the gastric juice, so that it can no longer be solidified by cold. 
 It is finally converted into diffusible substances somewhat resem- 
 bling peptones, but not identical with them. 
 
 ABNORMALITIES OF GASTRIC DIGESTION 
 
 (The clinical examination of the stomach contents is described under that heading.) 
 
 Hypersecretion. — Hypersecretion of gastric juice gives rise to 
 thirst, sour eructations, more or less epigastric distress, and it often 
 accompanies dilatation of the stomach. The secretion may digest 
 proteids well, but carbohydrates are ill borne in this condition, which 
 is believed to be chiefly caused by some form of neurosis. An ex- 
 cess of more or less acid gastric juice passes on with the chyme into 
 the small intestine, and causes an acid reaction therein, requiring 
 more of the intestinal digestive fluids — bile, pancreatic juice, etc. — 
 to neutralise it. The saliva is often increased at the same time, and 
 Roberts suggests that this may be a provision of Nature to neu- 
 tralise the acid in the stomach. 
 
 Hyperacidity. — Hyperacidity, or increase in the hydrochloric 
 acid of the gastric juice, does not necessarily imply hypersecretion 
 of juice. Hypersecretion may be abundant, watery, and weak in 
 acid, or more concentrated with stronger acid, or normal in quan- 
 tity but with increased hydrochloric acid. 
 
 Hyperacidity is common, and is especially apt to be present in 
 connection with gastric ulcer and certain forms of chronic dyspepsia. 
 
350 FOOD DIGESTION 
 
 Absence of Hydrochloric Acid. — The persistent absence of hydro- 
 chloric acid from the gastric contents does not absolutely indicate 
 the presence of any one disease, but rather that a considerable extent 
 of the gastric mucosa is diseased, or it may be absent in nervous dys- 
 pepsia without organic lesion. This condition may exist with car- 
 cinoma. 
 
 Pyrosis. — Pyrosis, or eructation of gas from the stomach, if it 
 occurs very soon after ingestion of food, is usually due to lactic or 
 other organic acid fermentation. Occurring later, during active 
 digestion, it may be due to the same cause or to hyperacidity from 
 excess of hydrochloric acid. The latter condition is less common 
 when due to lactic acid ; the giving of hydrochloric acid stops further 
 fermentation, whereas sodium bicarbonate, although it momentarily 
 neutralises the lactic acid, soon produces an alkaline reaction in 
 which the further development of the acid rapidly proceeds. On 
 the other hand, pyrosis due to hydrochloric acid must be checked 
 by alkalies. 
 
 FOOD IN THE INTESTINE 
 
 After preliminary maceration under the conditions of the mois- 
 ture, warmth, and motion in the stomach, and after partial digestion 
 there, the food, mixed with gastric juice, passes in a pultaceous mass, 
 known as chyme, into the duodenum. Here the physical conditions 
 are almost identical with those found in the stomach, but the chem- 
 ical composition of the new digestive fluids — namely, the bile and 
 pancreatic and intestinal juices — is alkaline, and a number of new 
 ferments complete the solution and digestion of the food. 
 
 The starches which were but partially digested by the saliva are 
 converted into dextrin, maltose, and glucose by a diastatic ferment — 
 amylopsin — contained in the pancreatic juice. Cane sugar is con- 
 verted by the intestinal juice into glucose, any proteids which have 
 been but partially digested in the stomach are completely converted 
 into proteoses and peptones by the proteolytic ferment trypsin of 
 the pancreatic juice, and the fats are emulsified and saponified by 
 the combined action of the bile and a pancreatic ferment. 
 
 Pancreatic juice is the most active and comprehensive digesting 
 fluid of the body. It is not only much stronger than the gastric 
 juice in its action upon proteids, being able to form peptones with 
 fewer intermediate products, but it possesses the distinct advantage 
 that it also digests fats and carbohydrates by a ferment, called steap- 
 sin, which acts in either acid or alkaline media. 
 
 Its amylolytic power is stronger than that of the saliva, for it 
 digests the raw starch and cellulose which is eaten in such vegetables 
 as celery, lettuce, or radishes, and in fruits like the apple. 
 
 The ultimate products of trypsin digestion are antipeptones and 
 hemipeptones. The ferment acts best in a fluid medium rendered 
 
FOOD IN THE INTESTINE 35 1 
 
 alkaline by from 0.5 to 1 per cent sodium carbonate. It also digests 
 proteids energetically in a neutral medium, but free acid soon de- 
 stroys it. Chittenden has shown that combined acids do not neces- 
 sarily put a stop to trypsin proteolysis. 
 
 The bile plays several roles in intestinal digestion, but its chief 
 action is in aiding the emulsion of fats, described below. It can 
 accomplish the absorption of fats even in the absence of pancreatic 
 juice. When bile is absent the fatty food may decompose in the 
 intestine and develop gases and foul odours. 
 
 Voit says that the white colour of icteroid stools is dependent 
 rather upon the presence of undigested fat than the absence of bile, 
 for with a meat instead of a milk diet they may still be of a dark 
 colour. When a biliary fistula is made in dogs and the bile is drained 
 away, they emaciate and have a ravenous appetite if fed upon meats 
 and fats, but not if fed upon carbohydrates (Voit). 
 
 The quantity of bile secreted is increased by a nitrogenous diet, 
 and diminished upon an exclusive fat diet (Ufrelmann). Vegetable 
 foods colour the bile green ; animal foods make it yellow or orange. 
 
 Bile is often said to prevent putrefactive changes in the food in 
 the intestine. It is not, however, an antiseptic substance, for, un- 
 like the gastric juice, it easily undergoes decomposition, and the 
 influence attributed to it is due rather to its promotion of peristalsis, 
 thereby keeping the intestinal contents moving and preventing stag- 
 nation and putrefaction. 
 
 The Digestion of Fats. — When fat is cooked in the food, a good 
 deal of it is converted into rancid fat — i. e., fat containing free fatty 
 acids. In the mouth the fatty food is unaltered, unless it be in the 
 form of adipose tissue, when the process of mastication breaks it 
 down and liberates some of the fat globules, which are melted by 
 the natural warmth. If eaten in the form of oil or butter, with 
 starchy or vegetable food, the fat coats the particles of food in the 
 mouth. Bread thus mingled with butter is less likely to form a large 
 and too tenacious bolus. 
 
 In the stomach the fat remains unaltered, and when the semifluid 
 chyme begins to flow into the intestine it passes in with it. The 
 connective-tissue elements of fatty meats, etc., are dissolved away 
 and digested like other proteids by the gastric juice. 
 
 In the intestine the fat is subjected to a double process of emul- 
 sification and saponification, which is accomplished by the combined 
 action of the bile and pancreatic juice. The latter splits fats into 
 glycerin and fatty acid, and this action is favoured by the admix- 
 ture with bile, which simultaneously occurs in the duodenum. Ac- 
 cording to Rachford, the fat-splitting power of pancreatic juice is 
 more than quadrupled by bile, although the latter has no fat-splitting 
 influence of its own. He also declares that the presence of hydro- 
 chloric acid which has just entered the upper duodenum with the 
 
352 
 
 FOOD DIGESTION 
 
 chyle, like the bile, still further aids the pancreatic action upon fats, 
 as four to one. 
 
 It is held by the majority of authorities that pancreatic juice also 
 contains an emulsifying ferment, steapsm, and that the free fatty 
 acid above described splits up the sodium bile salts and liberates 
 their sodium, which unites with a portion of the free fatty acid, 
 forming a soap. The soap coats the droplets of emulsified fat with 
 a thin film (like a soap bubble) and prevents them from coalescing 
 again. The emulsion is then absorbed by the lacteals. 
 
 It is, however, not a necessary part of the theory of digestion of 
 fatty food that the fat must all be emulsified. No doubt a large part 
 of it is absorbed more directly or as a soap without emulsification. 
 
 Extracts of both the liver and spleen have been said to favour 
 the absorption of fats by emulsification. 
 
 Undigested food reaches the intestines under the following con- 
 ditions : (a) When too much food is eaten, (b) when gastric digestion 
 is imperfect, (c) when the food is improper. 
 
 Intestinal Gases. — During the digestion of certain foods in the 
 intestine more or less gas is evolved. The gas, by distending the 
 walls of the gut, serves the purpose of keeping them from agglu- 
 tinating, and thereby facilitates the free movement and intermingling 
 of the digestive fluids and food, and the absorption of the latter. 
 
 Ruge has published the following table of the percentage of 
 gases evolved by several different kinds of foods : 
 
 
 MILK. 
 
 MEAT. 
 
 PEAS OR BEANS. 
 
 Food. 
 
 X- 
 
 2. 
 
 I. 
 
 2. 
 
 3- 
 
 I. 
 
 2. 
 
 3- 
 
 C0 2 .... 
 
 H 
 
 CH 4 .... 
 
 N 2 
 
 16.8 
 
 43-3 
 0.9 
 
 38.3 
 
 9.9 
 
 54-2 
 
 36.7 
 
 13.6 
 
 3-o 
 37-4 
 
 45-9 
 
 12.4 
 2. 1 
 
 27-5 
 
 57-8 
 
 8.4 
 
 O.7 
 
 26.4 
 
 64.4 
 
 34-0 
 2-3 
 
 44-5 
 19. 1 
 
 38.4 
 
 49-3 
 10.6 
 
 2I.O 
 4.0 
 
 55-9 
 18.9 
 
 ARTIFICIAL DIGESTION 
 
 To physiologists we are indebted for the discovery and develop- 
 ment of the scientific preparation of digestive ferments or enzymes 
 and the predigestion of food outside of the body. The composition 
 of the various digestive ferments and their action in general have 
 been understood for a long time, but it is only within the last two 
 or three decades that the use of these organic bodies has been made 
 practicable on a large scale for rendering food more digestible or 
 assimilable by invalids, and the whole question of artificial digestion 
 of foods is one which is receiving more and more careful attention 
 and thorough study. The subject may be said to be yet in its in- 
 fancy, and it is highly probable that the extensive researches which 
 are being conducted by so many investigators at the present day 
 
ARTIFICIAL DIGESTION 353 
 
 will yield even more practical and important results than those al- 
 ready attained. The use of predigested food at present forms an 
 indispensable adjunct to the treatment of a large number of serious 
 diseases, both acute and chronic, especially those which concern the 
 alimentary canal, and the methods of infant and invalid feeding have 
 been practically reorganised by it. 
 
 The different ferments which can be used for increasing the ac- 
 tivity of digestion within the body or for partially digested foods 
 outside of the body are principally diastase, pepsin, and extracts of 
 pancreatic juice, which are usually called " pancreatin," and which 
 are compounds of several substances. Besides these there are sev- 
 eral vegetable ferments, such as papain from the American papaw, 
 and ferments are present in the juice of the pineapple, and the cen- 
 tury plant or agave. 
 
 Predigestion of Starches 
 
 There are a variety of ferments and other materials which have 
 the power of converting starch into dextrin and sugar. They are 
 ptyalin in the saliva, amylopsin in the pancreatic juice, diastase, a 
 ferment in the intestinal juice, and the substances inulin and lichen- 
 in. The latter is obtainable from various lichens, such as Iceland 
 moss. Mucin and certain gums are also amylolytic. 
 
 Of these different ferments, the one which is found to be of most 
 practical service for predigestion is diastase. 
 
 The action of the diastase of malt resembles that of the ptyalin 
 of the saliva and the amylopsin of the pancreatic juice, which alter 
 starches into dextrin and maltose. It is prepared in several ways, 
 as, for example, in meal of malt, which may be added to farinaceous 
 foods, and in the form of malt extracts, and various malted foods 
 (malted milk, etc.) are sold for invalid use or for infant feeding. 
 
 Taka-diastase is a stable concentrated form of diastase, said to 
 possess the power of converting ioo times its weight of starch into 
 sugar in ten minutes. The dose is 2.\ grains after eating. 
 
 In such preparations the predigestion of amylaceous foods is 
 carried to the extent of more or less complete conversion of the 
 starch into dextrin and maltose. The diastase has no action in the 
 stomach provided the acid gastric juice is being secreted, for it only 
 causes fermentation in a neutral or alkaline medium ; in fact, the 
 ferment is probably destroyed before reaching the intestine, but it 
 may act in the stomach for half an hour or so before the reaction 
 of the gastric juice becomes too strongly acid. The presence of 
 alkaline carbonates retards the action of diastase. In early infancy 
 the amylolytic ferments of the salivary and pancreatic fluids are not 
 well developed and are very meagre in quantity. If a young child 
 is unable to digest milk for any reason, malted food may be tern- 
 
354 FOOD DIGESTION 
 
 porarily supplied in some cases, because in it the starch is already 
 more or less completely digested and is ready for absorption. In 
 general, the value of malted foods and malt extracts depends upon 
 the predigested starch which they contain, which furnishes nutrition, 
 rather than upon the action of the diastatic ferment within the ali- 
 mentary canal. 
 
 Ground malt itself possesses even stronger digestive action upon 
 starches than malt extracts. The latter contain the ferment dias- 
 tase, dextrin, maltose, and a portion of the salt and some nitro- 
 genous ingredients of barley. Both ground malt and malt extracts 
 digest starches at a moderate heat, not exceeding 150 F. There 
 are many varieties of malted foods, but Liebig's Infant Food is a 
 good illustration of this type. It is prepared as follows (see also 
 p. 148) : 
 
 Mix a half ounce each of ground malt and wheat flour, seven 
 and one fourth grains of potassium bicarbonate with one ounce of 
 water and five ounces of sweet cow's milk. Warm slowly and stir 
 until thick. Remove from fire, stirring for five minutes, replace 
 over fire, and remove when quite thick. As the diastase continues 
 to act the mass will become thin and sweet. Boil and strain. It 
 contains gluten and albumin of flour and barley, besides dextrin and 
 maltose. The food thus prepared is very nutritious, for it not only 
 contains the proteid materials of the milk, but those also of the wheat 
 flour and malted barley (gluten and albumin), as well as the predi- 
 gested starch. The malted foods which are made with desiccated 
 milk and malted flour are deficient in fats, salt, and proteid material, 
 but the lack of these substances can be supplied by the addition to 
 the food, when used, of cream and beef juice. The digestibility of 
 bread may be increased by adding 5 grains of diastase to the pound 
 of flour mixed in the dough. 
 
 For manufacturing malted foods the wheat or barley flour should 
 be baked in order to rupture the starch granules and make them 
 more soluble. 
 
 Predigestion of Proteids 
 
 The digestion of proteids may be accomplished either within the 
 body by prescribing pepsin and hydrochloric acid, or without the 
 body by use of the same agents, or, as it is more often done at 
 present, by pancreatinisation. 
 
 Pepsin was the first among the digestive ferments to be isolated 
 and employed for artificial fermentation. 
 
 This ferment differs from diastase in the fact that it is capable of 
 continuing its digestive functional activity within the body, and it is 
 therefore frequently prescribed in cases of deficient gastric secretion, 
 to be taken with the meals, or immediately after, as a powder or in 
 solution. The action of pepsin is confined to the conversion of 
 
ARTIFICIAL DIGESTION 355 
 
 albuminous food, and it requires an acid reaction. It is sometimes 
 claimed that the continual administration of pepsin and dilute hydro- 
 chloric acid may weaken the stomach by doing the work of that 
 organ while it rests ; but it is difficult to see any true ground for the 
 statement, for this action in no wise concerns the stomach wall or 
 its secretion, but is limited to the conversion of food into more easily 
 soluble material, which increases the general bodily nutrition, and 
 therefore indirectly improves the stomach digestion. 
 
 Pepsin is destroyed by dilute solutions of sodium bicarbonate as 
 well as by the alkaline pancreatic intestinal fluids and the bile. It 
 is obtained in a number of forms for use in aiding gastric digestion, 
 such as scales, dry powder, pills, and solution. There is con- 
 siderable variation in the strength of the preparations, depending 
 upon the care taken in their manufacture and differences in the 
 processes of extracting the ferment ; but all of them have some 
 digestive action, and they are very serviceable remedies for gastric 
 indigestion. 
 
 Peptones or amphopeptones are the ultimate products of stom- 
 ach digestion. They are derived from primary and secondary pro- 
 teoses by pepsin proteolysis through hydration and cleavage. In 
 regard to the artificial digestion of proteid foods by pepsin, Chitten- 
 den says : " Peptones are truly formed, and many times in large 
 amount, but never under any circumstances have I been able to 
 effect a complete transformation of any proteid into true peptone 
 by pepsin-proteolysis ; there is always found a certain amount of 
 proteoses more or less resistant to the further action of the ferment. 
 Even with a large amount of active ferment, an abundance of free 
 hydrochloric acid, a proper temperature, and a long-continued 
 period of digestion, even five and six days, there is never found a 
 complete conversion into peptone. Indeed, the largest yield of pep- 
 tone I ever obtained in an artificial digestion is sixty per cent, while 
 the average of a large number of results under most favourable cir- 
 cumstances is somewhat less than fifty per cent." Hence, artificial 
 pepsin is not a complete digester, as often supposed, and too great 
 reliance should not be placed upon it. 
 
 Pepsin should never be given in combination with an alkali, such 
 as sodium bicarbonate, excepting in cases of hypersecretion of 
 hydrochloric acid with scanty pepsin formation. 
 
 The pepsin-secreting cells predominate over the acid-forming 
 cells in the stomach so largely that they are seldom destroyed to 
 the same degree as the latter, and hence pepsin is of much less 
 importance than hydrochloric acid in the treatment of both func- 
 tional and organic disease of the stomach. It is a very common 
 practice to prescribe it in tablet form without acid, but as a rule, to 
 which there are almost no exceptions other than that of hyper- 
 acidity, in those cases in which the exhibition of pepsin is indicated 
 
35^ FOOD DIGESTION 
 
 hydrochloric acid is equally if not more important, and they should 
 be prescribed together. 
 
 The pepsin is given in doses of three to five or ten grains imme- 
 diately after meals when proteid food of any kind has been eaten. 
 Ten grains may be added to a pint of milk, but if long continued in 
 excess of twenty grains per diem, it may excite purgation. 
 
 Pancreatin is the name given to a complex fermentative body 
 derived from extracting the pancreatic gland. It is obtained in the 
 form of a dry powder, and also as a solution or liquor. Its intro- 
 duction is mainly due to the researches of Dr. William Roberts, of 
 England. 
 
 The extract made from the pancreatic gland is a powerful digest- 
 ive agent and, on the whole, is more serviceable for the predigestion 
 of food than any of the other ferments. It contains both trypsin 
 and amylopsin. This extract also emulsifies fats, and it is as easy, 
 if not easier, to obtain the pancreatic extract than pepsin, and 
 since its action is so powerful and varied, the majority of the pre- 
 digested food preparations — the so-called " peptonised foods " — 
 are made with pancreatin instead of pepsin. Pancreatin is sometimes 
 prescribed by physicians for internal use, but unless protected in a 
 keratin-coated capsule the ferments are entirely destroyed in the 
 stomach by the action of the gastric juice. Keratin is a horny sub- 
 stance derived from feathers which is not soluble in acid fluid, but 
 is quite soluble in alkaline media. Hence a capsule containing five 
 grains of pancreatin coated over with keratin may remain undis- 
 solved in the stomach until gastric digestion is completed, when it 
 will pass into the intestine, where the coating is dissolved and the 
 ferments act upon the chyle. It is customary to add some alkali, 
 such as sodium bicarbonate, to the pancreatin in the process of 
 artificial digestion, although it will also operate on protein in the 
 presence of a neutral reaction. All the products of pancreatin 
 digestion, as well as the ferment derived from the juice itself, decom- 
 pose if exposed for any length of time to the air. Pure meat pep- 
 tones, prepared either by pepsin and hydrochloric acid or by trypsin 
 in alkaline solution, are ready for immediate absorption and are 
 nutritive, but a very general objection to their use exists in the 
 exceedingly disagreeable odour and taste which they possess, which 
 to many persons are nauseating and disgusting. This difficulty is 
 overcome when peptones are used for rectal injection, for which 
 purpose they are most valuable. Efforts are often made to disguise 
 the disagreeable taste and odour of beef peptones in various ways. 
 When obtained in solution, wines and aromatic substances are added 
 to them or they are sometimes evaporated to dryness, pulverised, 
 and redissolved in sherry, but the taste is exceedingly persistent and 
 it is often difficult or impossible to disguise it in any manner, so that 
 patients will not sooner or later object to it. Among the principal 
 
ARTIFICIAL DIGESTION 357 
 
 peptones which are used are Koch's, Kemmerich's, Catillon's and 
 Carnrick's, Savory and Moore's, and Benger's. Some of the pan- 
 creatinised foods are strengthened by the addition of predigested 
 starches and sugars. Some of them constitute very good foods 
 for cases of enfeebled digestion or diminished absorptive power. 
 Among them may be mentioned Benger's Food, which is made 
 with cooked wheat meal and pancreatic extract. The latter par- 
 tially converts the starches into malt and diastase, and when added 
 to milk at the proper temperature for fermentation, it acts upon the 
 casein and converts it into a soluble peptone. Oat flour and lentil 
 flour are similarly prepared. Carnrick's Infant Food is made on the 
 same principle with Benger's Food, with wheat flour, pancreatin, 
 and milk, to which is added a certain percentage of lactose. Savory 
 and Moore prepare a concentrated predigested milk and milk with 
 cocoa, which have an agreeable taste and considerable nutrient 
 value. Another preparation is Loeflund's Peptonised Kindermilch. 
 
 All peptonised or pancreatinised foods are open to the objection 
 that they are much more expensive if used for a long time than the 
 preparations which can be easily made at the bedside by any intel- 
 ligent person by the use of the simple pancreatin extracts. Among 
 these extracts are Benger's Liquor Pancreaticus and Peptonising 
 Powders and Fairchild's Zymine, which act upon lean meat as well 
 as milk. If complete peptonisation is required, large quantities of 
 the ferment must be used, and the process should be continued 
 longer than for a lesser degree of peptonisation. One. or two 
 drachms of Benger's Liquor Pancreaticus with fifteen grains of 
 sodium bicarbonate will completely peptonise half a pint of milk in 
 a few minutes if the bottle be immersed in water which is heated, 
 but which is not too hot for the hand to bear. Roberts's rule for 
 pancreatinised milk gruel is quoted by Yeo as follows : " A good 
 thick gruel made with oatmeal or other meal while still boiling hot 
 is added to an equal quantity of cold milk. The temperature of the 
 mixture will then be about 140 F. To a pint of this mixture two 
 or three teaspoonfuls of Liquor Pancreaticus and twenty grains of 
 bicarbonate of soda are added ; it is kept at the same temperature 
 for about two or three hours, and then boiled for a few minutes and 
 strained. This mixture contains not only the casein of the milk 
 peptonised, but the starch of the material is converted into sugar 
 and its albuminates are peptonised. The bitterness of the pepton- 
 ised milk is scarcely perceptible in this gruel." 
 
 Papoid is a vegetable ferment derived from the papaw tree 
 (Carica Papaya) which is thus described by Chittenden : 
 
 ■" Extended study of the reactions of the vegetable ferment pa- 
 poid shows that it is composed essentially of a mixture of vegetable 
 globulin, albumoses and peptone, with which is associated the fer- 
 ments characteristic of the preparation. 
 
358 FOOD DIGESTION 
 
 " Papoid, so far as my observations extend, has the power of 
 digesting to a greater or less extent all forms of proteid or albu- 
 minous matter, both coagulated and uncoagulated. Furthermore, 
 papoid is peculiar in that its digestive power is exercised in a neu- 
 tral, acid, and alkaline medium. 
 
 " Papoid will act in dilute solutions, but the best and character- 
 istic action is seen only when a small volume of fluid is present. 
 In this respect it differs very markedly from the animal ferment 
 pepsin, and for this reason any direct comparison of the two fer- 
 ments is practically impossible, but blank experiments without pa- 
 poid [with acid and alkali as used in these experiments] showed 
 that these reagents have in themselves only a comparatively light 
 solvent action on raw fibrin." After ingesting the ferment it is found 
 in the stools, showing that it is not wholly destroyed in the alimen- 
 tary canal. The dose is from one to three grains after each meal. 
 
 Caroid is a vegetable digestive ferment made, like papoid, from 
 the papaw (Carica Papaya) in the form of a dry yellowish powder. 
 According to Chittenden's analysis, it retains a strong proteolytic 
 action in either acid, neutral, or alkaline media. It softens and dis- 
 integrates proteids, coagulates milk like rennet, and is also anxio- 
 lytic. It is a solvent of gastric mucus. 
 
 FOOD ABSORPTION 
 
 The absorption of food takes place from the stomach to a limited 
 extent, to a great degree from the small intestine, and to a lesser 
 degree from the larger intestine. The rectum is capable of absorb- 
 ing enough predigested food to sustain life for several weeks. (See 
 Food Enemata.) The entire digestive process does not have to be 
 completed before absorption begins. Usually those foods which 
 are first digested, or which are administered in predigested form, 
 are first absorbed. 
 
 The rate of absorption depends upon the degree of digestibility 
 of the food, the extent of absorbing surface with which it is brought 
 into contact by the peristaltic movement, the composition of the 
 blood, the relative pressure in the intestine, blood vessels, and 
 lymphatics, and, probably more than anything else, upon the func- 
 tional activity of the cells covering the intestinal villi. The accom- 
 panying table shows the percentage of food swallowed which is 
 actually absorbed : 
 
 Weight of Food. 
 
 Absorbed. 
 
 Residue. 
 
 
 89.9 
 8l.2 
 96.9 
 
 II . I 
 
 
 18.8 
 
 •• ** fats or carbohydrates 
 
 3-1 
 
 
ELIMINATION OF FOOD WASTE 
 
 359 
 
 ELIMINATION OF FOOD WASTE 
 
 The data given below, which are derived from Bauer, exhibit the 
 balance of income of food and output of waste of the body under 
 different conditions of rest and activity. 
 
 Income of Food and Output of Waste (Bauer) 
 
 Income 
 
 Meat 
 
 White of egg 
 
 Bread 
 
 Milk 
 
 Beer 
 
 Suet 
 
 Butter 
 
 Starch 
 
 Sugar 
 
 Salt 
 
 Water 
 
 Oxygen from air 
 
 Total 
 
 Output 
 
 Urine 
 
 Faeces 
 
 Breath 
 
 Total 
 
 Balance 
 
 Rest and 
 
 abundant diet. 
 
 Work and 
 abundant diet. 
 
 Small, ill-nour- 
 ished man ; 
 rest and _ 
 abundant diet. 
 
 Grammes. 
 
 Grammes. 
 
 Grammes. 
 
 139-7 
 41-5 
 
 I5I-3 
 48.I 
 
 I5I-I 
 61.8 
 
 450.0 
 
 450.O 
 
 450.0 
 
 500.0 
 
 500.0 
 
 509.6 
 
 1,025.0 
 70.0 
 
 1,065.9 
 6o.2 
 
 I,OI2.7 
 58.8 
 
 30.0 
 
 30.0 
 
 30.0 
 
 70.0 
 
 70.0 
 
 70.0 
 
 17.0 
 
 I7.O 
 
 17.0 
 
 4.2 
 286.3 
 709.0 
 
 4.9 
 
 489.I 
 
 1,006. I 
 
 4-3 
 4I.4 
 
 600.7 
 
 3.342.7 
 
 3,892.6 
 
 3,007.4 
 
 i,343-i 
 
 I,26l. I 
 
 1,069.6 
 
 "4-5 
 
 I29.O 
 
 I37-I 
 
 1,739-7 
 
 2,545-5 
 
 i,597.8 
 
 3,197.3 
 
 3,935-6 
 
 2,804.5 
 
 + 145-4 
 
 -43-o 
 
 + 202.9 
 
 The following data are quoted by Yeo : 
 
 " According to Dujardin-Beaumetz, a man loses, in connection 
 with the processes of nutrition, nitrogen, carbon, water, and salts, 
 In twenty-four hours these losses [for an adult man at moderate 
 labour], on an average, amount to 20 grammes (300 grains) of nitro- 
 gen, 310 grammes (4,650 grains) of carbon, 30 grammes (450 grains) 
 of salts, and 3 litres (about 6 pints) of water. The chief part of the 
 nitrogen (14.5 grammes) passes away in the urine in the form of 
 urea and uric acid, and the remainder (5.5 grammes) in the faeces, 
 perspiration, and mucous discharges. Of the carbon, 350 grammes 
 are consumed in the lungs, 45 grammes are eliminated by the kid- 
 neys, and 15 grammes in the other secretions. The water passes off 
 by the skin, lungs, kidneys, and bowels. A man's food must con- 
 tain the elements necessary to repair these incessant losses. 
 
 " The 20 grammes of nitrogen represent 124 grammes of dry 
 proteid matters, and as these contain 64 grammes of carbon, on 
 subtracting the 64 grammes from the 300 grammes necessary for 
 25 
 
360 FOOD DIGESTION 
 
 nutrition there remain 236 of carbon to be derived from starch 
 substances or from fats." 
 
 When waste matter has accumulated in the system its elimina- 
 tion may be assisted in various ways, as follows : 
 
 1. Through active exercise, which produces more complete oxi- 
 dation and the formation of a larger proportion of water and carbon 
 dioxide. 
 
 2. By diuretics, large draughts of saline waters, and occasional 
 doses of saline cathartics. 
 
 3. By Turkish baths, which increase the elimination from the 
 skin. 
 
 THE URINE AND FOOD 
 
 The relation of the composition of the urine to the quality and 
 quantity of the food is highly important. 
 
 Independently of renal disease and of excessive perspiration, the 
 occurrence of a scanty urine means that too little fluid is being 
 ingested, and that the nitrogenous waste is accumulating faster than 
 it is being removed. 
 
 The urine secretion is normally increased in quantity after meals, 
 and is diminished during fasting and in sleep. The increased rate 
 of secretion lasts for two or three hours, and then lessens. The 
 increase usually begins within an hour after breakfast, but not for 
 two or three hours after dinner. This may be owing to the slower 
 absorption of fluid which occurs with the heavier meal — i. e., while 
 solid food is retained in the alimentary canal, it holds back the fluid 
 like a sponge. The maximum rate of secretion is also reached 
 somewhat later after dinner, sometimes not for four hours. 
 
 After mixed meals the quantity of urea is more than doubled, 
 and the phosphates and urates are increased in nearly the same ratio. 
 Proteid foods always increase the output of urea, urates, or uric 
 acid, while vegetable foods increase the phosphates and sulphates. 
 
 Klemperer has stated that in diseases characterised by nitro- 
 genous tissue waste the latter is reduced by giving carbohydrates. 
 In other words, the carbohydrates save the consumption of tissue 
 and consequent production of urates or urea. 
 
 Meat and albuminous foods in general tend to make the urine 
 more acid, whereas milk and vegetables make it more alkaline. 
 
 TOBACCO AND FOOD 
 
 The use of tobacco in its relation to digestion is a subject very 
 closely allied to dietetics, but a brief mention of it only can be made 
 here. Like alcohol, undoubtedly most persons are better without 
 it, and its abuse is well known to disorder digestion through the 
 action of nicotine upon the circulation, and especially upon the 
 vagus nerve. No definite rules can be formulated for the use of 
 
FOOD EQUIVALENTS 
 
 361 
 
 tobacco in relation to meals beyond those suggested by the fact 
 that the action of tobacco is always less likely to prove irritating 
 if it is smoked while there is abundant food in the stomach. The 
 after-dinner cigar in many persons promotes the secretion of gastric 
 juice, and there are those in whom a mild cigar after breakfast 
 favours peristalsis and the evacuation of the bowels. If there is 
 any tendency to indigestion of starchy or saccharine foods, it is 
 usually aggravated by the use of tobacco in any form. 
 
 As observed elsewhere, when food cannot be obtained after 
 fatiguing exercise or a forced march, the moderate use of tobacco 
 is often found to temporarily replace it, at least to the extent of 
 lessening the feeling of weariness. (See Substitutes for Food, p. 
 282.) Smoking immediately before meals may destroy the appetite 
 and interfere with the digestion of the food. 
 
 FOOD EQUIVALENTS 
 
 It is easy to compute the chemical equivalents of foods as ana- 
 lysed outside of the body. It is quite another matter to compute 
 them with accuracy within the body. Most writers upon dietetics, 
 however, make some attempt to do this, and the following data may 
 be accepted as approximately correct : One pound of lean beef equals 
 in nutrient value three eggs or two pints of milk. Roast beef con- 
 tains about the same protein percentage as an tgg, but much more 
 fat. One pound of wheat equals 3.5 pounds of potatoes. 
 
 Of common cheese, Parkes estimated that " about half a pound 
 contains as much nitrogenous substance as one pound of meat, and 
 one third of a pound as much fat." It requires about 27 pounds of 
 milk to make a pound of butter, and about 10 pounds to make a 
 pound of cheese. 
 
 Van Noorden estimates that as a fat former seven grammes of 
 fat equal 9.3 grammes of alcohol. 
 
 Oertel says that " one part of fat is iso-dynamic with 2.4 parts of 
 carbohydrates, on an average," and one part of fat develops as much 
 heat and force as 2. 11 parts of albumin (Voit). 
 
 Church gives the following table of the estimated equivalents of 
 foods which would yield the necessary daily supply of nitrogen if 
 eaten alone : 
 
 
 Pounds. 
 
 Ounces. 
 
 
 2 
 2 
 
 3 
 
 24 
 
 54 
 6 
 
 3 
 
 IO 
 
 
 
 
 I 
 
 
 13 
 
 
 White turnips 
 
 4 
 
 
 8 
 
 
 7 
 
 
362 FOOD DIGESTION 
 
 To obtain the necessary daily supply of carbon 
 
 
 Pounds. 
 
 Ounces. 
 
 
 Bacon 
 
 8 
 2 
 
 5 
 1 
 20 
 6 
 6 
 
 II 
 
 8 
 
 3 
 11 
 
 
 6 
 
 
 Cow's milk 
 
 
 Wheat bread 
 
 
 Ee'e's 
 
 
 Rice 
 
 
 Turnips 
 
 
 Lean beef 
 
 
 Potatoes 
 
 
 
 
PART VI 
 
 THE GENERAL RELATIONS OF FOOD TO SPECIAL 
 DISEASES.— DISEASES WHICH ARE CAUSED BY 
 DIETETIC ERRORS 
 
 THE GENERAL RELATIONS OF FOOD TO SPECIAL 
 
 DISEASES 
 
 There are two methods of adapting diet for the sick : First, by 
 giving one half, one third, or one fourth of the ordinary quantity 
 of food for health ; second, by altering the quality of the different 
 classes of foods, and reducing the total amount simultaneously or 
 not, as required. The former method is simpler and less trouble- 
 some, and for some few cases it may prove sufficient. It is to be 
 regretted that it is a routine method adopted in many hospitals, for 
 it is unscientific, besides being often wasteful and radically wrong. 
 The second method presupposes a knowledge of the relations of 
 diet to disease, and requires careful supervision. In speaking of 
 this subject Parkes wrote : " It is certain that the physician can in 
 this way wield a great power, which, if less striking than that ob- 
 tained more rapidly by drugs, is yet of immense moment." 
 
 The same aliments which in health produce definite results in 
 furnishing energy and repairing tissue loss may fail completely in 
 disease. Such is the case in diabetes when starches become not only 
 a useless but a harmful food, and in severe albuminuria, when meats 
 only aggravate the albuminuric waste. 
 
 In the majority of severe diseases, and especially of acute and 
 febrile diseases, the proteids and fats, aside from those of milk, be- 
 come less assimilable than the carbohydrates. Beneke attributes 
 this to the fact that carbohydrates are respiratory foods — i. e., their 
 consumption results in the production of carbon-dioxide gas and 
 water, and the elimination of carbon dioxide proceeds in disease 
 very much as in health. If carbohydrates are not therefore fur- 
 nished, inanition ensues, for the tissues begin to consume their own 
 substance. 
 
 There are, on the other hand, some few diseases, such as tuber- 
 
 363 
 
364 GENERAL RELATIONS OF FOOD TO SPECIAL DISEASES 
 
 culosis, chlorosis, and secondary anaemia, in which proteids and fats 
 may be distinctly required, and others again may temporarily de- 
 mand a purely nitrogenous diet. 
 
 Food improper in quality or deficient in quantity is sure to be 
 not only a direct source of disease, but indirectly, by lowering the 
 vitality of the body, it leaves it an easy prey to epidemic and con- 
 tagious diseases of every sort. This was strikingly shown during 
 the ravages of the plague in the Middle Ages, and it has been ap- 
 parent in the history of all recent famines. (See Starvation, p. 297, 
 and Famine, p. 304.) 
 
 The important relation of food to disease in regard to its quantity 
 and composition, as well as the frequency and method of its ad- 
 ministration, are becoming more and more thoroughly appreciated. 
 This is owing in great part to improved methods of diagnosis and 
 to modern means of clinically discriminating between different kinds 
 of gastric and intestinal indigestion. It is also due to an increasing 
 knowledge of the chemistry of food, of food preparation by cooking, 
 and of " artificial digestion." 
 
 There is still much difference of opinion in regard to the best 
 dietaries for certain diseases, such, for example, as gout and obesity, 
 but the general principles of dietetics are to-day well established and 
 more widely understood and practised than ever before, and starva- 
 tion in fevers, like excessive venesection and similar depleting meas- 
 ures, is no longer carried to the former injurious extreme. There 
 remains much to be learned in regard to dietetics ; and the great 
 variations in digestive power which are encountered in individual 
 cases of disease and in personal idiosyncrasy, together with the 
 increasing varieties of foods and food preparations, make the rela- 
 tion of diet to disease a constantly broadening subject, the impor- 
 tance of which cannot be overrated. It is to be regretted that the 
 study of dietetics is not more thoroughly taught as a necessary 
 part of medical education, and that thorough systematic instruction 
 in this practical branch of science is omitted from the curriculum 
 of most medical schools. For many physicians it seems far easier 
 to write a brief prescription for a " nerve tonic " or cathartic pill 
 than to take the time and pains to state in writing for their patients 
 a definite dietary which in very many cases will prove an invaluable 
 adjunct to medicinal treatment, if not in itself a curative measure. 
 Sometimes indeed they appear possessed with the idea that the 
 minutiae of dietetics are beneath consideration, whereas in reality, 
 like the details of good nursing, they are most important, and a 
 careful attention to them and a close interrogation into the ordinary 
 habits of the patient in regard to his daily regimen is sure of appre- 
 ciation and of beneficial results. 
 
 In all acute febrile diseases and in all so-called " wasting " dis- 
 eases in which there is faulty assimilation of the food, the digestive 
 
DISEASES CAUSED BY DIETETIC ERRORS 365 
 
 functions are impaired, while the rapid tissue waste increases the 
 need for nutriment to replace it. In such cases enfeebled digestive 
 powers must be taken into account, and while endeavouring to sup- 
 ply the increased demand for food, every effort should be made to 
 relieve the alimentary canal of unnecessary labour by supplying 
 those preparations which will yield the necessary amount of nutri- 
 tion and force with a minimum expenditure of energy. More- 
 over, the conditions of elimination of waste materials from the 
 tissues must be studied in relation to the composition of dif- 
 ferent foods in order to prevent the overworking of the excretory 
 organs. 
 
 It may be asserted that there is almost no disease of long dura- 
 tion and severity, and certainly no disease accompanied by grave 
 constitutional disturbances, the course of which cannot in a measure 
 be controlled or benefited by thorough study of the nature and uses 
 of foods. There are many acute aliments in which undoubted bene- 
 fit is derived from greatly diminishing or altogether withholding 
 temporarily the consumption of food, while there are others in which 
 forced feeding — that is, increasing the quantity of food to the utmost 
 capacity of the digestive organs — is a necessity. 
 
 The general relations of food to the organism, as well as the 
 nature of foods and the processes involved in their digestion, ab- 
 sorption, and assimilation, have received full consideration in the 
 preceding pages. In the following chapters the principles briefly 
 outlined above will be considered in their application to individual 
 diseases. At the risk of some repetition, it has been thought best 
 to make the dietetic treatment of each disease as comprehensive as 
 possible under the different headings considered, and to emphasize 
 its value by a brief synopsis of the more important symptoms which 
 arise, and a discussion of the indications to be met by appropriate 
 dieting. 
 
 DISEASES CAUSED BY DIETETIC ERRORS 
 
 While the course of the majority of all diseases is obviously 
 influenced by the quantity and quality of the food eaten, there are 
 particular diseases which are directly caused by improper diet. This 
 causative relation concerns : 
 
 I. Insufficient food. II. Overeating and overdrinking. III. 
 Food in itself wholesome, but which is injurious because the in- 
 gredients are not properly balanced. IV. Food containing parasites 
 or their embryos. V. Food containing ptomaines. VI. Food con- 
 taining other poisons, grain poisoning, etc. VII. Food containing 
 adulterants. VIII. Food containing micro-organisms. IX. Food 
 which is in itself wholesome, but against which personal idiosyncrasy 
 exists. X. Alcohol as a food and poison. 
 
366 DISEASES CAUSED BY DIETETIC ERRORS 
 
 I. Insufficient Food 
 
 The general effects of starvation have been described in the study 
 of the proper quantity of food (p. 297). The effects of the depri- 
 vation of water are discussed on p. 43. Insufficient food may 
 cause the condition of marasmus, and is an important agent in pro- 
 ducing some forms of anaemia. (See Marasmus.) 
 
 II. Overeating and Overdrinking 
 
 Both overeating and overdrinking may be (1) temporary — that 
 is, the result of an occasional debauch ; or (2) chronic. 
 
 1. Temporary overeating may apply to the excessive consump- 
 tion (a) of a mixed diet, or (6) of particular articles of food. The 
 former (a) causes dyspepsia, or, in extreme cases, acute gastroenter- 
 itis. The latter (b) may also cause dyspepsia and diarrhoea, or such 
 affections may be produced as glycosuria, from excessive indulgence 
 in candy and sweets ; acne and other skin diseases, from the too 
 liberal consumption of fats. 
 
 Temporary overeating at one or two meals may not produce any 
 serious effect, but if the excess in feeding be long continued a variety 
 of ills result, attributable directly to overloading of the alimentary 
 canal and to the accumulation of waste matter in the tissues, and 
 consequent imperfect oxidation processes. 
 
 The excess of food may be injurious in one of two ways : 
 
 First, if it is not absorbed, it ferments abnormally in the alimen- 
 tary canal. There is a limit to the quantity of every food which 
 can be digested in a given time ; beyond this the food, whether 
 starches, fats, sugars, or proteids, may decompose, or pass away 
 unaltered. 
 
 Second, if the excess be absorbed the blood is overwhelmed, and 
 the excretory organs are overworked. 
 
 The inability to sing with precision after a too hearty meal is 
 often attributed to temporary congestion of the vocal cords. While 
 this is observed in the thickened speech of alcoholism, the difficulty 
 in singing caused by overeating is mainly due to inability to regulate 
 the actions of the diaphragm and other respiratory muscles when 
 the stomach is too greatly distended. 
 
 2. Chronic overeating may cause such diseases or diatheses as 
 obesity, gout, lithaemia, oxaluria, and the formation of renal, vesical, 
 and hepatic calculi. It is very certain to cause congestion of the 
 liver and the condition known as " biliousness," in which the stom- 
 ach and intestines are engorged, constipation results, the tongue is 
 heavily coated, the bodily secretions are altered in composition, the 
 urine especially becoming overloaded with salts, the liver becomes 
 congested, and finally the nervous and muscular systems are affected, 
 
OVEREATING AND OVERDRINKING 367 
 
 with the result of the production of headache and feelings of fatigue, 
 lassitude, drowsiness, and mental stupor. 
 
 For persons leading sedentary lives, excessive consumption of 
 animal food is more injurious than that of vegetable food, for the 
 reasons given above, although obesity is more favoured by excess 
 in vegetable diet and sweets. The nitrogenous foods, requiring, as 
 they do, a large consumption of oxygen for their complete com- 
 bustion and reduction to urea and allied products, produce forms 
 of waste matter in the system which are more deleterious than the 
 carbohydrates that are converted into water and carbonic acid, and 
 are more easily eliminated. It is for this reason that defective nitro- 
 genous metabolism alters the composition of the blood and paves 
 the way for disorders of nutrition, such as lithiasis. 
 
 Patients suffering from severe epilepsy and from certain forms 
 of insanity, chiefly manias, and sometimes hypochondriacs, at times 
 gorge themselves with food and drink. 
 
 The presence of intestinal roundworms and tapeworms may give 
 rise to overeating, though this by no means always follows. 
 
 Overeating is apt to be carried to an injurious extent by the 
 half-starved poor if they have sudden access to plenty, and by con- 
 valescents from typhoid fever. 
 
 Bulimia is a form of perverted sensation, causing inordinate 
 craving for food. (See p. 328.) 
 
 Overeating not only taxes the digestive system, but, what is often 
 more serious, it throws too great a strain upon the glandular and 
 excretory organs, especially the liver and kidneys, and if the habit 
 is long continued, disease of the nature above described inevitably 
 results. In like manner the overfed boiler becomes sooner burned 
 out, and its fires choked with ashes which accumulate faster than 
 they can be removed. Overeating, especially among the well-to-do, 
 is the commonest dietetic error, and looking at the question in its 
 broadest aspects, it is quite certain that the foundation for more 
 disease is laid by this habit than by overdrinking. (See Alcohol, 
 p. 225.) The former, indeed, sometimes conduces to the latter, 
 and there are some examples of alcoholism in which the desire for 
 drink is only aroused and fostered by previous excesses in eating. 
 
 Overdrinking, except of alcohol (which is considered under the 
 heading of Alcoholism), is not common, and is mainly confined to 
 the excessive consumption of tea and coffee, which results in in- 
 somnia, cardiac palpitations, and various neuroses. Dilatation of 
 the stomach has been attributed in some cases to overindulgence 
 in mineral waters, but such instances are very unusual. Polyuria 
 and diabetes insipidus have also been ascribed to the abnormal con- 
 sumption of fluids, but without strong proof. Excessive use of milk- 
 as a beverage usually results in " biliousness " and constipation, but 
 for the reason that it is really a solid food — that is, it becomes such 
 
368 DISEASES CAUSED BY DIETETIC ERRORS 
 
 immediately on entering the stomach. Thirst is often extreme in 
 fevers, diabetes, and other conditions, but the drinking of exception- 
 ally large quantities of water is by no means always harmful, and it 
 is often desirable to recommend it as a diluent and diuretic. The 
 propriety of restricting its use in dropsies, gastric disorders, etc., 
 will be considered under the appropriate headings. (See Gastric 
 Catarrh, Ascites, Diabetes.) 
 
 III. Food in itself Wholesome, but which is Injurious 
 
 BECAUSE THE INGREDIENTS ARE NOT PROPERLY BALANCED 
 
 Such diet may produce anaemia, from lack of meat or other 
 animal food; scurvy, from preponderance of salt meat and fish and 
 lack of fresh fruits and vegetables ; rickets and marasmus, from 
 errors in infant feeding, such as excess of amylaceous and lack of 
 animal food, necessary salts, etc. ; acne, or eczema, from food too 
 rich in fats ; constipation, from a too nutritious and concentrated 
 diet ; gout from various dietetic errors. 
 
 The belief is held by some authorities that a diet of coarse cereals 
 and vegetables favours the development of chronic arteritis. (See 
 Vegetarianism, p. 35.) 
 
 IV. Food containing Parasites or their Embryos 
 
 Food sometimes serves as the medium for the introduction of 
 parasites or their embryos, such as the tapeworm, roundworm, echi- 
 nococcus, and trichina. 
 
 In many cases the source of infection is found in the consumption 
 of raw or very imperfectly cooked swine flesh and other meats used 
 in the manufacture of sausages and similar preparations which are 
 carelessly handled and come in contact with the viscera of the ani- 
 mals in which the parasites or embryos reside in some intermediate 
 stage of development. Another possible source of infection, espe- 
 cially of intestinal worm larvae, is in the excrement of animals, which 
 is permitted to pollute raw vegetables growing upon the ground. 
 Manure is freely spread about, and dogs infested with worms, or a 
 casual pig allowed at large in a vegetable garden, may contaminate 
 by their faeces such vegetables as grow low upon the ground and 
 are usually eaten raw, as lettuce, celery, cabbage, etc. Fortu- 
 nately, this is by no means a common source of infection, but it 
 is well to remember that several diseases have been definitely 
 traced to such a source, and this explains the occasional presence of 
 tapeworms in people who never eat raw meats, ham, or sausage, or 
 the flesh of swine in any form. No animal should ever be allowed 
 to roam in a vegetable garden. Other varieties of parasites or their 
 larvae may occasionally be introduced with the food or water, such, 
 
INTESTINAL WORMS 369 
 
 for example, as the Dracimculus medinensis, which produces the 
 Guinea-worm disease, or Dracontiasis, the larvae of which are some- 
 times swallowed in drinking water by the natives of parts of Africa 
 .and the East Indies. 
 
 INTESTINAL WORMS 
 
 The presence of intestinal worms, such as the roundworm, 
 Ascaris lumbricoides, and various species of cestodes or tapeworms, 
 requires no special dietetic care beyond the preventive treatment of 
 avoiding raw or imperfectly cooked flesh and submitting to a period 
 of starvation for twenty-four hours, in order that the intestine may 
 be completely emptied of food before an anthelmintic is given, so 
 that it may more certainly reach the worms. 
 
 There are two principal varieties of tapeworm in man, besides 
 four or five others, which are very rarely present in the intestine, 
 being derived from the lower animals through habits of filth or 
 carelessness in preparing food. 
 
 Of these two varieties, the commonest in this country is the Tcenia 
 saginata, or mediocanellata ; the other, the pork tapeworm, or Tcenia 
 solium, is more often found in Europe and Asia. The larval stages 
 of Tcenia solium and Tcenia echinococcus also are observed in man, and, 
 according to C. W. Stiles, one half the persons affected by the latter 
 die within five years. H. O. Sommer has collected 100 cases of 
 echinococcus (hydatid) disease in this country. The larvae are de- 
 rived from the dog. 
 
 The Tcenia mediocanellata is a segmented worm, having a large 
 square head presenting four suckers, by which it maintains its hold 
 upon the intestinal mucosa without the aid of hooklets. The seg- 
 ments increase very slowly in size behind the head, and finally attain 
 a breadth of eight to ten millimetres and a length of seventeen to 
 eighteen millimetres, while the whole animal may reach a length of 
 twenty feet, or even become longer than the intestine. Fragments 
 of the worm are constantly breaking off, compressed by the waste 
 matter of the food, and with it are swept out of the gut. The larvae 
 live in swine. 
 
 The Tcenia solium is not so long as the mediocanellata, measuring 
 usually from six to twelve feet. The head, which is quite small, 
 presents four suckers and several minute hooks, which enable the 
 animal to secure a firm hold upon the mucous membrane. Behind 
 the head are a series of segments, many hundred in number, con- 
 stituting the body. They gradually increase in size, and the larger 
 ones contain male and female organs of generation, each segment 
 being supplied with both varieties. The larger segments attain a 
 size of seven to eight millimetres by ten millimetres. Each mature 
 segment contains an enormous number of ova — often several thou- 
 sand — and in about three months, when the worm has reached its 
 
370 DISEASES CAUSED BY DIETETIC ERRORS 
 
 full size, the segments, which are narrower and smaller than those of 
 mediocanellata, are continually breaking off and passing out with the 
 faeces. Pigs eat the ova, and digest them. The ova consist of shells 
 which contain minute embryos with six hooklets. The embryos 
 make their way into the viscera or muscles of the animal, where 
 they lodge and develop to form the larvae or cysticerci, called also 
 " measles." If the measled hog meat is eaten by man, and im- 
 perfectly cooked, the cysticerci develop with the intestinal worms 
 above described. 
 
 The worms infest man at all ages, from early childhood up. 
 They may cause no symptoms, but sometimes give rise to a raven- 
 ous appetite, as they interfere with intestinal digestion and absorp- 
 tion. They occasionally excite reflex nervous disturbances. Their 
 presence is made certain by the finding of either the ova or the 
 complete segments in various lengths in the stools. 
 
 Treatment. — The patient should be put upon very short rations 
 for two days, during which time the bowels must be well emptied. 
 The evening before giving the vermifuge the patient should take a 
 light supper of bread and milk or a sandwich, and that night a brisk 
 cathartic. It is best to give the medicine the next morning fasting. 
 By this means the intestines become almost empty, and the head of 
 the worm is left unprotected, so that whatever remedy is used to 
 kill it will make it loosen its hold. Another laxative may be given 
 a few hours later, and if the patient eats bulky food, such as bread 
 and potatoes, for a day or two, and keeps the bowels active, the 
 worm may be completely dislodged and crowded out. The stools 
 must be floated in water and closely examined for the head, for if 
 this is not obtained the worm is sure to grow again in three or four 
 months. There are many taeniacides. One of the least disagree- 
 able and most efficient when properly administered is pumpkin seed. 
 The seeds should be husked, and three ounces may be pounded in a 
 mortar, macerated, mixed with honey into a paste, and eaten spread 
 like jam upon a thin slice of bread. 
 
 TRICHINOSIS 
 
 Etiology. — Trichinosis is a parasitic disease produced by the 
 embryos of a worm, the Trichina spiralis, which work their way 
 into the voluntary muscles and there become embedded. Among 
 the parasites liable to be eaten with raw meats this one is by far the 
 worst and most fatal in its effects. The habitat of the adult worm 
 is the small intestine. During the emigration of the embryos into 
 the voluntary muscles a group of characteristic symptoms is pro- 
 duced. The parasites have the following appearance : The adult 
 male measures 1.5 millimetre in length; the female is from two to 
 two and a half times as long. The embryo is 0.6 to 1.0 millimetre 
 
TRICHINOSIS 371 
 
 in length, and when at rest, encapsulated in the muscle, is coiled in 
 a spiral. It has a blunt tail and a sharp head. The adult male has 
 two small projections from the caudal end. The ovoid capsule first 
 appears translucent, but later, from the deposition of salts of lime, 
 it becomes opaque. 
 
 Infection in man is caused by the eating of ham and pork from 
 hogs whose bodies contain the parasite. Among these animals it is 
 of quite frequent occurrence. It is also spread through the agency 
 of rats, which are eaten by hogs (Dock). 
 
 Natural History of the Parasite. — After eating flesh which con- 
 tains the embryos the process of digestion dissolves their capsules, 
 and they are liberated, passing into the small intestine, where, with 
 the presence of the favourable conditions of warmth, moisture, and 
 food, they reach their adult growth in from three to six days. Rapid 
 reproduction takes place in the intestine, and the number of young 
 produced by a single female worm varies up to at least a thousand. 
 In a week or more after the ingestion of the parasites the newly 
 developed embryos pass out through the intestinal wall and mesen- 
 tery, seeking the muscles, which they enter ; they then work their 
 way through the connective tissue between the fasciculi or the sepa- 
 rate muscle fibres, and finally enter the latter, where a fortnight's 
 further development produces the complete muscle form. 
 
 The observations of Askanazy point to the conclusion that the 
 adult female deposits the embryos within the walls of the intestinal 
 villi, not setting them free in the intestine, as originally supposed. 
 From the villi they penetrate the muscles, as above stated. 
 
 Thornbury reported at the Buffalo Academy of Medicine the 
 results of analysis of 500 cases of infected swine. In these animals 
 the parasite was found in the diaphragm 400 times, in the loin 290 
 times, and in the neck 170 times. " The point of predilection there- 
 fore appears to be the diaphragm. This is explained by its close 
 proximity to the digestive tract, from which the trichinae primarily 
 bore." In three cases in man which he examined the trichinae were 
 found principally in the extremities, " one microscope slide from 
 the biceps of an arm containing fifty of the parasites." They were 
 also present in the diaphragm, intercostal and abdominal muscles. 
 
 The embryos, when lodged in the muscle fibres, act as foreign 
 bodies or irritants and excite an interstitial myositis with the forma- 
 tion of a capsule around each embryo. One embryo may be lodged 
 in a single capsule. Once within the muscle fibres, embryos remain 
 without change until the capsule, the completion of which requires 
 about six weeks, is in some way destroyed. After formation of the 
 capsule a precipitation of lime salts occurs slowly within it for four 
 or five months. The embryos, thus securely protected in a strong 
 envelope, may retain their vitality for many years, and it is claimed 
 that they have survived for at least two decades, but the worms 
 
37 2 DISEASES CAUSED BY DIETETIC ERRORS 
 
 themselves not infrequently become calcified. Other animals be- 
 sides hogs may harbour this parasite, among which are the rat, cat, 
 mouse, and fox, and it can be artificially inoculated. 
 
 Prophylaxis. — The prevention of trichinosis should consist in 
 the more careful feeding of swine upon grain instead of offal, and 
 for man the only absolute prevention is the extremely thorough 
 cooking of all swine flesh, for a temperature of 140 F. is fatal to 
 the embryos. Smoking and pickling is also preventive. 
 
 " In the usual curing solutions trichinae are killed within six 
 weeks in thin pieces of meat, but in thick pieces they can exist as 
 long as four months " (Dock). 
 
 The presence of the parasites in countless numbers in the flesh 
 of the hog may give rise to no symptoms of any kind in the animal, 
 and it is this fact which makes the eating of raw ham, pork, and 
 sausages particularly dangerous unless the meat of the animals killed 
 has been subjected to a searching microscopic examination. It is 
 the safest rule never to eat such meats. The difficulty of detecting 
 the parasite in the hog is considerably increased by the fact that the 
 calcification is very much slower than it is in man, so that the worms 
 are more readily overlooked. The parasites fortunately are com- 
 pletely killed by boiling for some time the meat which contains 
 them, but pickling or corning meat or smoking ham and bacon are 
 not necessarily fatal to them. 
 
 Frequency. — Cases of trichinosis are occasionally reported in 
 this country chiefly among the Germans, whose fondness for raw 
 ham and a variety of sausages is well known. Osier reports the 
 finding of 456 cases, including 122 deaths recorded in America. 
 Many persons are often simultaneously affected from eating the 
 meat of the same animal, thus giving the disease the false character 
 of an epidemic. 
 
 Symptoms. — The symptoms vary with the number of parasites 
 which have been eaten. If very few are ingested, the embryos are 
 not reproduced in sufficient number to give rise to any symptoms. 
 Usually, however, they are well marked, and embrace a stage of 
 gastro-intestinal irritation followed by systemic infection. The pa- 
 tient, three or four days after eating raw pork or ham, suffers from 
 more or less severe abdominal cramps, with anorexia, vomiting, and 
 diarrhoea. The latter occasionally becomes severe. General mus- 
 cular prostration is also present, and there may be chills. In a 
 number of cases the gastro-intestinal symptoms may not be severe 
 enough to attract attention, and the first symptoms are those of 
 general infection, which develop at the commencement of the second 
 week. There is an increase of temperature, amounting to 103 or 
 104 F., of an intermittent or remittent character. As soon as 
 the embryos have extensively penetrated the muscles they give 
 rise to great local pain and tenderness, accompanied by swelling 
 
TRICHINOSIS 373 
 
 and tension of all the muscles affected. The patient naturally 
 assumes the position in which there will be the least strain upon 
 the muscles. 
 
 These symptoms increase in intensity, and general cedema is apt 
 to follow, which may appear first in the face. When certain muscles 
 are implicated more serious symptoms may result. If the diaphragm 
 is invaded or other muscles of respiration, there may be extreme 
 or even fatal dyspnoea. If the parasites reach the muscles of the 
 face, jaw, and pharynx, mastication and deglutition become difficult 
 or impossible. There is more or less itching and burning of the skin 
 and perspiration. Urticaria has been observed ; anaemia and a maras- 
 mic condition eventually develop in a majority of cases, and marked 
 eosinophilia amounting to 30 or 40 per cent is observed in the blood 
 in this type as it is in other varieties of intestinal parasitic disease. 
 There is comparatively little disturbance of the nervous system, and 
 patients are usually conscious until the time of death, but in some in- 
 stances a typhoid state supervenes with delirium. The other symp- 
 toms which have been reported as occasionally present are loss of 
 tendon reflex, bronchitis, pneumonia, pleurisy, albuminuria, and 
 polyuria. 
 
 Prognosis. — Mild cases may end in recovery within a fortnight. 
 In severe cases in which there has been great prostration and ema- 
 ciation convalescence is retarded for many weeks. 
 
 Children are more apt to recover than adults, but the outlook 
 depends chiefly upon the number of parasites ingested. Cases pre- 
 senting severe diarrhoea are more likely to end favourably, probably 
 because some of the parasites are eliminated in this way. 
 
 Mortality. — The greatest mortality occurs between the fourth 
 and sixth week. The causes of death may be exhaustion from 
 choleraic discharges, dyspnoea, and inability to swallow. In pro- 
 tracted cases inanition results. 
 
 Autopsies show that but few organs aside from the muscles are 
 affected by anatomical lesions. Cohnheim observed fatty degenera- 
 tion of the liver and enlargement of the mesenteric glands. The 
 muscles present the appearances of lesions of acute interstitial myo- 
 sitis around the capsules of the embryos. 
 
 Diagnosis. — The affection differs from acute rheumatism in the 
 absence of swelling in the joints and the much greater local tender- 
 ness along the surface of the muscles. The latter are exceedingly 
 painful both to pressure and voluntary movement. The disease in 
 its protracted form has-been mistaken for enteric fever, and un- 
 doubtedly it has many times escaped detection. The most valuable 
 features in determining the diagnosis are the extreme tenderness to 
 pressure of the muscles, their swollen condition, and the general 
 oedema and dyspnoea. Under cocaine anaesthesia a small piece of 
 muscle may be excised from the arm or thigh for microscopic exam- 
 
374 DISEASES CAUSED BY DIETETIC ERRORS 
 
 ination. Osier advises searching the stools for the parasites, which 
 may be found with a low-power lens as glistening threads. 
 
 Treatment. — The basis of treatment is to at once evacuate the 
 alimentary canal, providing the fact of eating the infected meat is 
 known within a day or two. Diarrhoea should not be checked. If 
 constipation exists, a strong purgative of calomel and jalap or castor 
 oil should be administered. When systemic symptoms develop, the 
 treatment must be purely symptomatic, because there is no known 
 remedy which will reach and destroy the trichinse. Every effort 
 must be made to support the strength of the patient until the em- 
 bryos have become encysted, after which the acute symptoms will 
 subside of themselves. 
 
 V. Food containing Ptomaines 
 
 Ptomaines are substances resembling alkaloids which are formed 
 in the alimentary canal by the decomposition or putrefaction of ni- 
 trogenous foods. They may also form in such food outside of the 
 body. This decomposition is the result of the action of certain 
 micro-organisms simultaneously first described by Gautier in France 
 and Selim in Bologna. It is at present believed that the constitu- 
 tional symptoms observed in many infectious diseases are caused by 
 similar poisons called toxins, which originate in the blood and 
 other tissues of the body through the action of specific germs. The 
 artificial cultivation of micro-organisms has proved that they are 
 capable of forming substances which have distinct physiological 
 actions that are sometimes highly poisonous. Many of these micro- 
 organisms flourish in beef juice, milk, and various solutions of ni- 
 trogenous material ; and in the alimentary canal, when such food is 
 taken, all the most favourable conditions are present for the devel- 
 opment of toxins. When the poisonous germs are ingested, their 
 toxins are readily absorbed by the intestinal mucous membrane, 
 and it is probable that ptomaine poisoning would occur very much 
 oftener were it not that the liver, acting as it does as a gate- 
 way for the admission of nutritive matter for the body, is capa- 
 ble of destroying many poisons which enter it from the intestines 
 through the branches of the portal vein. Corroboration of this 
 statement is found in the fact that snake bites of the surface of the 
 body may prove highly poisonous by immediate absorption of toxic 
 material into the circulation, whereas snake poison may be swal- 
 lowed with impunity, for if it is absorbed from the alimentary canal 
 it is destroyed in the liver before reaching the nervous system. 
 
 The same is true of the action of putrefying meat, which in very 
 small quantities may not produce severe gastro-intestinal symptoms 
 or constitutional disturbances, and yet if inoculated through a cut 
 in the finger may cause symptoms of a violent septic character. 
 
POISONING BY MEAT OR GAME 375 
 
 Richard (Diseases of Modern Life) reports a fatal case of poison- 
 ing from eating tainted hare. The victim had had a small ulcer be- 
 neath the tongue for some time, which became gangrenous after 
 eating the meat, and which was the undoubted source of inocula- 
 tion. 
 
 Ptomaines may be developed from a variety of foods, but the 
 principal ones from which poisoning from time to time occurs are 
 spoiled meat, milk, shellfish, and fish. 
 
 POISONING BY MEAT OR GAME . 
 
 When meat has been kept too long exposed to the air, or when 
 it has become contaminated in any manner with putrefactive bac- 
 teria, it is unfit for food, yet if thoroughly cooked it may not 
 be necessarily poisonous. This is the case with " high " game. 
 The bacilli especially associated with meat poisoning are the Bacillus 
 enteritidis of Gartner, and the anaerobic Bacillus butyricus of van 
 Ermenghem. Dangerous and even fatal cases of systemic poison- 
 ing by meat ptomaines have resulted from eating sausages, pork pie, 
 ham, meat juice, beef, head-cheese, mutton, or veal. Two hundred 
 and ninety-one severe cases of meat poisoning, one of which ended 
 fatally, developed upon the U. S. transport City of Rio de Janeiro, 
 in 1899, while proceeding from Honolulu to Manila. The putrefac- 
 tive change may have already begun in the meat although it may not 
 be apparent by an altered taste. Sausage poisoning is called botu- 
 lism or allantiasis. 
 
 It is a curious fact that certain persons have great toleration for 
 tainted meats. Among civilised races, and especially in England, 
 the use of " high " game and mutton is much less in vogue at pres- 
 ent than formerly, but the Eskimos and many savage tribes in 
 Africa eat with relish, and digest well, decomposing meat the mere 
 odour of which nauseates a white man. Bishop Colenso stated that 
 among the Zulus of Natal the synonym for heaven is " ubomi" which 
 means " maggoty meat." The natives of Siam and Cambodia prefer 
 to keep their fish until it has begun to putrefy. In some parts of 
 China foul eggs several months old are enjoyed as a delicacy. 
 
 Measly swine flesh rapidly decomposes, and the various processes 
 of drying, smoking, and salting still leave it unfit for food. On 
 the contrary, drying and smoking affect the superficial layers only, 
 while the minor portion furnishes a culture medium for bacilli. 
 Gluckmann has reported a case of poisoning by the Bacillus pro- 
 teus vulgaris from eating cured ham. 
 
 The meat of very young animals should never be eaten, and 
 the sale of young or " bob " veal two or three weeks old is 
 prohibited by law. It is indigestible, innutritious, and it readily 
 decomposes. 
 26 
 
37^ DISEASES CAUSED BY DIETETIC ERRORS 
 
 Symptoms. — The symptoms of meat poisoning from these various 
 substances are substantially the same in each case, being those of 
 severe gastro-intestinal irritation, but in bad cases they are accom- 
 panied by dangerous collapse. The symptoms may follow almost 
 immediately or after an interval of four or five or more hours. The 
 former is much better for the patient, for the sooner vomiting and 
 diarrhoea relieve the alimentary canal of the toxigenic material, the 
 greater the chance of recovery. The symptoms usually begin with 
 suddenness and violence, but they may be preceded by malaise, nau- 
 sea, lassitude, and mild abdominal cramps. The sudden onset is 
 ushered in by rigours with vertigo or faintness, or violent head- 
 ache. Exceptionally there is dyspnoea, and there may be cold per- 
 spiration and sudden severe pains in the epigastrium or in the thorax, 
 especially between the shoulders. Intense thirst has also been ob- 
 served. Soon after one or more of these symptoms have appeared 
 there is violent colicky pain in the bowels, accompanied by retch- 
 ing and vomiting, sometimes haematemesis, and profuse watery 
 diarrhoea. There is an extreme degree of muscular prostration 
 which comes on suddenly and prevents the patient from standing. 
 It may be due to the abdominal pain, but it also occurs independ- 
 ently. The tongue is dry and coated with a thick brownish-yellow 
 fur on the dorsum, but the margins are of a bright red with distinct 
 papillae. Fever is usually present, and the temperature may rise to 
 103. 5 or 104° F., although the skin may feel cold and moist. The 
 pulse is somewhat accelerated and the rate may reach 130 or 140. 
 
 Occasional symptoms which have been noted by Ballard are 
 severe cramps in the legs and arms, convulsive twitching of the mus- 
 cles of the face and hands, stiffness in the joints, and various abnor- 
 malities of sensation, such as numbness, tingling, and flashes of heat 
 and cold in the extremities. There may also "be drowsiness, photo- 
 phobia, and, in the worst cases, insomnia, nervous excitement, or 
 mild delirium. If the poison results fatally, the prostration increases, 
 the pulse grows rapid and feeble, the watery evacuations are uncon- 
 trollable, and rapid emaciation ensues. The patient becomes cya- 
 notic and passes into a state of collapse resembling that of the last 
 stage of cholera. 
 
 The poisoning presents all degrees of severity, depending on the 
 amount of the tainted food which has been taken, the nature of the 
 putrefactive process, and the condition of the alimentary canal at 
 the time. In mild cases, more or less abdominal pain, vomiting, 
 diarrhoea, and headache, with slight prostration, are the only symp- 
 toms. In the more severe rases, if convalescence follows the attack, 
 it is prolonged, and the weakness of the patient may be fully as 
 great as after some of the severe infectious fevers affecting the ali- 
 mentary canal, such as cholera or yellow fever. In cases in which 
 the symptoms develop very slowly, after an interval of a day or 
 
POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE 377 
 
 more the nervous symptoms are apt to predominate over those of 
 the gastro-enteric system. There are painful muscular cramps, 
 dyspnoea, aphonia, delirium, and palpitation. This variety of poi- 
 soning is extremely dangerous. 
 
 Diagnosis. — The diagnosis is almost always obtainable from the 
 history of the case in connection with the symptoms above de- 
 scribed, and when canned food has been eaten, the only difficulty 
 consists in determining whether the poisoning is the result of eating 
 tainted meat or of acute metallic poisoning from chloride of zinc, 
 tin, or lead used in the process of tinning and soldering the cans 
 (see p. 278). 
 
 POISONING BY MILK, CREAM, ICE CREAM, AND CHEESE 
 
 Poisoning by plain milk is less common than from certain vari- 
 eties of cheese and from cream. When ice cream is made in large 
 quantities, the cream is allowed to accumulate, and if a portion of it 
 becomes infected with pathogenic organisms it will soon convert 
 the whole mass into highly poisonous material. In a small town in 
 Indiana, in 1900, over one hundred persons were seriously poisoned 
 by ice cream from soiled cans. Many other such casualties have 
 been observed of late years. Sixty-seven men, at the San Juan 
 garrison in Porto Rico, were poisoned in 1900 by condensed milk. 
 In the U. S. Surgeon-General's report for 1900, the symptoms are 
 described as follows by Assistant Surgeon George M. Wells, 
 U. S. A. : 
 
 " The symptoms were persistent vomiting, severe cramps in the 
 stomach, purging, great prostration, dilatation of the pupils, head- 
 ache, clammy perspiration, chilliness, and great thirst. The stomach 
 in each case was washed out by means of the stomach tube. In 
 some cases the stomach was empty, and nothing but water and 
 mucus came away ; in others the washings were tinged with bile, 
 and in others again a moderate amount of food that had been 
 eaten for breakfast was washed out, but in no case was the stomach 
 overdistended or even full. The vomiting was controlled in several 
 instances by the washing out of the stomach, but in many it per- 
 sisted for several hours afterwards. The prostration was so great 
 that some of the patients fainted before reaching the ward. A large 
 number vomited blood in small clots, in most instances mixed with 
 nothing but mucus, showing that the haemorrhage had not taken 
 place until after the contents of the stomach had been expelled. 
 Purging began in most before the vomiting had ceased, and con- 
 tinued for twelve to fifteen hours. At first the stools were natu- 
 ral, soon watery, afterwards becoming mucous and blood tinged. 
 Cramps in the voluntary muscles were mild in some, but other pa- 
 tients writhed in agony, their sufferings being relieved only after 
 
378 DISEASES CAUSED BY DIETETIC ERRORS 
 
 thorough kneading and massage by the hospital attendants. Forty 
 were discharged from hospital on the following morning ; the others 
 from day to day until the fifth morning, when all were returned 
 to duty." 
 
 Vaughan and Novy in this country have thoroughly studied the 
 whole subject of ptomaine poisoning, and Vaughan has isolated from 
 cheese and ice cream a toxin to which he has given the name of 
 " tyrotoxicon," and in Michigan in i883~'84 nearly three hundred 
 instances of cheese poisoning were collected by him. In 1890 he 
 isolated three proteid substances from germ cultures from the in- 
 testines of infants having milk infection. The symptoms of tyro- 
 toxicon poisoning are substantially the same with those of meat 
 poisoning, consisting of severe gastro-intestinal disturbance with 
 collapse. 
 
 This toxin produces almost immediately after ingestion by a 
 previously healthy infant violent symptoms of cholera morbus, 
 which prove fatal in a few hours unless the poison can be eliminated. 
 (See Cholera Morbus Treatment.) Of this poison Vaughan says : 
 " Post-mortem examination shows but little change. [There is 
 time for but little in fatal cases.] The mucous membrane of the 
 small intestine is bleached and softened, and possibly deprived here 
 and there of its superficial epithelium." 
 
 The poison apparently acts somewhat as the toxin of Asiatic 
 cholera, by absorption from the intestinal wall, and by violently 
 deranging the nervous and vascular systems, producing sudden and 
 extreme loss of fluid from the body through osmosis into the in- 
 testine. 
 
 POISONING BY SHELLFISH AND FISH 
 
 Poisoning by shellfish and fish results from infection with pto- 
 maines developed by micro-organisms, as in cases of milk and meat 
 poisoning. In addition, it must be remembered that there are a 
 number of persons who, from idiosyncrasy, possess an extreme de- 
 gree of sensitiveness to the action of shellfish of all kinds. To 
 such persons the eating of clam broth or raw oysters, crabs or lob- 
 sters, may give rise to violent outbreaks of urticaria or eczema, or 
 produce severe headache, nausea, and vomiting. It is scarcely prob- 
 able that these cases are due to the same source as those of true 
 ptomaine poisoning, for they occur when the shellfish have been 
 eaten in perfectly fresh condition ; the symptoms, moreover, are 
 usually less violent than those caused by ptomaines, and similar 
 effects are produced in some people by certain vegetables and fruits, 
 like the strawberry. Among shellfish the mussel furnishes the most 
 violent poison. This substance Brieger has isolated under the name 
 of " mytilotoxin." It develops particularly in the liver of the ani- 
 mal. The intensity of the poison depends somewhat upon the local- 
 
FOOD CONTAINING OTHER POISONS THAN PTOMAINES 379 
 
 ity in which the animal has lived and fed. The same mussels may 
 become non-toxic in different waters. The name ichthysmus is ap- 
 plied to fish poisoning in general. 
 
 Symptoms. — The symptoms of poisoning from eating raw fish 
 or cooked mussels in which ptomaines have developed are somewhat 
 different from those of meat and milk poisoning in that they con- 
 cern the nervous system with less gastro-intestinal disorder. For 
 this reason the poison is very much more dangerous, and cases have 
 been known to result fatally two hours after eating mussels. In 
 such instances there may be no nausea, vomiting, or fever, but there 
 is sudden and extreme prostration, with numbness, faintness, cold- 
 ness of surface, dilatation of the pupils, double vision, restlessness, 
 nervousness, anxiety, and a feeble and very rapid pulse. In France 
 hard-roed herrings have caused such symptoms. Decomposing oys- 
 ters and fish may also produce symptoms of gastro-intestinal poison- 
 ing resembling those from the use of bad meat. The salted sturgeon 
 which is eaten extensively as a food in parts of Russia has caused 
 death from its decomposition, and a variety of fishes both in Euro- 
 pean and Eastern waters are capable of developing very active tox- 
 ins. In Russia poisoning has been produced by eating the ova of 
 the pike, barbel, and perch, and decomposed sturgeon roe (caviare). 
 Portions of the porpoise, eaten in China, may prove poisonous un- 
 less thoroughly boiled. The mackerel family has three species which 
 are poisonous, namely the jurel, bonito, and chicaro. They are 
 found in the West Indies. Two species of herring are poisonous ; 
 one of them, the meletta, taken along the Atlantic coast from Florida 
 to New York, has caused several fatal cases of poisoning. 
 
 VI. Food containing other Poisons than Ptomaines- 
 Grain Poisoning, etc. 
 
 It sometimes happens that flesh becomes poisonous from the 
 animal having fed upon some noxious substance shortly before it 
 was killed. The flesh of pigs fed on garbage may cause diarrhoea 
 (Parkes). It is a well-known fact that the flavour and digestibility 
 of game, and even fish, varies much with the season of the year and 
 the consequent nature of the food which the animal has had. Oys- 
 ters are not wholesome food from May to September, or in " the 
 months without an R." Cow's milk becomes unhealthful for infants 
 when the animal eats improper food, and instances have been re- 
 ported — although, fortunately, they are very exceptional — of illness 
 of adults caused by eating meat which had been poisoned during the 
 animal's life, as in the case of a sick ox to which a large dose of 
 tartar emetic was given. The animal died, and the meat subse- 
 quently was found to contain enough of the substance to severely 
 poison those who ate it. 
 
380 DISEASES CAUSED BY DIETETIC ERRORS 
 
 Game sometimes disagrees on account of the nature of the food 
 upon which the animal has previously been living. This is said to 
 be particularly true of the grouse in various parts of the country at 
 some seasons of the year. The laurel buds act in this manner. 
 Hares fed upon rhododendron are poisonous (Letheby). 
 
 A curious instance of poisoning from eating turkey meat was 
 reported by Seelye, of Amherst, Mass. Several young women at 
 a boarding school showed symptoms of atropine poisoning after 
 eating a bird which had fed upon the deadly nightshade berries. 
 
 GRAIN POISONING 
 
 Old unripe grain and mouldy flour develop poisons from decom- 
 position of their gluten. 
 
 Ergotism. — The fungus known as ergot, or Claviceps purpurea, 
 grows upon rye, and in Europe the careless admixture of this sub- 
 stance with grain in the preparation of flour has several times re- 
 sulted in violent symptoms of poisoning. Collectively the symp- 
 toms are described as " ergotism," and they are commonly divided 
 into two varieties, the gangrenous and the convulsive. The ergot- 
 containing flour or meal must have been eaten for a considerable 
 time, as a rule, in order to develop the symptoms. 
 
 Ergot is sometimes employed too freely in medicine. In appro- 
 priate cases it may be given in considerable quantity for a brief 
 period without exciting toxic symptoms. When, however, its use 
 is prolonged beyond a few days, serious poisoning results. 
 
 In the gangrenous form of ergotism the early symptoms are 
 referable to local vasomotor disturbances, affecting principally the 
 extremities. These symptoms are anaesthesia, numbness, prickling 
 pain, and spasmodic twitching of the muscles, with an impeded blood 
 flow due to vasoconstriction. In the convulsive variety the nervous 
 system is profoundly disturbed. After a period of indefinite symp- 
 toms, such as lassitude, headache, and prickling sensations, spasms 
 of the muscles with contractures begin. The spasms may be inter- 
 mittent, or may assume a tetanic character, lasting sometimes 
 through many days ; the arms are strongly flexed and the legs and 
 toes are extended. Spasmodic rigidity of the muscles may give 
 place to violent convulsions, which become general and fatal. There 
 is sometimes slight fever, and in the chronic cases melancholia or 
 dementia results. Delirium also is sometimes present. In cases 
 reported by Siemens and Tuzzek the posterior columns of the spinal 
 cord were found sclerosed. 
 
 Lathyrism. — A grain called the chick-pea vetch is sometimes used 
 for the adulteration of flour from various cereals. Several varieties 
 are used which have a similar effect to ergot in producing a condi- 
 tion of spastic rigidity in the lower extremities. This form of poi- 
 
FOOD ADULTERATION 38 1 
 
 soning has been observed in India by James Irving, and by others in 
 Italy and France. It is, however, rare, and but little is known as to 
 the exact nature of the lesions. 
 
 Pellagra. — Pellagra is a functional disturbance caused by eating 
 fermented unripe maize or Indian corn, made into polenta. It is 
 unknown in this country, but prevails in the south of Europe, in 
 portions of Spain, France, and Italy. The first symptoms noticed 
 are those of dyspepsia with more or less nervousness, insomnia, and 
 debility. These symptoms are followed by an eruption, the pella- 
 gral erythema, which develops in the spring. After the eruption 
 has lasted for some time, the skin becomes very dry and extensive 
 desquamation ensues accompanied by burning pains, or, if neglected, 
 the surface may become incrusted with areas of suppuration. With 
 the appearance of the eruption the dyspeptic symptoms are increased, 
 and there may be salivation and severe diarrhoea. The disease lasts 
 in greater or less severity for several months and ends in slow 
 convalescence, or else, in the worst forms, the nervous system is 
 involved and emaciation, headache, convulsions, delirium, and pa- 
 ralysis of the legs may appear. The peasants who eat this spoiled 
 food sometimes hftve severe attacks in successive years, and melan- 
 cholia and suicidal mania have been observed among them. There 
 are no definite lesions other than those of malnutrition, such as 
 fatty degeneration of various organs (Arnold). 
 
 The disease is not contagious, and it is said to be preventable 
 by adding salt to the cornmeal ; but salt is a Government monopoly 
 in Italy. The peasants resist the tax upon it, and, through prejudice 
 as much as through ignorance and poverty, they fail to make use 
 of it. 
 
 VII. Food Adulteration 
 
 Food adulteration consists of : 1. The addition of deleterious sub- 
 stances. 2. Fraudulent substitution of cheaper articles of food or the 
 sale of food not as fresh or good as it is represented. 
 
 A. J. Wedderburn, in a report to the United States Department 
 of Agriculture, makes the statement that of all food products sold 
 in this country, 15 per cent is adulterated, but only 2 per cent is 
 deleterious. 
 
 With the exception of milk and alcoholic beverages, the adul- 
 teration of foods in the United States is of comparatively little 
 importance from any harmful influence it may have upon health. 
 Its moral are often worse than its physical aspects. 
 
 In this country almost all food products are so abundant and 
 cheap that adulteration would be too expensive, and it offers small 
 temptation to unscrupulous dealers. There are, however, certain 
 articles of diet which form exceptions to this statement, although 
 the adulteration is more often merely fraudulent than a menace to 
 
382 
 
 DISEASES CAUSED BY DIETETIC ERRORS 
 
 health. These articles are included in the following table of exam- 
 inations made in a single State (Kentucky) by the Agricultural Ex- 
 periment Station. Forty per cent of all samples taken were found 
 adulterated. 
 
 Kind and Number of Scmiftles collected from Jujie ij, i8g8, to December 
 
 31, 1899 
 
 Articles Sampled. 
 
 Baking powder 
 
 Butter 
 
 Canned goods , 
 
 Catsups, pickles, etc , 
 
 Coffee 
 
 Cornstarch , 
 
 Flour (wheat) 
 
 Jellies, preserves, etc 
 
 Lard 
 
 Milk (sweet and buttermilk) 
 
 Milk colour , 
 
 Mince-meat „ 
 
 Oleomargarine. 
 
 Olive oil 
 
 Pepper, spices, etc 
 
 Sweet cider and grape juice. 
 
 Soda (cooking soda) 
 
 Sirups, honey, and sugar.. . . 
 Vinegar 
 
 Total 
 
 Not found 
 adulterated. 
 
 Adulterated. 
 
 II 
 
 45 
 
 Il8 
 
 29 
 
 6 
 
 
 12 
 
 45 
 
 2 
 
 1 
 
 I 
 
 
 20 
 
 
 5 
 
 18 
 
 29 
 
 n 
 
 115 
 
 35 
 
 1 
 
 
 
 7 
 
 2 
 
 16 
 
 1 
 
 1 
 
 3 
 
 11 
 
 
 3 
 
 3 
 
 
 4i 
 
 9 
 
 67 
 
 59 
 
 437 
 
 290 
 
 Total. 
 
 56 
 147 
 
 6 
 
 57 
 
 3 
 
 20 
 
 23 
 
 40 
 
 150 
 
 1 
 
 7 
 18 
 
 2 
 14 
 
 3 
 
 3 
 
 50 
 
 126 
 
 727 
 
 At the Connecticut Agricultural Experiment Station, 41 \ per 
 cent of 574 samples of spices were found adulterated, and over 25 
 per cent of coffee samples were adulterated (1899). 
 
 The object of adulteration of food — namely, to cheapen cost of 
 production— is attained by (a) increasing the bulk, (b) altering the 
 appearance, and (c) giving false strength. 
 
 In many States stringent laws have been enacted against all adul- 
 teration of food products, beverages, and drugs, but the ingenuity 
 of manufacturers and dealers in evading them necessitates the con- 
 stant vigilance of the experts of health boards. 
 
 Among the common adulterations may be mentioned the follow- 
 ing : Isinglass adulterated with gelatin ; wheat flour with bran or 
 cowpeas ; powdered sugar with barium sulphate ; mustard with flour 
 and turmeric ; " essences " of peppermint, cinnamon, etc., with poi- 
 sonous wood alcohol ; distilled coloured vinegar sold as cider vine- 
 gar ; pickles adulterated with iron and copper (Massachusetts State 
 Board of Health Reports) ; oleomargarine sold as butter ; ground 
 spices are adulterated with cocoanut shells, rice, flour, and ashes 
 (Ohio Dairy and Food Commission) ; water, sugar, and tartaric acid 
 are sold as lemonade. Wines and liquors are sometimes adulterated 
 
FOOD ADULTERATION 383 
 
 with alum, baryta, caustic lime, salts of lead, salicylic acid, and pig- 
 ments, especially haematoxylon. 
 
 Candies are adulterated with terra alba, kaolin, and various pig- 
 ments, and the different chewing gums, gum drops, etc., are largely 
 made with petroleum-paraffin products. 
 
 Most of the maple sugar sold is made from glucose, and maple 
 sirup is also derived from other sugars and artificially flavoured with 
 extract of hickory bark (Wiley). 
 
 Cotton-seed oil is often sold as olive oil. 
 
 Nearly half the liquid honey sold is adulterated with glucose. 
 
 Cocoa and chocolate are adulterated with both starch and 
 sugar. 
 
 Coffee is very extensively adulterated with sugar, caramel, pea 
 meal, chicory, and saccharin extracts. Coffee berries are artificially 
 made in moulds out of mixtures of starch, molasses, or caramel, 
 chicory, etc. Baking powder is often adulterated. 
 
 Prof. R. H. Chittenden, as a result of elaborate investigations 
 made with a view to determine the effect upon digestion of borax and 
 boric acid when added, as they often are, to preserve foods, con- 
 cludes that " borax and boric acid, when present in moderate quan- 
 tities, can have little or no deleterious effect upon the more impor- 
 tant chemical processes of digestion. On the contrary, it would 
 appear that the presence of these agents may, in some cases at least, 
 even accelerate the normal digestive processes of the alimentary 
 tract." 
 
 Pigments. — Artificial colouring matters are added to foods, both 
 to intentionally deceive and also merely to make different substances, 
 such as preserved green vegetables, candies, or confections, appear 
 more attractive to the eye. 
 
 Formerly highly injurious copper or zinc salts were much used 
 to colour canned peas and beans, and not infrequently they were 
 found in poisonous quantities, but the green plant pigment chloro- 
 phyll is so much cheaper, and is so abundant and harmless, that it 
 has superseded them almost entirely since its introduction for this 
 purpose in 1877. 
 
 Ultramarine is much used to colour sirups ; safranin, eosin, fuch- 
 sin, anilin violet, and many other anilins are employed in the manu- 
 facture of candies, as is also cochineal. 
 
 The pigments most in vogue to colour butter and cream are tur- 
 meric, saffron, an orange pigment from the stigmas of a flower, sul- 
 phonated anilin yellow, and annotto, a yellow pigment derived from 
 the fruit of a South American tree. Annotto as used by dairymen 
 to colour milk and cream is not harmful. To detect it, add a tea- 
 spoonful of baking soda to a quart of the milk, and immerse in it 
 a strip of unglazed paper. In a few hours the latter becomes orange- 
 coloured if annotto is present (Leffmann). 
 
384 DISEASES CAUSED BY DIETETIC ERRORS 
 
 Salicylic Acid. — The French Commission of Public Hygiene 
 made an exhaustive investigation of the subject of adulteration of 
 bottled beer, cider, milk, grape juice, and other aliments with sali- 
 cylic acid, which is mainly added to prevent decomposition. They 
 reported that its daily use in the quantities employed for preservation 
 is not harmful to healthy persons, but if renal or hepatic disease 
 exists it may become so, for under these conditions it is not promptly 
 eliminated. Used in any considerable quantity, it in time produces 
 anaemia, as it does in rheumatism. 
 
 Wiley found salicylic acid in seven out of ten samples of canned 
 tomatoes bought in markets. Formic aldehyde is extensively em- 
 ployed as a preservative of milk and other foods. 
 
 Vaseline is sometimes used to adulterate butter for making pas- 
 try and cakes. It does not become rancid, and is therefore difficult 
 of detection. Fortunately, it is not especially harmful. 
 
 TIN AND LEAD POISONING 
 
 Both tin and lead poisoning may arise from the prolonged use 
 of preserved meats, vegetables, or fruits. In tin cans the lead is 
 derived from the action of various organic acids upon the solder 
 (which in this country is usually 50 per cent lead), and the tin used 
 for coating the inside of the can eventually is dissolved in a similar 
 manner. (See also Canning, p. 278.) 
 
 Of late years attention has been directed to this subject by chem- 
 ists, and a number of cases are reported from time to time of serious 
 metallic poisoning. As a general rule, if the canning is properly 
 conducted and the meats or vegetables have not decomposed, there 
 is no danger in their use provided they are thoroughly cooked, and 
 provided also that the cans have not been kept too long. The 
 amount of tin dissolved is directly proportionate to the age of the 
 contents of the cans. The food in cans that have been unopened 
 for two or three years is very apt to produce poisonous effects. 
 Professor Bettink declares that malic acid is the solvent of the tin 
 when fruits and vegetables are canned. 
 
 Hehner examined many canned foods, and found tin present, in 
 most of them as a stannous hydrate, which existed in sufficient quan- 
 tity to be fatal when given to guinea pigs. 
 
 Ungar and Bodlander have reported a number of cases of poison 
 from canned asparagus. Tin present in such food in an insoluble 
 form may be dissolved and absorbed during digestion. 
 
 Professor Beckurts reported that a sulphate of tin is formed by 
 the action of vegetable albuminoids or of meat albumin on the can. 
 This is very liable to take place with canned asparagus, and two 
 cases of severe poisoning of this nature have come under my per- 
 sonal observation. Violent gastro-intestinal symptoms occurred, 
 
MILK INFECTION 385 
 
 such as severe vomiting and diarrhoea, accompanied by faintness and 
 vertigo. The symptoms came on two or three hours after eating the 
 asparagus from cans which had been kept for a long time. 
 
 Johnson (in The Medico-Legal Journal, vol. iii, p. 53) reports 
 cases of dangerous poisoning from eating tinned tomatoes which 
 were accompanied by symptoms of violent gastritis, stupor, and 
 coma. 
 
 Winckel reported the cases of 270 soldiers who had been made ill 
 from eating lettuce and meat preserved in tins. In their cases it was 
 estimated that the quantity of tin in solution was from 19 to 72 milli- 
 grammes per kilogramme. Roos advises the coating of such cans on 
 the inside with insoluble varnish, which prevents the albuminoids or 
 vegetable acids from coming in contact with the tinned surface and 
 dissolving the metal. He found upon opening a can of asparagus 
 preserved for thirty-one years that the inside tin coating was wholly 
 dissolved in the liquid. A can of beef preserved for eight years, 
 weighing 976 grammes, contained yy milligrammes of oxide of tin, 
 and a can of asparagus preserved only four months contained 11 
 milligrammes of oxide of tin and 6 of copper. Preserved apples, 
 corn, apricots, meats, and soups have also all been found to possess 
 the same solvent action upon tin cans. This is almost entirely pre- 
 vented in those instances in which a coating of varnish has been put 
 over the tinned surface. 
 
 Pears cooked in a tin stewpan have been known to cause severe 
 poisoning. 
 
 One hundred and fifty cases of severe metallic poisoning occurred 
 among the soldiers of a Tyrolese regiment who ate food from a tin- 
 lined copper kettle. 
 
 In general, food cooked or allowed to stand for any length of 
 time in either brass or copper vessels not kept absolutely clean is 
 dangerous to life. 
 
 VIII. Food containing Micro-organisms 
 
 Recent developments in the study of micro-organisms conducted 
 within the past decade have demonstrated very clearly the dangers 
 of infection upon a large scale from consumption of meat, milk, and 
 other foods contaminated by the germs of infectious diseases. 
 
 MILK INFECTION 
 
 Milk is an admirable culture medium for a great variety of germs, 
 and some bacilli, like those of typhoid fever and tuberculosis, thrive 
 particularly well in it. Moreover, its abundant and varied proteid 
 material furnishes substance out of which to develop powerful toxins 
 for absorption. 
 
 The following are the chief diseases whose germs are capable of 
 
386 DISEASES CAUSED BY DIETETIC ERRORS 
 
 being sometimes conveyed by milk : Tuberculosis, typhoid fever, 
 cholera, diphtheria, scarlet fever. 
 
 Milk, and food in general, should never be kept standing in an 
 ice box or cellar near an open or defective drain, as it becomes 
 rapidly tainted in noxious air. 
 
 TUBERCULAR INFECTION THROUGH MILK AND MEAT 
 
 Tubercular Milk Infection. — This matter is of special importance 
 in regard to the danger of conveying tuberculosis to infants through 
 raw milk. That this may happen is generally accepted as proved 
 (although Koch, at the Tuberculosis Congress held in London in 
 1901, made an emphatic statement to the contrary), and State boards 
 of health m this country are everywhere endeavouring to secure 
 proper legislative authority to inspect and condemn tuberculous 
 cattle. 
 
 Milk infected with tubercle bacilli when fed to animals has been 
 shown to produce primary intestinal and mesenteric tuberculosis, 
 and this may occur in infants. H. C. Ernst produced tuberculosis 
 in pigs by feeding them milk from tubercular cows even when 
 the latter had normal udders. Cow's milk may contain tubercle 
 bacilli even when the disease is located in the lungs of the animal 
 (Ernst). It is possible that this is the case w T ith the milk of tuber- 
 cular mothers, although it is not yet an established fact. The danger 
 to the infant is less in such cases, for the disease in the mother is 
 usually recognised in time to discontinue breast nursing. 
 
 It has been estimated in regard to the Eastern States that 15. per 
 cent of the common dairy stock is tubercular. Stall-fed animals who 
 live in filthy barns and get but little exercise show the largest per- 
 centage of infection. In healthy adults the gastric juice may succeed 
 in destroying tubercle bacilli swallowed with such food, and no doubt 
 it often does so. Fortunately the milk of all tubercular cows does 
 not contain the bacilli, but it is almost certain to do so when the 
 udders become involved in the disease. In large dairies the cows 
 should be given the tuberculin test once in six months, and if they 
 respond should be condemned as milk producers. (Conference of 
 State Boards of Health, 1898.) 
 
 In infants who live largely upon raw milk, and whose gastric 
 digestion is less vigorous than that of adults, mesenteric tubercu- 
 losis is relatively more common. 
 
 Tubercular Meat Infection. — Tubercular meat usually proves less 
 virulent than raw milk, probably because it is subjected to thorough 
 heat in cooking, but all the bacilli are not invariably killed by im- 
 perfect cooking, and infected meat or milk should on no account 
 be eaten. This fact is being gradually appreciated by the public, and 
 meat inspection at abattoirs is now much better regulated by law and 
 
TUBERCULAR INFECTION THROUGH MILK AND MEAT 387 
 
 supervised by local health boards than formerly ; but Billings says 
 that " probably one half of one per cent of the beef sold in market 
 comes from animals in whom tubercle existed at the time of death." 
 
 All slaughtering should be done in public abattoirs under com- 
 petent inspection, and not only should the animals be examined be- 
 fore killing, but the meat should be inspected afterwards. 
 
 The Bacillus tuberculosis has been found not only in the meat or 
 muscle of the ainmal butchered, but in the liver, kidneys, and other 
 viscera. It has also been seen in peripheral caseous nodules grow- 
 ing upon fowls (Sibley), and barnyard fowls have been known to eat 
 tuberculous sputum carelessly expectorated within their reach. The 
 bacillus is not killed by salting meat nor always by its digestion in 
 the stomach. Moreover, salt meat is not so thoroughly cooked as 
 fresh meat, as a rule. 
 
 Theobald Smith (Annual Report, Massachusetts State Board of 
 Cattle Commissioners, 1897) says it is doubtful whether the muscles 
 of cattle ever contain bacilli, but the latter are liable to be smeared 
 over the meat by the butcher's knife fresh from cutting into a tuber- 
 culous lymphatic gland or lung. According to this writer, there 
 are several varieties of tubercle bacilli as found in different animals, 
 which show decided differences in morphology and pathogenic ac- 
 tivity, but their morbific processes appear to be substantially the 
 same. He suggests that the bovine and human varieties may under 
 some conditions pass into one another, but he denies that cattle are 
 susceptible to human tuberculous sputum. He believes that the 
 danger of infection of man through milk and meat is greatly exag- 
 gerated, for while human tuberculosis has been decreasing for a 
 whole generation, that of cattle, at least until very recently, has been 
 on the increase. One or two curious cases are recorded of fowls 
 dead of tuberculosis acquired by pecking at human tuberculous spu- 
 tum, and Peter Paterson, of Glasgow, reports a death from eating 
 tuberculous poultry. 
 
 D. E. Salmon, Chief of the United States Bureau of Animal 
 Industry, in a report covering the two years ending June 30, 1899, 
 says: 
 
 " The number of condemnations per 10,000 animals slaughtered 
 was : 
 
 
 Cattle. 
 
 Sheep. 
 
 Swine. 
 
 
 
 22 
 26 
 
 7-5 
 O.6 
 
 24 
 13 
 
 
 
 
 
 
 Total 
 
 48 
 
 8.1 
 
 37 
 
 
 
 
 " Of the whole carcasses of cattle condemned 26 per cent were 
 affected with actinomycosis and 36 per cent with tuberculosis. Of 
 
388 DISEASES CAUSED BY DIETETIC ERRORS 
 
 the parts of carcasses of cattle condemned 13 per cent were affected 
 with actinomycosis and 1 per cent with tuberculosis. Nevertheless 
 these diseases are surprisingly rare, as only 8.1 carcasses per 10,000 
 animals were condemned for tuberculosis, and 9.2 per 10,000 for 
 actinomycosis. Tuberculosis is one of the principal diseases of 
 swine, but is found only in 1.3 carcasses per 10,000 animals. Tuber- 
 culosis in sheep is a rare disease. Including tuberculosis and pseudo- 
 tuberculosis, which are given together in the reports, there are speci- 
 fied but 6 per 100,000 sheep inspected. 
 
 " The beef-cattle which come from large abattoirs are singularly 
 free from tuberculosis, only 1 animal in 1,500 or 2,000 being affected 
 to an extent to cause condemnation of any part of the carcass. Dairy 
 cattle may be affected to the extent of 5 to 10 per cent ! In Europe, 
 the slaughter-house statistics show from 20 to 50 per cent of all cattle 
 slaughtered to be affected with tuberculosis." 
 
 Other Infections. — Meat from animals dead of various acute dis- 
 eases is sometimes eaten, and if well cooked it may be harmless, but 
 it is not good food, and no part of any animal suffering from the 
 foot-and-mouth disease (or cattle plague), rabies, glanders, actino- 
 mycosis, anthrax, septicaemia, swine plague, sheep or cow pox, pneu- 
 monia, trichinosis, or tuberculosis should ever be eaten. 
 
 TYPHOID AND CHOLERA INFECTION 
 
 Typhoid infection is undoubtedly conveyed through milk which 
 has been diluted with water infected from a barnyard well or cess- 
 pool, or which has been placed in cans rinsed in such water. Hankin 
 describes cases of this fever derived from eating dahi, a curdled milk 
 made by East Indian confectioners. Fraenkel found that typhoid 
 bacilli may live in acid buttermilk. The typhoid bacillus may live 
 for several days in fresh milk without multiplying. 
 
 Three hundred and eighty-six cases from milk infection occurred 
 at Stamford, Conn., in May, 1895. Another epidemic occurred in 
 York, Pa., in 1899. 
 
 At Coseley, near Birmingham, England, five cases of typhoid 
 fever were traced to infection from ice cream. 
 
 Typhoid infection through contaminated drinking water has been 
 already mentioned (p. 39). Even brushing the teeth with such 
 water or using it as ice may convey the bacilli into the body. 
 
 INFECTION WITH TYPHOID-FEVER GERMS THROUGH EATING 
 
 OYSTERS 
 
 An epidemic of typhoid fever occurred at Wesleyan University 
 in the latter part of November, 1894, which affected only certain 
 students to the number of thirty, who had attended college-society 
 suppers and ate raw oysters. A very thorough investigation was 
 
TYPHOID-FEVER GERMS THROUGH EATING OYSTERS 389 
 
 made by Prof. H. W. Conn into the aetiology of the epidemic, and 
 the following account of it was published in the New York Times on 
 November 20, 1894: 
 
 " The investigators at first ascertained that neither the water of 
 the college well nor the milk supply had been the agent of infec- 
 tion. Six college societies had given initiation suppers. All of the 
 oysters eaten at these suppers had come from one dealer, who had 
 obtained them from one oyster grower. At three of these suppers 
 raw oysters were served, and all of the thirty victims had partaken 
 of the oysters in this condition ; no one of those present at the other 
 three suppers, where only cooked oysters were served, was attacked 
 by the disease. These facts indicated that the germs of typhoid had 
 been conveyed in the water and other matter which accompanied the 
 raw oysters. How had that water and other matter become in- 
 fected ? 
 
 " The oyster grower, who lives on the shore of the Quinnipiac 
 River, a stream which flows into New Haven harbour, had been in 
 the habit of laying down his oysters for a day or two in the river, 
 after taking them from the deep salt waters of the Sound and before 
 putting them on the market. At about the time when the first cases 
 appeared at the university his wife died of typhoid fever. His daugh- 
 ter had been ill with the same disease. The oysters which were sold 
 to the students had been bedded temporarily in the river at a point 
 near the place where a short drain from his house discharges into 
 the stream. The water became infected by the flow from the drain, 
 and when the oysters were taken up the liquid and other matter 
 which accompanies oysters so dislodged, either on the outside of the 
 shell or inside of it, contained the germs of typhoid. Cooking killed 
 these germs, but the raw oysters carried to those who ate them a 
 dose of typhoid poison. It is reported that several recent cases of 
 typhoid in New Haven have been traced to infection thus conveyed 
 by oysters from the same river." 
 
 It has generally been believed heretofore that typhoid bacilli do 
 not develop in salt water, but the circumstantial evidence points 
 strongly to their having existed in the brackish water above de- 
 scribed, and, according to Foote, of New Haven, the typhoid bacillus 
 will live eight days in water from an oyster bed. The oyster juice 
 also contains the bacilli, and the bacilli injected into oysters live a 
 fortnight in abundance, and are known to have survived for thirty 
 days. 
 
 Two fatal cases of typhoid fever have been reported in Berlin 
 as due to infection from raw oysters. Sir William Broadbent re- 
 ported in the British Medical Journal ten cases which he saw during 
 November and December, 1894, and attributed to the same origin. 
 A number of cases have been traced in Italy and France to the 
 eating of raw oysters. Arthur Newsholme, of Brighton, England, 
 
390 DISEASES CAUSED BY DIETETIC ERRORS 
 
 studied 181 cases of typhoid fever occurring there from 1893 to 1896, 
 of which nearly one third were attributed to eating raw shellfish — 36 
 to oysters, and 20 to other varieties. All the shellfish were con- 
 taminated by sewage. 
 
 Oysters may also give rise to severe enteritis, and possibly chol- 
 era when derived from infected sewage beds. Frankland, however, 
 has determined that cholera bacilli injected into oysters do not sur- 
 vive more than twenty-four hours. 
 
 It is possible, although it is not definitely proved, that typhoid 
 bacilli may be conveyed upon raw vegetables and fruits which have 
 been washed in contaminated water. It is known that cholera germs 
 are conveyed in all of these ways. From this reason, as well as 
 from the necessity of avoiding diarrhoea, it is customary to advise 
 against the use of all raw fruits and vegetables during the preva- 
 lence of a cholera epidemic. 
 
 DIPHTHERIA AND SCARLATINA 
 
 Diphtheria germs, and even those of scarlatina, can be conveyed 
 in milk should they have access to it. Several epidemics of both 
 diseases have been traced among families employing in common a 
 milkman whose children at home had one or other disease. In Buf- 
 falo, N. Y., in 1899, an epidemic of 29 cases of scarlatina was defi- 
 nitely traced to consumption of milk delivered by one milkman, who 
 obtained the supply from a farmer who had the disease at the time 
 of milking. 
 
 FOOT-AND-MOUTH DISEASE 
 
 The foot-and-mouth disease may be propagated from the use 
 of milk from an infected cow. Sometimes this milk is of a bad 
 taste and odour, or it may even be mixed with blood or pus if the 
 nipples are excoriated or if the udders are inflamed. In other cases 
 the milk appears normal, but when boiled coagulates readily into 
 small flocculi in a bluish whey. Such milk is rendered innocuous 
 by the process of boiling. Children are more likely to contract the 
 disease in this way than are adults, owing to their greater consump- 
 tion of cow's milk. 
 
 FOOD INFECTION THROUGH FLIES 
 
 The importance of preventing food infection through the agency 
 of common house flies is just beginning to be appreciated. These 
 insects are admirably adapted to convey infection from their great 
 numbers and incessant activity, as well as their numerous feet, capa- 
 cious intestines, their frequent evacuations, and disgusting habits 
 of alighting and feeding upon sputum, manure heaps, and all animal 
 
IDIOSYNCRASIES IN REGARD TO FOOD 39 1 
 
 discharges. When fed on tubercular sputum the bacilli have been 
 discovered alive in their intestines, and cholera germs have been 
 found adhering to their feet by which they are easily transported 
 from a choleraic stool to a piece of bread or a raw fruit or vegetable, 
 destined in turn to infect the first person who is unlucky enough to 
 eat it. During the cholera epidemic in Hamburg Dr. Simmonds 
 found comma bacilli in the intestines of flies in the post-mortem 
 room where dead cholera patients were examined. The bacilli re- 
 mained one and a half hour in the flies — time enough to be carried 
 a long distance or to be widely distributed. When the matter is 
 further investigated it will doubtless be shown that other kinds of 
 infection are often spread by the medium of these vulgar pests. 
 Ordinary pus infection is readily carried by flies. In the hastily con- 
 structed camps of our troops in the Spanish-American War, and in 
 those of the British soldiers in the Boer War, many cases of typhoid 
 fever were traced to infection by flies that had access to the latrines 
 in which typhoid stools had been emptied. 
 
 IDIOSYNCRASIES IN REGARD TO FOOD 
 
 Idiosyncrasies are found to exist with some persons in regard to 
 special articles of food, and these cannot be readily explained. As 
 a rule, if marked, they extend throughout life, but it is not seldom 
 the case that some people pass through periods when a particular 
 article of food disagrees with them which they have been previously 
 able to eat with impunity. Some are unable to digest milk and are 
 immediately nauseated or made " bilious " by it, while others cannot 
 eat eggs, and yet can drink milk, while some cannot take either. 
 Some can eat the white and not the yolk of eggs. Others, again, 
 cannot eat fat in any form or are unable to digest some one variety 
 of fat, especially hot mutton fat. Some persons acquire a head- 
 ache whenever they eat butcher's meat in excess. Among the com- 
 moner idiosyncrasies of diet are the revolt of the system which 
 occurs from the use of shellfish of all kinds, but especially lobsters, 
 and from strawberries. Fothergill reported the case of a lady who 
 all her life was unable to drink coffee, of which she was very fond, 
 without having diarrhoea from it within an hour or two. Temporary 
 or functional visual disturbances may be produced by alcohol and 
 by indulgence in " high " game or eating spoiled food. Casey A. 
 Wood, of Chicago, has reported a case of recurrent amblyopia in a 
 physician of fifty-four years of age, who invariably had an attack 
 resulting from the eating of chocolate in any form. 
 
 Food idiosyncrasies are not infrequently hereditary, and may 
 affect several members of one family. They are wholly independ- 
 ent of ordinary dyspeptic conditions, and may be present in those 
 whose digestive organs are exceptionally robust. 
 27 
 
392 DISEASES CAUSED BY DIETETIC ERRORS 
 
 X. Alcohol Poisoning — Alcoholism — Delirium Tremens 
 
 The position of alcohol as both a food and a stimulant has al- 
 ready been fully discussed in connection with its physiological and 
 dietetic action (p. 228). 
 
 ALCOHOL POISONING 
 
 The effects of poisoning by alcohol differ according as they are 
 acute or chronic, and according to the previous alcoholic habits of 
 the patients. Habitual drinkers easily consume quantities of raw 
 spirits which might prove fatal if drunk by one not inured to their 
 use. Men have been known to drop dead a few moments after 
 quickly drinking a pint or more of whisky on a wager. Although, 
 according to Professor Atwater, two and a half ounces of alcohol 
 may be daily oxidised by a person in health, the continued use of 
 beverages containing this quantity is liable to produce alcoholism in 
 any one. 
 
 When alcohol is used to excess as a stimulant its effects are 
 manifested by the increased mental excitement of intoxication. 
 There is a period of restlessness, insomnia, loss of memory, and 
 irritability. The stage of insensibility and final stupor or coma de- 
 velops later after long taking large quantities of alcohol. Patients 
 suffering from alcoholic coma are always in danger of heart failure 
 from paralysis of that organ, which forms no exception to the gen- 
 eral rule that overstimulation of any muscle produces exhaustion 
 and paresis. When in this condition, however, they are fortunately 
 incapacitated from making any sudden or violent exertion, and in 
 acute cases alcohol is eliminated with considerable rapidity from 
 the various excretory organs of the body, especially the kidneys, 
 in the form of waste matter, which it produces. 
 
 The continued use of strong spirits, as well as the occasional use 
 of alcohol in excess, almost invariably results after some time in 
 the establishment of chronic gastric catarrh, which is characterised 
 by the formation of thick, ropy mucus, and thickening of the gastric 
 mucous membrane, with atrophy of the gastric glands. There is 
 always malfermentation with more or less acidity and heartburn and 
 considerable nausea, especially in the morning, when the mucus or 
 products of indigestion have accumulated overnight. There is also 
 an increased production of connective tissue in the stomach wall. 
 The effects of chronic alcoholism upon the alimentary canal are 
 chiefly manifested in the stomach, although the intestine may share 
 in the pathological changes. This is due to the fact that the alcohol 
 reaches the stomach in a more concentrated form, and that being! 
 very diffusible it is absorbed in great part without entering the) 
 intestine. 
 
ALCOHOL POISONING 393 
 
 In addition to the local gastric catarrh and inflammation which 
 it may produce, alcohol gradually alters various viscera, causing cir- 
 rhosis of the liver, nephritis, chronic endarteritis, etc. Chronic alco- 
 holism is one of the commonest causes of multiple neuritis, chronic 
 pachymeningitis, and myelitis. 
 
 In chronic alcoholism the intense craving for alcohol in any 
 form tends to weaken and overcome the will power and debase the 
 moral nature of the individual, and those who are afflicted by this 
 habit very often drink periodically — that is, the intervals between 
 their excesses may be prolonged for one or several months, during 
 which time they touch no alcohol in any form, and, indeed, in some 
 cases they may have a positive loathing for it. The very sight of it 
 nauseates them. The craving then returns and becomes so irresisti- 
 ble that if they cannot obtain liquor they have been known to drink 
 raw alcohol from spirit lamps or in any shape in which they can 
 obtain it. The craving consists partly of a special appetite for liquor 
 in the stomach, and in part of the general irresistible desire of the 
 system, which is somew T hat akin in its effect to intense hunger, al- 
 though the effect on the will power is more disastrous. 
 
 The evil results of excessive indulgence in alcohol are strikingly 
 shown by its effect upon liquor dealers, the mortality among whom, 
 from various diseases, as compared with that of other men, bears 
 the ratio of 3 to 2. When a similar comparison is made in regard 
 to the mortality of liquor dealers from special diseases, the result 
 is still more striking; thus for liver diseases the ratio is 6 to 1, for 
 nervous diseases nearly 2 to 1, and for alcoholism 5.5 to 1. 
 
 The dietetic causes of inebriety form an interesting study. The 
 craving for alcohol is undoubtedly fostered in many cases by monot- 
 ony of diet, by ill-prepared food, and the resulting catarrhs of the 
 alimentary canal and lack of nutrition. To meet the symptoms of 
 anorexia, heartburn, and weakness from malnutrition " tonics " and 
 " bitters " containing alcohol are often resorted to, or alcohol is 
 taken more directly in the form of strong spirits. While this may 
 temporarily relieve the craving for some form of stimulation, it often 
 merely makes the digestive disturbance worse and increases the 
 mental depression of " biliousness." In such manner the drink habit 
 is easily established. 
 
 Dietetic Treatment of Mild Cases. — In the milder cases charac- 
 terised by nervousness, muscular tremors, indigestion, dyspepsia, 
 a foul breath, coated tongue, and urine loaded with urates or crys- 
 talline deposits, if the patient can be induced to stop all alcoholic 
 drink and take abundant water or alkaline effervescing waters 
 (Vichy, Seltzer, Apollinaris, etc.), together with a proper diet, 
 much can be done to ward off an acute attack. A very good 
 example of the appropriate diet is the following from Foods and 
 Dietaries : 
 
394 DISEASES CAUSED BY DIETETIC ERRORS 
 
 " Breakfast. — A lightly boiled egg, or a little bit of whitefish or 
 of bacon, or a light savoury omelet ; toast, or bread and butter ; a 
 cup of weak tea or of coffee and milk. 
 
 " Early Dinner, I o'clock. — A slice of roast mutton, or the wing 
 of a chicken, or a plain cutlet, with a spoonful of mashed potato 
 and some well-boiled green vegetable. A few spoonfuls of any plain 
 milk or bread pudding, with occasionally some stewed fruit. Bever- 
 age. — A glass of plain or aerated water, to be taken slowly towards 
 the close of the meal. 
 
 " Afternoon. — A cup of tea with milk may be allowed, with toast 
 or rusk. 
 
 " Supper, 7.30. — A light meal of fresh fish, or of bird, or of calf's 
 head, or of tripe, with dry boiled rice or bread. Beverage. — Small 
 glass of milk and soda water." 
 
 In cases of periodic alcoholism, in which the patient has no crav- 
 ing for drink between his attacks, it is best to recommend for the 
 intervals a non-stimulating diet, avoiding condiments and richly 
 cooked or highly seasoned food of all sorts. Fruits, plainly cooked 
 cereals, and vegetables should constitute the staple diet, and animal 
 food should be eaten only in moderation. 
 
 In some of these cases overindulgence in food excites the crav- 
 ing for alcohol. 
 
 Dietetic Treatment of Severe Cases. — The treatment of the severer 
 cases, in which dyspeptic or gastro-intestinal symptoms predominate, 
 but in which delirium tremens is not necessarily present, is mainly 
 that of gastric catarrh, described elsewhere. It must be adapted 
 to the degree of inflammatory or cirrhotic changes which have al- 
 ready taken place in the different organs. The patients usually feel 
 much worse in the mornings, having nausea and vomiting or 
 loathing for food, but later in the day they may recover con- 
 siderable appetite and power of digestion. Advantage should 
 be taken of this fact in feeding them. The following menu from 
 Foods and Dietaries is very well adapted to this stage of chronic 
 alcoholism : 
 
 " Breakfast, say 8 o'clock. — A cup of weak tea with an egg beaten 
 up in it, and a slice of toast. 
 
 " Second Meal, 10.30. — A cupful of good meat soup, thickened, 
 or a cup of peptonised milk, warmed, with toast or rusk. 
 
 " Early Dinner, 1 o'clock. — A tablespoonful of pounded meat on 
 toast, or a small teacupful of fresh meat juice, with fingers of toast. 
 A couple of spoonfuls of sago, custard, or tapioca pudding. Bever- 
 age. — Half a tumblerful of milk and soda water (equal parts). 
 
 " Afternoon Tea, 4.30. — A cup of weak tea or of cocoa nibs, with 
 rusk or a plain biscuit. 
 
 " Evening Meal, 7 o'clock. — A cup of soup or of mutton broth, as 
 at the forenoon meal. 
 
DELIRIUM TREMENS 395 
 
 " 9-3° or I0 - — A cup of peptonised milk and a slice of thin bread 
 and butter. 
 
 " Food During the Night. — In case of wakefulness there should be 
 within reach, and arranged so as to be readily warmed, peptonised 
 milk.'' 
 
 DELIRIUM TREMENS 
 
 Delirium tremens is a condition of active maniacal excitement 
 which in its worst form is accompanied by intense general nervous 
 excitement, muscular weakness, and hallucinations, chiefly of sight 
 and hearing, of a terrifying or disgusting nature. 
 
 Delirium tremens is sometimes excited by a temporary debauch, 
 but as a rule this results in a condition of coma rather than mani- 
 acal excitement. Delirium tremens is much more characteristic of 
 chronic than of acute alcoholism. 
 
 In the earlier stages the heart action may be apparently vigor- 
 ous and the pulse full and bounding, but the heart may become sud- 
 denly exhausted and cardiac failure is the chief danger. 
 
 Dietetic Treatment. — The indications for dietetic treatment are 
 to make sure that the alimentary canal, which has been previously 
 disordered and congested, if not inflamed by the excessive irritation 
 of strong alcoholic drink, is emptied of any accumulation of abnor- 
 mally fermenting food. In the earlier stages brisk purgation or an 
 evacuant enema should be given. If the stomach is overloaded with 
 improper food, free vomiting should be produced by ipecac or apo- 
 morphine, provided the condition of the patient is sufficiently vigor- 
 ous to warrant this procedure. Large draughts of water, aerated 
 and saline waters, should be taken to promote the activity of the 
 kidneys and to dilute the poison in the system. The alimentary canal 
 having thus been emptied of fermentation products, it becomes nec- 
 essary to support the patient's strength with abundant nourishment. 
 The appetite for food is usually entirely absent, being replaced by 
 that for drink, but the patient must be urged to take all the nourish- 
 ment possible, and to this end it may be given in fluid form in small 
 frequent doses. The food should be stimulating and predigested. 
 If there is much gastro-intestinal irritation, pancreatinised milk, 
 strong meat soups, beef tea with dropped eggs added to it, and egg- 
 albumin may all be given. The mucous surface of the stomach has 
 been long accustomed to the stimulating effect of strong alcohol, 
 and if this be suddenly and completely removed, gastric discomfort 
 and craving for drink become intolerable. This condition is often 
 relieved by using strong spices or condiments, such as ginger or 
 Cayenne pepper, in quantities which would be injurious to a normal 
 stomach, and might possibly produce gastritis. These substances 
 may be added to food and non-alcoholic drink, although the stomach 
 may be actually inflamed. Experience proves that highly seasoned 
 
396 DISEASES CAUSED BY DIETETIC ERRORS 
 
 food is sometimes borne with the effect of diminishing the suffering 
 of the patient. This applies, of course, only to very robust cases, 
 in which an otherwise vigorous constitution has been abused by 
 excessive indulgence in drink, and the gastric stimulant should not 
 be long continued. In this variety of cases the quantity of food 
 which the patient is encouraged to take need only be limited by the 
 ability to digest it, for the digestive organs can be kept fairly active 
 without being overloaded to the extent of exciting abnormal fer- 
 mentation. The nervous system is always strengthened and soothed 
 by abundant nourishment. 
 
 Ginger ale constitutes a very serviceable non-alcoholic beverage, 
 which in part relieves the craving for stronger drink. It may be 
 drunk in considerable quantity, and it possesses the advantage of 
 being somewhat laxative, diuretic, and mildly stimulating to the 
 stomach. Care should be taken to obtain a pure article, as there is 
 much inferior ale in market. 
 
 It is well known that persons who for many years have indulged 
 excessively in spirituous drinks are very apt to develop delirium 
 tremens if taken suddenly ill, or if they sustain an injury such as a 
 fracture, although they may have drunk no liquor for many weeks. 
 In such cases the patient's life is in serious danger and it may be 
 necessary to give more alcohol to maintain the accustomed influence. 
 The conditions here to be met are very different from those resulting 
 from an ordinary debauch, when liquor should be entirely withheld. 
 
PART VII 
 ADMINISTRATION OF FOOD FOR THE SICK 
 
 METHODS OF FEEDING THE SICK 
 
 General Rules 
 
 In no branch of her work can the nurse be of more service than 
 in her ability to feed a very sick patient properly. There are many 
 details which can only be mastered by extensive bedside experience 
 and close observation, and so much depends upon tact and discretion, 
 which can never be learned from text-books or lectures, that it is im- 
 possible to formulate rules for feeding which shall cover all cases ; 
 but the following suggestions will be found applicable in many in- 
 stances. 
 
 Miss Nightingale wrote that " to watch for the opinions which 
 the patient's stomach gives, rather than to read ' analyses of foods,' 
 is the business of all those who have to settle what the patient is to 
 eat — perhaps the most important thing to be provided for him after 
 the air he is to breathe." 
 
 The Appetite. — In judging of the patient's appetite it must be 
 remembered that what is supposed to be a lack of desire for food is 
 possibly due merely to defective cooking, to serving meals at inop- 
 portune moments, or to selecting food which is not to his liking. 
 There may be appetite enough for food, but not for the particular 
 food offered, and it is the province of the nurse to differentiate such 
 matters. She should not only save the patient from physical exer- 
 tion, but from the effort of thinking as well. 
 
 It is the function of the nurse to observe and record all the con- 
 ditions of the patient's appetite, digestion, and likes and dislikes for 
 different foods, and when her instructions have not been specific, or 
 have not provided for emergencies, she should make it a point to 
 have them understood at the next visit of the physician. A thorough 
 practical knowledge of dietetics should be the foundation of the 
 nurse's education, and this subject should receive much more atten- 
 tion in the curriculum of training schools than is at present bestowed. 
 
 The nurse has a far better opportunity than the physician to 
 judge of the patient's appetite and study his whims and fancies in 
 regard to food, and she should not fail to report them and under- 
 
 397 
 
398 ADMINISTRATION OF FOOD FOR THE SICK 
 
 stand very positively from the physician in charge to what extent 
 she is to be permitted to humour them and substitute one form of 
 food or drink for another. Directions are apt to be given too in- 
 definitely to the nurse, and with the best intentions, from lack of 
 instruction, she may neutralise the effects of medicines by overfeed- 
 ing, or by irregularities in feeding which disorder digestion and in- 
 terfere with the action of the drugs, besides making the patient 
 worse. She is often merely told to give " soft diet " or " fluid food," 
 and she promptly resorts to milk and eggs, which may or may not 
 agree and nourish. Or instead of such vague orders she may be 
 directed to give only some one form of food, which she conscien- 
 tiously does, offering it in spite of the patient's accumulating nausea 
 and disgust, with the result of half starving him, because the physi- 
 cian has forgotten to allow the nurse any latitude or discretion. 
 
 Regularity in Feeding. — The hospital nurse should be taught 
 that it is as important to give food as medicines at regularly appointed 
 intervals. Punctuality should be carefully observed in serving all 
 meals to the sick. There is much unconscious habit in regard to 
 eating, and an appetite which was ready at the accustomed hour of 
 receiving food may vanish if the meal is delayed. It is well, when 
 possible, to bathe the patient's face and hands before offering a 
 meal. It is best always for the same nurse to have the charge of 
 feeding a definite number of hospital patients. If they are served 
 by a different nurse at each meal it is much more difficult to report 
 those whose appetites are defective or capricious. 
 
 Quantity of Food. — Among the first considerations is the proper 
 quantity of food to offer the sick, and the extent of its dilution. 
 Miss Nightingale has said that " an almost universal error among 
 nurses is the bulk of the food, and especially of the drinks, they offer 
 to their patients," and " it requires very nice observation and care 
 (and meets with hardly any) to determine what will not be too thick 
 or strong for the patient to take, while giving him no more than the 
 bulk that he is able to swallow." 
 
 By diluting milk, stimulants, and gruels too much, or making 
 beef tea too weak, the quantity of the fluid is so great that the patient 
 soon tires of swallowing, and stops before enough nourishment has 
 been obtained. Predigested milk possesses the decided advantage 
 that it aids the assimilation of the milk without adding to its bulk, 
 as lime water and other substances do. 
 
 When the appetite flags it is unwise to ask the patient each time 
 beforehand what he would like to eat. It is often the unexpected 
 which pleases. The smell of cooking and the noise of the prepara- 
 tion of food should be kept from the sick-room. The nurse should 
 never eat her own meals in the presence of the patient. 
 
 Details of serving Food. — Hot food should be served very hot 
 and cold articles very cold, for lukewarm food is unpalatable. In 
 
METHODS OF FEEDING THE SICK 399 
 
 serving hot beverages or foods the cups or plates should be first 
 well heated. Milk and butter should be kept cold and well covered. 
 A simple refrigerator is easily improvised by placing a few large 
 lumps of ice in a dish pan or pail kept by an open shaded window, 
 and wrapping them in flannel to prevent evaporation. 
 
 Patients may appear too ill to notice details, whereas they are 
 often only too ill to speak of them, and a refined, fastidious, or nerv- 
 ous patient may have the appetite wholly destroyed by the careless- 
 ness of a nurse who tastes the food in the. patient's presence or with 
 his spoon, or who serves food with unclean hands. Untasted food, 
 dishes after use, or half-emptied cups or glasses should never be 
 left standing about the sick-room. Nothing is more uninviting than 
 to have to drink from a glass to the sides of which stale milk is 
 adhering. If there is any suspicion of the absolute freshness of 
 milk, eggs, butter, or fish, they should never be served. 
 
 It is equally important to make all food look inviting by offering 
 it with the most attractive china which the house affords, and with 
 only the cleanest of linen. Dishes should always be wiped dry on 
 the outside, and pains should be exercised not to spill the contents 
 of cups into their saucers. 
 
 These may appear trivial details, but it must be remembered that 
 the horizon of the sick-room is very limited, and a patient who has 
 been long confined to bed with a serious illness thinks a great deal 
 of his immediate surroundings. The taking of food is the chief event 
 of the day for him, and too much care cannot be bestowed upon the 
 minutiae of service, while the natural stimulants to appetite — such 
 as fresh air, exercise, and enlivening companionship — are necessarily 
 wanting. 
 
 When patients are able to partially sit up for their meals, the 
 nurse should see that they have a comfortable position in the bed, 
 and that the food tray does not cramp the arms or legs. The effort 
 of sitting up may cause fatigue too soon and destroy the appetite 
 before the meal is half done. 
 
 As a rule, twice-cooked food should not be served to invalids. 
 This applies especially to meat, fish, and vegetables. Whenever 
 economy is an important consideration, it is better to cook but little 
 food at a time, and serve it fresh and hot. Food is often made un- 
 palatable by being too greasy, and this is one of the chief objections 
 to the use of meat broths, and mutton or chicken broth should 
 always be several times skimmed before they are given, and blotting 
 paper or a bit of bread can be passed over the surface to remove 
 the last trace of oily substance. A chafing dish is invaluable for the 
 convalescent from protracted illness. 
 
 When the dietary ordered' is very limited in variety, the patient is 
 often gratified by having his food served in " courses," and will eat 
 more than if given everything at once. 
 
400 ADMINISTRATION OF FOOD FOR THE SICK 
 
 In other cases, when a patient is first allowed to sit up for half 
 an hour or more beside the bed, it may be well to utilise this time 
 for giving the principal meal of the day, which will be eaten with 
 more relish, and perhaps better digested in consequence. 
 
 Patients having nausea or other gastric disorder or diarrhoea 
 should be given but little food at once. Small, oft-repeated feed- 
 ings are best for them. As a rule, invalids need more salt as a condi- 
 ment, but less sugar, than those in health. 
 
 When patients are being fed with fluids, wholly different recep- 
 tacles should be used for holding their medicines, or the association 
 of ideas may be strong enough to destroy what little appetite there 
 is, and even to produce nausea. 
 
 The nurse should always have a cheerful manner and a cleanly 
 and tidy appearance, which contribute much towards the patient's 
 appetite. She should never offer nourishment too soon after re- 
 moving the vessels employed for the patient's discharges or evacu- 
 ations, but should allow a proper interval to elapse, and let it be 
 evident that she has thoroughly cleansed her hands. No form of 
 perfumery should ever be used by the nurse. Bread crumbs should 
 never be allowed to fall into the bed, especially of a helpless patient. 
 
 When possible, it is well to divert the patient's mind from his 
 ailments while feeding him by introducing some cheerful or inter- 
 esting topic. 
 
 Feeding Helpless Patients. — In feeding helpless patients with 
 fluids, if the head is to be raised, it should be done by placing the 
 hand beneath the pillow and lifting it gently. This affords much 
 better support, and is more comfortable for the patient, for the head 
 is less likely to be bent so far forward as to interfere with swallowing. 
 If a tumbler is used, it should always be small and not more than 
 two thirds filled. An average breakfast-cup holds eight fluid ounces, 
 and an average tea-cup six fluid ounces. A thirsty patient derives 
 more satisfaction from draining a small glass than from sipping from 
 a large one which he is not allowed to empty. The feeble patient 
 should not be allowed to swallow during inspiration, and the nurse 
 should be careful that each mouthful is swallowed before another is 
 given, to prevent serious coughing. 
 
 When a glass tube is used for feeding, it should have a flattened 
 end to hold in the mouth, and should be bent near the centre at a 
 slight angle, so that it is unnecessary to flex the patient's head. If 
 feeding-cups with spouts are employed, they should be of glass, so 
 that the nurse can see how much the patient is taking; otherwise 
 fluid is apt to be poured into the mouth in too large a quantity. As 
 a rule, the bent tube is decidedly better to use when the patient has 
 any power of suction at all. Even when he has not, the glass may be 
 raised by the nurse, so that the fluid flows into the mouth without 
 effort. The cup and tube should always be prevented from dripping. 
 
METHODS OF FEEDING THE SICK 401 
 
 Sleep and Feeding. — Patients need only be aroused from sleep 
 to take nourishment in serious cases. Usually the ease with which 
 a patient drops asleep should determine the necessity for awakening 
 him. Sleep is often more beneficial even than food, but there are 
 cases in which a patient awakens to take a sip of milk or a few 
 mouthfuls of food, and will immediately drop off to sleep again. 
 Such patients may be aroused for food every two hours if there is 
 need, as there may be in typhoid fever. Some patients are annoyed 
 by awakening at three or four o'clock in the morning, not being able 
 to sleep again. Food of some sort should always be kept on hand 
 during the night, and drinking a cup of hot bouillon or cocoa will 
 often enable them to fall asleep again for two or three hours. 
 
 Cleansing the Mouth. — The patient's comfort is very dependent 
 upon keeping a clean mouth, as indeed are his appetite and taste. 
 A helpless patient whose mouth and lips are allowed to become 
 parched and sour will refuse nourishment which he might otherwise 
 gladly take. The mouth should be rinsed each time after eating 
 with pure water, hydrogen peroxid, or diluted Listerine (two tea- 
 spoonfuls to the tumbler of water), or borax water of similar strength. 
 It is much easier to keep the mouth clean in this manner than to 
 disinfect it after it has been neglected. Milk especially lingers on 
 the mucous surface, and, fermenting there, destroys the sense of 
 taste and develops germs that interfere with digestion. When the 
 patient cannot rinse his own mouth, it must be frequently cleansed 
 by the nurse with a swab of fresh cotton fastened on a small flexible 
 stick, such as a piece of splint, and moistened with the mouth wash. 
 The best tongue scraper is made with a piece of whalebone, about 
 nine inches long, bent into a loop. If this be applied before the 
 patient's meals, the taste nerves of the tongue will be uncovered from 
 the accumulated debris which coats them, and the appetite will be 
 improved. Dry lips should be moistened with vaseline or cold 
 cream, not glycerin. 
 
 Cracked ice will keep much longer if not allowed to float in melt- 
 ing water. The contact of a metal spoon or dish also melts it sooner, 
 by virtue of the great conductivity of metal. 
 
 A piece of cheese cloth, mosquito netting, or linen may be tied 
 over a cup by an elastic band, and the fragments of ice split off with 
 a pin may be laid upon the cloth, so that the melted fluid drains away 
 beneath. 
 
 Disinfection of Utensils. — All dishes or utensils used in serving 
 food to patients having syphilis, stomatitis, or diphtheria, or any 
 infectious disease likely to be communicated through such means, 
 should be boiled for at least an hour in water containing a few 
 teaspoonfuls of soda. Syphilitic patients, especially, should have 
 their own set of food receptacles, spoons, forks, etc., properly la- 
 belled, to prevent any one else from using them. 
 
402 
 
 ADMINISTRATION OF FOOD FOR THE SICK 
 
 Feeding Unconscious Patients. — The feeding of unconscious pa- 
 tients demands special care and skill. They should never be given 
 anything but fluid nourishment, and this must be fed with a spoon or 
 through a catheter. Sometimes, if the jaw is set, a medicine dropper 
 may be utilised. Not over a teaspoonful should be given at once, 
 and the nurse must make sure that it is swallowed before she repeats 
 the experiment. It should be remembered that the mechanism of 
 deglutition is not excited by one or two drops of fluid, but usually 
 at least half a drachm is required to start this reflex. In feeding 
 comatose infants or children with tubercular meningitis, apoplexy, 
 etc., fluid may be poured into the nostril with a spoon rather than 
 into the mouth. It disturbs the child less than does the effort to 
 force open the mouth, and if the head is lying back the fluid trickles 
 down the posterior pharyngeal wall. Any excess of fluid is re- 
 turned through the other nostril. There is no greater danger of 
 choking when fed by this method than by the mouth. It is usually 
 better, however, to use a soft catheter with a funnel attached to 
 the free end. The catheter is oiled or dipped in vaseline or butter, 
 and passed gently through the nostril down into the oesophagus, 
 or, if desired, into the stomach. Before pouring any fluid into it 
 through the funnel it must be made certain that the patient is breath- 
 ing easily, and that the tube has not made a false passage into the 
 larynx. Such an accident is very rare. This topic will receive fur- 
 ther attention in connection with Lavage. 
 
 Gavage, or feeding with the stomach tube, is described under that 
 heading. Xasal feeding is employed sometimes for gavage in young 
 infants, in feeding children with diphtheria, or the insane, who may 
 refuse food or resist the passage of a tube through the mouth by 
 biting, and it may be used when the mouth is sore from ulceration 
 or the effect of corrosive poisons. 
 
 When patients are living upon " teacup diet," or broths and 
 gruels, it is a common mistake to give them a diet which is either 
 too low in carbohydrates or deficient in protein. The proper pro- 
 portions to be prescribed, unless there is some special indication for 
 the contrary, will be appreciated by a comparison of the following 
 table, compiled by Mrs. E. H. Richards, and those previously given 
 on p. 287. 
 
 A Common Invalid Ration too Low in Cai-bohydrates (Mrs. Richards) 
 
 1 pint of beef juice, containing 7 per cent.. . . 
 1 pint of whole milk 
 
 1 quart of flour gruel made with whole milk. 
 
 2 quarts of liquid. Total 
 
 Protein. 
 
 66.7 
 
 Fat. 
 
 Grammes. 
 
 Grammes. 
 
 3i-5 
 
 
 17.0 
 
 18.O 
 
 18.2 
 
 18.2 
 
 Carbo- 
 hydrates. 
 
 36.2 
 
 Grammes. 
 
 22 
 
 38 
 
 60 
 
 Calories. 
 
 129.O 
 325-5 
 397-9 
 
 852.4 
 
METHODS OF FEEDING THE SICK 403 
 
 Nutrient Enemata 
 
 Rectal Absorption. — That all mucous membranes are capable of 
 absorbing* certain materials from their surfaces and passing them 
 into the blood vessels or lymphatics has long been recognised ; but 
 it is only of comparatively recent years that this knowledge has been 
 applied extensively to the purpose of nourishing patients by means 
 of the rectum, and the fact is now established that sufficient aliment 
 may be absorbed from the mucous membrane of the rectum or 
 sigmoid flexure alone to sustain life for a considerable period, 
 amounting in some cases to from four to seven weeks. Moreover, 
 the rectum may be utilised for accessory feeding for many cases in 
 which the stomach is able to digest some food, but not in sufficient 
 quantity to prevent emaciation. 
 
 Whenever rectal food enemata are employed certain principles 
 should be observed : 
 
 1. The rectal surface must be cleansed from all mucus and faeces. 
 
 2. The irritation of the rectum should be allayed as far as pos- 
 sible. 
 
 3. The quantity and quality of food thus administered should be 
 so regulated as to avoid exciting peristalsis, and yet allow of the 
 complete absorption of one injection before another is given. 
 
 The minutest details which will secure the best conditions for 
 absorption should never be regarded as too insignificant. Some 
 patients find the idea of rectal feeding very repulsive, and dislike to 
 submit to it ; but with a little tact and perseverance their objections 
 can usually be overcome. 
 
 CONDITIONS NECESSITATING RECTAL FEEDING 
 
 The conditions which may require the use of rectal feeding are 
 these : 
 
 I. Temporary obstruction to the entrance of food into the ali- 
 mentary canal. Rectal feeding must be resorted to until the ob- 
 struction — such as the presence of new growths and foreign bodies, 
 or inflammatory conditions with swelling in the mouth, pharynx, or 
 oesophagus — can be overcome. 
 
 II. Inability to swallow food from coma, delirium, or paralysis 
 affecting the mechanism of deglutition, as, for example, post-diph- 
 theritic paralysis. 
 
 III. Extreme irritability, pain, acute inflammation or ulceration 
 of the upper portion of the alimentary canal, such as that excited by 
 corrosive poisons like carbolic acid, ammonia, etc. 
 
 IV. Stricture occurring in any part of the alimentary canal above 
 the rectum. 
 
404 ADMINISTRATION OF FOOD FOR THE SICK 
 
 A'. Prolonged reflex vomiting, such as may occur in pregnancy 
 and seasickness. 
 
 VI. Gastric ulcer, for the purpose of resting the ulcerated surface 
 and allowing it to heal. 
 
 VII. Cancer of the stomach with inability to absorb or digest 
 sufficient food, especially with obstruction to either the cardiac or 
 pyloric end of the organ. 
 
 VIII. Any form of severe gastric irritation, such as occurs in 
 acute gastritis. 
 
 IX. Exhausted conditions of the system which may be present 
 during the course of severe fevers in which absorption of even pre- 
 digested food is largely suspended. 
 
 X. For the insane who refuse food by the mouth. 
 
 XL To supplement the action of a feeble stomach, or when for 
 any reason, such as total lack of appetite, emaciation is rapidly pro- 
 gressive. 
 
 Hunger and Thirst during Rectal Feeding. — These symptoms are 
 not necessarily present after the first day or two of rectal feeding. 
 In an obstinate case of gastric haemorrhage in which absolutely 
 nothing — not even water — was given by the mouth for more than 
 a week, I questioned the patient in regard to her sensations of 
 hunger and thirst, and she told me that they were entirely relieved, 
 after the first twenty-four hours' use of nutrient enemata. The 
 mouth and tongue were not dry, and she did not lose weight during 
 this period. I have been told the same thing by other patients. 
 
 An interesting case was reported by C. W. Brown, of Washing- 
 ton, in which a patient suffering from carcinoma with ulceration of 
 the pyloric end of the stomach was supported for forty-three days 
 upon exclusive rectal nourishment consisting of from four to six 
 ounces of beef tea and milk, which were given on an average once in 
 three hours, with the occasional addition of laudanum and a little 
 whisky. During an interval of improvement which followed the 
 exclusive use of injections, the patient was able to take some food 
 by the stomach, though not enough to satisfy the craving of hun- 
 ger and prevent a feeling of faintness ; but these symptoms were 
 overcome by giving four nutrient injections daily in addition to the 
 milk taken by the stomach. 
 
 Method of Injection. — The common practice of giving nutrient, 
 enemata by a Davidson syringe with a short hard-rubber or steel 
 nozzle is always to be condemned. In the hands of an unskilful 
 nurse, irritation and sometimes haemorrhages are likely to be pro- 
 duced in this way, sooner or later. 
 
 In commencing the use of rectal alimentation, especially in cases 
 which manifest much irritation of the lower bowel, it is important 
 to employ a long, soft, flexible rubber catheter or rectal tube which 
 can be passed well up, for eight inches or more, to the sigmoid 
 
METHODS OF FEEDING THE SICK 405. 
 
 flexure. In selecting the tube, one should be chosen which is not 
 so flexible that it is liable to bend or double upon itself, but which 
 is not so stiff as to give pain or damage the mucous membrane if 
 it happens to catch in a fold of its surface. For children a No. 12 
 or No. 14 ordinary " velvet-eyed " flexible catheter may be used, 
 and passed up as high as the sigmoid flexure. For adults the tube 
 should be of moderate calibre, not exceeding the diameter of a 
 stout pen handle. The tube or catheter should be dipped in sweet 
 oil, melted butter, or vaseline ; but glycerin must not be used, for 
 it excites peristalsis. 
 
 In adults the tube should be passed in for from ten to twelve 
 inches, for the injection should be placed as high up as possible. 
 When this is done there is less liability to its rejection, and it is 
 brought in contact with an extensive mucous surface. There is a 
 further physiological or anatomical reason for placing the injection, 
 as high up as may be, in the fact that the sigmoid veins and those 
 returning the blood from the upper rectum communicate with the 
 inferior mesenteric vein, while those from the lower third of the 
 rectum communicate with the inferior vena cava. Consequently, 
 whatever is absorbed by the wall of the inferior third of the rectum 
 passes into the inferior vena cava without going to the liver, but 
 that which is absorbed higher up is returned to veins whose contents 
 reach the liver directly through branches of the vena porta. It is 
 in the liver that the further assimilation of protein takes place in 
 great part, and hence the desirability of observing this rule. 
 
 It was found by Brown, in the case above cited (p. 404). that 
 the patient was able to discriminate between the taste of iodide of 
 potassium and ergot, etc., in from a quarter to half an hour after 
 these medicines had been given per rectum. The same phenomenon 
 has been noticed from the injection of such substances directly into 
 the stomach through a gastric fistula, and it is due to their ready 
 absorption and conveyance in the blood to the taste bulbs in the 
 tongue or to the saliva, in which fluid the iodide of potassium is 
 promptly excreted. 
 
 According to some observers, under the best conditions not over 
 one fourth of the necessary nutriment can be absorbed from the 
 rectum (Bauer). Such a statement should be considerably modified, 
 for, as a matter of practical experience, many patients may be kept 
 alive and gain slightly in weight upon the use of nutrient enemata, 
 when they are intelligently given. If injected but a short distance 
 into the intestine, the absorbing surface is so limited that compara- 
 tively little material is taken up ; but if given in the manner pre- 
 scribed above, through a long catheter inserted high up, much more 
 will be retained, and the benefit derived from such injections will 
 be enhanced. 
 
 The injection should be applied by means of a small hard-rub- 
 
406 ADMINISTRATION OF FOOD FOR THE SICK 
 
 ber syringe, which need not hold over two ounces. Very little force 
 should be used, and the patient must be told not to strain. After 
 the syringe is filled, by holding it vertically nozzle uppermost and 
 pressing it until the fluid exudes from the nozzle, all air is excluded. 
 When a Davidson syringe is used for the purpose of injecting small 
 quantities of fluid, it very often happens that air is drawn into the 
 syringe in addition to the materials of the enema, which, when in- 
 jected, is very apt to excite peristalsis and evacuate the bowel. The 
 use in unskilful hands of a funnel or fountain syringe for filling the 
 tube is open to the same objection — that air is likely to enter the 
 rectum. In any case it is well to fill the tube with the injection fluid 
 before it is inserted. 
 
 When the enemata are given in gynaecological or obstetric cases, 
 it should be remembered that tight tamponing of the vagina may 
 interfere with absorption from the rectum. 
 
 Aids to Retention. — Upon withdrawing the tube, if there is danger 
 that the injection will not be retained, a soft compress or folded 
 towel should be pressed up firmly against the anus for twenty min- 
 utes or half an hour. 
 
 The retention of the enema is aided by placing the patient in a 
 proper position. He should lie, if possible, upon the left side, with 
 the hips raised high upon a pillow, and the injection should be given 
 very slowly and carefully. The " Sims " gynaecological position is 
 the best, but with the hips more elevated. 
 
 Temperature of Injections. — All food enemata should be given 
 moderately warm, at a temperature of 90 or 95 F. They are less 
 likely to excite peristalsis than if administered very hot or very cold. 
 
 Number of Injections. — The question of how many injections can 
 be given must depend upon the irritability of the rectum. It can 
 never be used like the stomach, and it is advisable to begin by order- 
 ing an enema only once in six hours. If the rectum is in good 
 condition the number may be increased to one every four, or even 
 every three hours. In exceptional cases or for emergencies small 
 injections, not exceeding one and a half ounce, may be given once 
 in two hours ; but if repeated at such brief intervals, they are almost 
 certain to excite irritation. 
 
 CARE OF THE RECTUM 
 
 When it is important that nutrient enemata should be continued 
 for some time, the exact condition of the rectum should be ascer- 
 tained by the physician, and the most minute directions should be 
 given to the nurse. The matter is not infrequently left to an attend- 
 ant, who is wholly ignorant of the proper conditions to be observed, 
 and failure is sometimes reported when a little intelligent attention 
 bestowed upon details would overcome all difficulties. 
 
METHODS OF FEEDING THE SICK 407 
 
 As already stated, many cases have been recorded in which pa- 
 tients have been nourished exclusively by nutrient enemata for sev- 
 eral weeks, and it is an important fact that the rectum may acquire 
 a certain degree of toleration for them. For the first few days they 
 may be rejected, but when correctly prepared and administered they 
 will soon be successfully retained. But it is only in the most favour- 
 able cases that rectal alimentation can be long continued without 
 eventually producing irritation and mucous diarrhoea, and in the 
 majority of instances this is likely to occur after two or three weeks. 
 The enemata must then be discontinued, but may, if necessary, be 
 resumed again after a brief interval. Queirolo, of the University of 
 Pisa, has fed typhoid-fever patients exclusively by nutrient enemata 
 four times a day with success, his idea being to avoid putting any- 
 thing into the small intestine capable of fermenting or producing 
 toxins, but this practice is not in accord with modern views of the 
 disease. 
 
 The presence of haemorrhoids is a serious drawback when the use 
 of rectal feeding becomes imperative, and care should be exercised 
 not to irritate or inflame them by the passage of the catheter or 
 nozzle of the syringe. In such cases it is necessary to use only a 
 very soft and flexible catheter, and to allay irritation by the topical 
 application of a 2-per-cent solution of cocaine. 
 
 Whenever nutrient enemata are employed for a long time the 
 rectum should be thoroughly evacuated and cleansed, at least once 
 a day, by flushing with a copious injection of warm soapsuds and 
 water, amounting to two or three pints, immediately after which a 
 food enema should be given. 
 
 The cleansing enemata may be given through a double or single 
 catheter. If a double catheter is preferred, a larger quantity, two 
 or three quarts, of water may be advantageously given, and a few 
 grains of common salt should be added to each injection. If the 
 rectum is irritable, and much mucus coats its inner surface, it may 
 be well to add boric acid to the water in saturated solution. The in- 
 jection washes out any particles of waste matter or remains of a 
 previous nutrient injection, cleanses the mucous surface, stimulates 
 its circulation, and prepares it for better absorption. 
 
 Opium in Enemata. — Opium, while it prevents peristaltic action 
 and favours retention of the enema, may also tend to interfere with 
 its absorption. It is consequently to be avoided, if possible, but 
 when irritation of the rectum exists it becomes necessary to inject 
 a little laudanum. Ordinarily, three to four minims is sufficient, but 
 ten, or even twenty, may be required in some cases. This dosage 
 must not be often repeated. Its effect, of course, should be watched, 
 and it must not be given too freely. If nutrient enemata are con- 
 stantly employed it is sometimes found that a larger dose injected 
 by a small hard-rubber syringe half an hour or an hour before giving 
 28 
 
408 ADMINISTRATION OF FOOD FOR THE SICK 
 
 an enema allays the irritation more completely than if the opium 
 is given in one of its constituents. Injected by itself, the quantity 
 of opium is so small that it is not ejected, but is absorbed, 
 and its local action is obtained before the larger bulk of fluid 
 in the enema is injected. In other cases it is sufficient to give the 
 laudanum in very small quantity, five or six minims with each enema. 
 Instead of laudanum, the deodorised tincture of opium or McMunn's 
 elixir may be used. 
 
 SUBSTANCES AVAILABLE FOR RECTAL FEEDING 
 
 Of the different classes of food stuffs, there are some which are 
 absorbed readily by the rectum, while others are scarcely taken up 
 at all. To the latter class belong starches and most of the fats. 
 Those starches which are predigested and partially converted into 
 sugar may be absorbed to a very limited extent, but not sufficiently 
 to add to the nutrition of the body. Maltine may sometimes be 
 absorbed. Fats and oils not only remain unabsorbed by the rectum, 
 but they prevent the absorption of other foods by coating either the 
 mucous membrane or the food itself, and are therefore worse than 
 useless. Attempts have been made to give them saponified or finely 
 emulsified, prepared with pancreatin or otherwise, but it is doubtful 
 if even under these circumstances enough of any form of fat or oil 
 can be taken up to be of practical benefit in rectal feeding. 
 
 It is exceedingly important to use only materials which will be 
 as completely absorbed as possible. Anything else acts as a foreign 
 body, and in time proves more or less irritating. Moreover, it is 
 found that many albuminous materials which are absorbed from the 
 surface of this portion of the intestine become irritating if given in 
 too concentrated a form, such as pure peptone, and they must be 
 diluted to two or three times their volume with water or some bland 
 fluid. Some forms of albumin are undoubtedly absorbed from the 
 mucous membrane of the rectum without predigestion, such as that 
 expressed from chopped meat or egg albumin, but it is much better 
 to at least partially pancreatinise it. 
 
 Pancreatinised Meat. — In preparing proteid food for absorption 
 one of the forms of pancreatic extract or pancreatin may be used. 
 Extracts of pancreas are open to the objection that they do not 
 keep very long, and unless perfectly fresh they are apt to prove irri- 
 tating, and glycerin extracts cannot be used in any quantity on ac- 
 count of the aperient action of the glycerin itself. To overcome 
 these difficulties, Leube suggests using the fresh pancreas, which is 
 to be added in the proportion of one part to three of beef. Both 
 the meat and the pancreatic gland should be scraped or thoroughly 
 minced and rubbed into a paste with a little warm water. Any fat 
 should be carefully removed. The pulp thus obtained is to be in- 
 
METHODS OF FEEDING THE SICK 409 
 
 jected by means of a suitable syringe with a rather wide nozzle. The 
 idea of using this combination is that the digestion, which is begun 
 outside, is continued within the rectum, and the products are gradu- 
 ally absorbed. Leube claims that this form of nutrient enema may 
 be retained for ten or twelve hours, and that it is very rarely irri- 
 tating. He sometimes adds egg albumin and even fat to the mixture. 
 
 It has been advised to inject hydrochloric acid into the rectum 
 with beef solutions as well as with milk, but this process is too 
 irritating, and all artificial digestion should be completed outside of 
 the body. Sansom gives the following formula for a meat peptone 
 enema for an infant or young child : Shred raw beef or mutton in 
 bulk about two tablespoonfuls, add an equal bulk of water, and let 
 stand for an hour; then add gradually four tablespoonfuls of milk, 
 heated to boiling. When all is well mixed the temperature of the 
 mixture will be about 140 F., then add a teaspoonful of Savory & 
 Moore's or Benger's liquor pancreaticus, and a pinch of bicarbonate 
 of soda. Let the whole remain for six hours, and heat to boil- 
 ing. Strain through muslin and preserve the liquid, which will suffice 
 for several enemas. 
 
 Blood. — Dried beef blood has sometimes been used as a rectal 
 food, but there is no evidence that it is absorbed. In those cases in 
 which I have employed it it has usually caked within the rectum 
 and prevented the absorption of other materials. Fresh defibrinated 
 blood has also been used for the same purpose — four ounces may be 
 given every six hours — but it possesses no advantage over predi- 
 gested milk or peptones, and is not to be recommended. 
 
 Milk. — Pancreatinised milk in which the process of predigestion 
 has not been carried too far is, on the whole, one of the most satis- 
 factory foods which can be used by rectum. It should not be rich 
 in cream. 
 
 Eggs. — Egg albumin is also one of the best ingredients of nutri- 
 ent enemata. It is absorbed unaltered to some extent through the 
 rectal mucous membrane, but it is better that it should always be 
 predigested by the use of a peptogenic or pancreatinising powder. 
 The whites of two eggs may be added to peptonised milk, or, better, 
 to peptone solution or one of the meat extracts. Ewald, who has 
 experimented extensively with rectal alimentation, states that un- 
 peptonised egg albumin is absorbed as promptly from the rectal 
 surface as commercial peptone, while peptonised egg albumin is 
 taken up even better. The absorption of the albumin is furthered 
 by the addition of a little table salt to the injection — about fifteen 
 grains to each egg — but this is sometimes irritating to the rectum. 
 
 The yolk of egg is not recommended for rectal use, for although 
 it contains albuminous material, so much fat is mixed with it, which 
 is not absorbed excepting by the intestinal villi in the small intestine, 
 that it is practically useless. 
 
410 ADMINISTRATION OF FOOD FOR THE SICK 
 
 Grape sugar is highly diffusible and nutritious. A teaspoonful 
 or two may be added to rectal enemata occasionally with advantage. 
 
 Alcohol. — The alcohol used for rectal injection should be in the 
 form of good liquor, somewhat diluted. If pure alcohol is given, 
 it should be diluted in three or four parts of water, when it becomes 
 less irritating to the mucous membrane and is more easily absorbed. 
 Very often a small injection of half an ounce of whisky in an ounce 
 and a half of water, or even an injection of whisky, brandy, or sherry 
 and water given alone, will be retained and completely absorbed, 
 when a larger volume of fluid or other ingredients added to the 
 alcohol will not be retained, and the whole enema will pass out 
 again. Rum may be used, or brandy, but, as a rule, good whisky 
 is the most serviceable. When alcohol is given in connection with 
 other rectal foods, it may be unnecessary to dilute it with water, 
 but undiluted whisky sometimes causes precipitation in milk. If 
 added too strong it coagulates casein which has not been pancrea- 
 tinised, and no solid matter, even in the form of a fine precipitate, 
 is of much use in the rectum, where it acts as an irritant. 
 
 PRESCRIPTIONS FOR FOOD ENEMATA 
 
 Ewald recommends the following: Beat the whites of two eggs 
 with a tablespoonful of cold water, add a teaspoonful or two of 
 starch boiled in a half teacupful of a 20-per-cent glucose solution, 
 a wineglassful of claret, and a teaspoonful of peptone solution. Mix 
 at a temperature below the coagulation point of the albumin. 
 
 Yeo prescribes expressed meat juice, egg albumin, and peptones. 
 
 Leube prefers the mixture of scraped meat and fresh pancreas 
 made into an emulsion as prescribed above (p. 408). 
 
 Roberts gives milk gruel and beef tea, with two teaspoonfuls of 
 liquor pancreaticus freshly mixed. He reports a case in which he 
 sustained the patient's life for nine weeks upon this treatment alone. 
 
 FOOD SUPPOSITORIES 
 
 Rectal food suppositories are sometimes made of predigested 
 and evaporated or condensed forms of milk or meat juice, which 
 are mixed with oil or cacao butter and pressed into an elongated 
 bougie or suppository. They sometimes prove useful, and are cer- 
 tainly convenient, but they possess no real advantage over nutrient 
 enemata, and if rectal feeding is to be long continued, the latter 
 are found more practical. 
 
 Inunction Foods 
 
 Attempts are sometimes made to get nourishment into the body 
 by means of inunction through the skin, and olive oil, cod-liver oil, 
 
MEDICINES AND FOOD 41 1 
 
 and cacao butter are rubbed into the integument of the abdomen 
 and thighs. This means is naturally only employed in cases of 
 extreme emaciation from wasting diseases, such as carcinoma, 
 marasmus, and phthisis. It has proved mainly useful with maras- 
 mic infants, but it is doubtful whether it possesses any true value 
 beyond the advantage of lubricating a dry and shrivelled skin, and 
 retaining some of the body heat in case of great feebleness. 
 
 Intravascular Feeding 
 
 In extreme cases of collapse, where death has seemed imminent, 
 nutrient injections have sometimes been given directly into the veins. 
 Of late years, however, it has been shown that in collapse from 
 haemorrhage, or from loss of fluid in the evacuations of Asiatic 
 cholera and cholera morbus in infants, salt-water injections (a drachm 
 to the pint) answer as well, and have the advantage of being much 
 safer and easier of application. 
 
 Hodder was the first to practise the intravenous injection of 
 milk in 1850 for collapse from Asiatic cholera, and T. G. Thomas 
 was among the first to inject warm milk into one of the veins of 
 the arm. He reported one case in which eight ounces of milk 
 administered in this way saved life. Both goat's and cow's milk 
 have been so used, but the milk must be rendered alkaline. 
 
 Down reports similar success. Fowler tried intravenous injec- 
 tion of peptone solution, and has given as much as six ounces of a 
 digested beef solution in this manner. The peptone does not re- 
 appear in the urine, but the casein of milk does, as well as solutions 
 of sugar or albumin when injected into a vein. Some of the fat drop- 
 lets in milk have greater diameter than the capillaries, which might 
 prove a practical objection to the injection of unskimmed milk. 
 
 Hypodermic Feeding 
 
 Feeding in cases of desperate exhaustion by hypodermic injec- 
 tions of milk and of peptone solutions has been several times at- 
 tempted, but the results, beyond the use of alcohol by this method, 
 have not proved sufficiently satisfactory to warrant its continuance. 
 
 MEDICINES AND FOOD 
 
 Too little attention has been bestowed upon the mutual relations 
 of food and medicines. So little is really definitely known of the 
 intricate chemistry of digestion and assimilation that it is difficult 
 to formulate rules for the right time of giving every drug in rela- 
 tion to fulness or emptiness of the stomach. The reaction of the 
 
412 ADMINISTRATION OF FOOD FOR THE SICK 
 
 stomach contents varies from alkaline to neutral and acid, and these 
 several reactions will decompose medicines in various ways. Besides 
 this, the reactions themselves are dependent upon a large number of 
 organic acids, salts, and other substances which may wholly alter 
 the composition of a medicine at one time, and not be present to 
 affect it at another. 
 
 A drug given after a full meal may be decomposed by the strong 
 hydrochloric acid of active digestion, which is unaltered in an empty 
 stomach. 
 
 Conversely, remedies which are not themselves influenced by the 
 gastric and pancreatic juices may affect these secretions as synergists 
 or the reverse. Chittenden says : " Take, for example, the influence 
 of such substances as urethan, paraldehyde, and thallin sulphate on 
 the proteolytic action of pepsin-hydrochloric acid, and we find that 
 small quantities (o.i to 0.3 per cent) tend to increase the rate of pro- 
 teolysis, while larger amounts, say one per cent, decidedly check 
 proteolysis. Similarly, among inorganic compounds, arsenious 
 oxide, arsenic oxide, boric acid, and potassium bromide in small 
 amounts increase the proteolytic power of pepsin in hydrochloric- 
 acid solution, while larger quantities check the action of the ferment 
 in proportion to the amounts added. Again, with the enzyme tryp- 
 sin, similar results with such salts as potassium cyanide, sodium 
 tetraborate, potassium bromide and iodide may be quoted as show- 
 ing not only the sensitiveness of the ferment towards foreign sub- 
 stances, but likewise its peculiar behaviour — viz., stimulation in the 
 presence of larger quantities. Furthermore, we have found that even 
 gases, as carbonic-acid and hydrogen-sulphide, exert a marked re- 
 tarding influence on the proteid-digesting power of trypsin." These 
 gases, being a product of intestinal malfermentation, may thus inter- 
 fere with digestion. 
 
 Hydronaphthol and bismuth salicylate retard gastric digestion. 
 Sodium bicarbonate and other alkalies check pyrosis in chronic gas- 
 tritis, which is caused by diminished hydrochloric-acid secretion, 
 but increase pyrosis subsequently, because of the greater alkalinity 
 produced, which favours the growth of lactic-acid organisms. Ac- 
 cording to Leffmann and Beam, beta-naphthol stops the action 
 of diastaste, but not that of the amylolytic ferment of pancreatin, 
 hence it is useful as an intestinal antiseptic without wholly stop- 
 ping digestion. It, however, retards proteid digestion. They also 
 state that salicylic acid and saccharin both prevent the amylolytic 
 action of diastaste and of pancreatin, but do not retard proteid 
 digestion. 
 
 These few examples are sufficient to illustrate the very diverse 
 influence of some of the common drugs. 
 
 The following rules are subject to many exceptions, but they 
 will serve as a general guide : 
 
MEDICINES AND FOOD 413 
 
 Rules for administering Medicines in Relation to 
 
 Food 
 
 1. Alkalies are best given shortly before meals, unless designed 
 to neutralise hypersecretion of hydrochloric acid. 
 
 2. Acids should be given within half an hour after meals. 
 
 3. Bitters should be given before meals. 
 
 4. Remedies such as iron and arsenic, which may prove some- 
 what irritant to mucous membranes, should be given either soon 
 after the regular meals or after taking some simple article of food. 
 Ammonium carbonate and potassium iodide, for example, may be 
 prescribed in milk. 
 
 5. Most cough medicines, cardiac tonics, diuretics, and systemic 
 remedies which are not especially irritating to the stomach should 
 be taken between meals. They will be more promptly absorbed 
 from an empty stomach, and are less liable to be altered in composi- 
 tion by digestive fluids or to inhibit digestion. 
 
 6. Remedies designed to act in the intestine and not in the 
 stomach, such as salol, should be given at the end of gastric diges- 
 tion, when the stomach contents are about to pass into the intes- 
 tine. 
 
 7. Saline laxatives should always be taken at least half an hour 
 or an hour before meals, preferably before breakfast; but the 
 stronger, more slowly acting cathartics should be given on an empty 
 stomach at night. 
 
 Cod-liver oil should be given an hour and a half after meals, or 
 on an empty stomach before retiring. 
 
 According to Whitehead, starchy food should be avoided while 
 iodine preparations are being administered, because of the insoluble 
 compound likely to be formed of iodine and starch. Syphilitics, he 
 says, should therefore eat meat and light green vegetables only, in 
 order to get a maximum effect from the remedy. If they are taking 
 very large quantities, such as half an ounce or more a day, this may 
 be advisable, but it is unnecessary for ordinary cases. 
 
 Foods and beverages may be often used to disguise the taste of 
 disagreeable or bitter medicines, especially for children. An un- 
 pleasant dose may often be smuggled down in a teaspoonful of jam 
 or a little molasses, and quinine is somewhat disguised by mixture 
 in chocolate lozenges. It may be given in solution to adults in 
 coffee. Castor oil is given floating on coffee or beer. Both milk 
 and Vichy partially disguise the taste of potassium iodide. 
 
 Milk is an excellent vehicle for powders, such as bismuth, mag- 
 nesium carbonate, or sulphonal. Many bitter medicines may be 
 followed by a lump of sugar or a strong peppermint lozenge, or the 
 mouth may be rinsed with a little brandy and water. Chocolate is 
 
414 ADMINISTRATION OF FOOD FOR THE SICK 
 
 also a good vehicle for the administration of bitter medicines, and 
 it may be employed to emulsify cod-liver oil. 
 
 DIET-KITCHEN OUTFIT 
 
 When a case of protracted severe illness occurs in a household it 
 is very convenient to improvise a small diet kitchen in a room next 
 the patient's bedroom. The outfit should consist of the following 
 articles, in addition to the usual receptacles for containing the food : 
 
 A spirit or gas lamp kept ready to heat a porcelain-lined sauce- 
 pan at any time, day or night. 
 
 A double porcelain-lined saucepan for a hot-water bath. 
 
 A cooking thermometer for use in hot fluids. 
 
 A measuring glass to hold six or eight ounces. 
 
 Pancreatin powders. 
 
 A bottle of rennet ferment. 
 
 Sodium bicarbonate, two or three ounces. 
 
 Borax, half a pound (to clean utensils). 
 
 A glass funnel with filter papers. 
 
 A meat-mincing machine. 
 
 A good chafing-dish and a pair of scales, although not necessary, 
 are highly desirable. 
 
 TRAINED PURVEYORS OF FOOD 
 
 The training of food purveyors for hospitals, asylums, and other 
 institutions has only quite lately received the attention which it de- 
 serves, and hospital managers are awakening to the fact that it is 
 truly economical to employ a skilful trained buyer who understands 
 something of food values, dietetically as well as pecuniarily, and who 
 studies the conditions of the market at different seasons of the year 
 in order to secure variety of food at a minimum cost. To meet the 
 constantly increasing demand for such persons, the Pratt Institute, 
 of Brooklyn, offers a series of three-months' courses for both men 
 and women, which are to cover the following topics : (i) The selec- 
 tion of food material as to quality, food value, and cost. Marketing 
 and buying by sample. (2) Methods of preparation in a large way 
 and by appropriate apparatus. (3) The care of food, cold storage, 
 etc. (4) Serving, embodying general dining economy, labour-saving 
 appliances, etc. Field work, visits to public kitchens, and manu- 
 factories of kitchens, and hotel furnishings. 
 
PART VIII 
 
 DIET IN DISEASE— DIET IN INFECTIOUS 
 DISEASES 
 
 DIET IN FEVER IN GENERAL 
 
 The general principles of the dietetic treatment of the condition 
 of fever which accompanies many different diseases are conveniently 
 studied collectively, while the special modifications of diet required 
 for certain infectious fevers will be considered under their several 
 headings. 
 
 The cardinal principles of feeding the sick involve, first, the 
 avoidance of all articles that disagree with the condition present, and 
 second, the giving of the food best adapted to relieve the digestive 
 organs of unnecessary labour and to maintain nutrition. In addition, 
 for certain special diseases there are classes of foods which have 
 distinctly curative value — for example, the use of fresh fruits and 
 vegetables in scurvy, fats and oils in scrofula and tuberculosis. Al- 
 though there is no curative food for fevers, it should be remembered 
 that there is nothing so easily assimilated as water, and advantage 
 must be taken of this fact to introduce other foods into the body 
 with it, giving them therefore in fluid form. 
 
 Pathological Physiology of Fever. — The former treatment of 
 fevers by starvation and depletion, on the theory that the poison 
 of the disease was soonest conquered by withholding all food and 
 drink upon which it might thrive, and starving out " a devouring 
 flame of inflammation," has long been superseded by more scientific 
 methods. This early treatment culminated in France in the first 
 part of this century, and was first combated in England by Graves 
 and his successful followers. 
 
 It is now known that in fevers by supplying the patient with 
 abundant nitrogenous food the tissues of the body are spared from 
 consumption — in other words, that the proteid matter of the food is 
 burned up or oxidised instead of the proteid matter of the patient's 
 muscles and other structures. The animal food thus given does not 
 add to the substance of the tissues, but saves them from wasting and 
 combustion. 
 
 415 
 
41 6 DIET IN DISEASE 
 
 Bauer believes that " the gravest possible injury to the organism 
 of the fever patient may be brought about by a diet too rich in albu- 
 minates," and to some extent carbohydrates and gelatin may be 
 substituted for them, yet he adds that while " an exclusive use of 
 albuminates is undesirable. ... In fever a larger relative proportion 
 of albuminates is requisite than in health, and so much larger as the 
 albuminous metabolism is greater." 
 
 Fever patients commonly excrete much more nitrogen than they 
 take in as food. In so doing it is believed that they first exhaust 
 whatever reserve supply may be on hand in the food proteids pre- 
 viously absorbed and circulating in the blood, and subsequently 
 draw upon the tissues, just as is the case in starvation. The urea 
 daily eliminated during fever may exceed by forty or fifty grammes 
 the normal amount voided in the urine during health, and this may 
 be the case even when no food is given ; hence the waste increase 
 is mainly nitrogenous (Bauer). In chronic fevers with remissions, 
 like tuberculosis, there is less rapid waste than in the continuous 
 forms such as typhoid. If the digestion remains fairly good in any 
 fever, the loss of body weight is proportionately checked. 
 
 Voit suggested the theory that the tissues act somewhat after the 
 manner of gland cells, and normally attract such albuminous sub- 
 stances as they need without themselves undergoing any serious 
 change, and Bauer believes that this hypothesis may be applied to 
 the consumption of proteids in fever, " that under those conditions 
 which the febrile processes bring with them the tissues yield up to 
 the circulation a larger proportion of their own albumin, and that 
 an abnormal amount of materials for metabolism is thus presented 
 to the cells." The organs meanwhile lose proteids faster than in 
 ordinary starvation, but by the same processes. A single albuminous 
 meal adds more protein to the circulation, which in starvation would 
 aid in restoring equilibrium ; but in fever it fails to do so, and the 
 loss continues because the inflamed cells have for the time being 
 lost their power of assimilation. Emaciation therefore proceeds. 
 
 Another theory which has been strongly advocated, but which, 
 on the whole, has less to recommend it, is that the inflamed cells 
 consume and destroy proteid material from the blood at a much 
 faster rate than in health, and supplying a purely proteid diet does 
 not check the waste. The entire question is exceedingly intricate 
 and difficult of solution. The experiments which have been made 
 in febrile metabolism are somewhat contradictory, and it is undoubt- 
 edly better to be guided at present by the results of clinical experi- 
 ence in feeding fever patients than by theoretical formulae. 
 
 This subject is physiologically very closely related to the paren- 
 chymatous and fatty degenerations of organs which attend many 
 diseases, but it is impossible within the practical limitations of this 
 work to enter into this discussion, and the reader is referred to a 
 
DIET IN FEVER IN GENERAL 417 
 
 very able presentation of these theories in the chapter upon Con- 
 sumption in Febrile Disease by Bauer in his Dietary of the Sick 
 {Handbook of General Therapeutics, v. Ziemssen). 
 
 Leyden and Frankel believe that in fever more fat as well as 
 more albumin is consumed than in health, but other authorities 
 think that fat destruction does not keep even with albuminous waste. 
 
 In fever the secretion of hydrochloric acid is diminished or sus- 
 pended in the stomach, and its peristaltic action is so lessened that 
 the food is apt to remain longer than it should and undergo mal- 
 fermentation, causing oppression or pain, nausea, and vomiting. 
 Absorption also is much reduced in fevers. The stomach may 
 wholly give out, and, as Roberts observes, it becomes merely a 
 conduit, so that the intestine must carry out the work of digestion 
 unaided. 
 
 Dietetic Treatment. — The conditions to be met in the dietetic 
 treatment of fever are as follows : 
 
 1. To save tissue waste by supplying sufficient nourishment. 
 
 2. To give semisolid or fluid nourishment in a form which will 
 not overtax the enfeebled digestive apparatus or leave a large residue 
 for decomposition. 
 
 3. To give abundant fluid with the object of relieving thirst and 
 to wash out through the kidneys the waste matter produced by the 
 increased rate of metabolism. 
 
 4. In some cases, to give alcohol as a food as well as a stimulant. 
 In all fevers presenting periods of remission it is desirable to 
 
 give the greater portion of the food while the temperature is lowest, 
 so that it will be better digested and absorbed, for at this time the 
 tissues appear to temporarily recover their assimilative power to 
 some extent. 
 
 In mild cases, with remissions, if the appetite holds out, it may 
 do no harm to allow some little variety in the diet ; but if the fever 
 is brief and the appetite fails, it is unnecessary to force the patient 
 to take food. 
 
 As a rule, in fevers which are protracted or severe, nourishment 
 should be given in fluid form. To offer solid food in serious fevers 
 is practically to place foreign bodies in the alimentary canal which 
 merely ferment and putrefy, causing discomfort with flatus, fetor, 
 and diarrhoea. There are some exceptions to this, notably the fever 
 of phthisis, some forms of protracted sepsis, and ague. 
 
 Milk being the first and " natural food " of man, it would seem 
 most appropriate that it should constitute the staple article of diet 
 in fevers in which the digestive powers are temporarily greatly en- 
 feebled or wholly suspended. The danger from its continuous and 
 exclusive use arises from its coagulating in lumpy masses, which act 
 practically as solid food, but the many means which are at the dis- 
 posal of the physician and nurse make it possible to overcome this 
 
41 8 DIET IN DISEASE 
 
 difficulty almost completely, and by processes of artificial digestion 
 milk may be given ready for absorption, so that nutrition is rendered 
 quite independent of stomach and intestinal digestion. In the ma- 
 jority of cases, therefore, milk is altogether the best food. The 
 methods of giving it have been described in the section upon 
 Adaptation of Milk for the Sick (p. 73), and the reader is also 
 referred to the section upon the Treatment of Typhoid Fever (p. 
 
 426). 
 
 Next in importance to milk in the diet of fever are to be men- 
 tioned the various preparations of meat — infusions, extracts, juice, 
 powder, broths, etc. (p. no). The fundamental idea of all such 
 preparations is the solution of the nutritious myosin of the muscle 
 fibres and its separation from the much less digestible sarcolemma 
 and the connective tissue constituting the sheaths of the muscle fas- 
 ciculi. These preparations may be made from tender veal, chicken, 
 roast beef, and beefsteak. Clear soups or consommes are nutritious 
 and mildly stimulating in fevers, but if given often or in large quan- 
 tities patients usually tire of them, and they may be considerably 
 varied by flavouring with vegetable juices and extracts or aromatic 
 herbs, which afford variety, and as a rule do no harm, unless exhaust- 
 ing diarrhoea be present. 
 
 Buss gives the following mixture to fever patients : Peptone, 100 ; 
 grape sugar, 300 ; rum or Cognac, 200 ; water, 600 grammes — the 
 quantity to be taken in twenty-four hours m addition to milk, yolk 
 of egg, bouillon, etc. If this food is too sweet, tincture of gentian 
 is added. 
 
 Purees may be given, made by thickening clear soup with well- 
 cooked arrowroot, or finely ground rice, or thoroughly baked wheat- 
 en flour. Bauer recommends the use of " fruit soups," which are 
 prepared by boiling fruit, either fresh or dried, with the addition, if 
 desired, of grape sugar, lemon peel, etc. The mass is then com- 
 pressed and strained, and the fluid obtained has an agreeable taste 
 and somewhat laxative action. 
 
 In cases of moderate severity and short duration, when the di- 
 gestive organs are not greatly disturbed, it is not necessary to 
 confine the patient to fluids, although solid food, especially meats, 
 should be withheld. Semisolid food may be given, such as milk 
 toast, cream toast, soft-cooked eggs, beef jelly, or plain rice pud- 
 ding. Thoroughly boiled oatmeal gruel sustains strength while un- 
 dergoing severe physical toil, and fever has some resemblance to 
 muscular effort in its temporary arrest of digestive activity, so that 
 sometimes substances of this class prove useful from their support- 
 ing power. 
 
 Many other varieties of farinaceous and other carbohydrate foods 
 are suitable in febrile cases when carefully prepared in fluid form. 
 Patients often object to these substances for the reason that they 
 
DIET IN FEVER IN GENERAL 419 
 
 are tasteless and monotonous, whereas if prepared with a little care, 
 by giving proper attention to their flavouring, they may be made 
 very palatable. Thin gruels of rice, oatmeal, or barley, from which 
 all solid matter has been very carefully removed by straining through 
 a cheese-cloth bag, may be salted and flavoured with any desirable 
 aromatic, such as cinnamon, clove, nutmeg, lemon or orange peel ; 
 grape sugar may also be added. Such gruels may be prescribed 
 either alone or combined with meat extracts, or beef tea, or beaten 
 eggs. The addition of grape sugar has been recommended by See 
 and others because of its ready absorption, and from the fact that 
 it is the form of sugar which is produced from the digestive fermen- 
 tation of starches, and is to be regarded, therefore, as an easily 
 assimilable carbohydrate which, to some extent, may prevent tissue 
 waste by furnishing fuel to the body. 
 
 If a patient be fed upon clear farinaceous gruels alone during 
 fever, he cannot thus obtain over eight or ten grammes of proteid 
 material per diem, or one twelfth of the quantity required by a 
 healthy man at rest, and obviously he will suffer within two or 
 three days from tissue waste and inanition. Egg albumin, meat 
 broths, or gelatin must therefore be added, or the soups must be 
 thickened. 
 
 Eggs may be eaten, but they should never be boiled, and in fact 
 they require but little cooking. They may be beaten with boiling 
 water and strained and dropped into consomme or light broth or 
 gruel. The yolk and the white may be used either separately or 
 together. The yolk may be beaten with hot milk and water, or with 
 hot tea sweetened with grape sugar (Yeo), or it may be added to 
 brandy. The brandy mixture of the British Pharmacopoeia (mistura 
 spiritus vini gallici, Br. Ph.) is made as follows : The yolks of two 
 eggs with half an ounce of refined sugar are beaten and added to 
 four ounces of Cognac and an equal amount of cinnamon water. 
 The brandy in this mixture may be still further diluted or reduced 
 to advantage. Some patients prefer to take eggs raw, while others 
 prefer to have them very slightly cooked by immersing them in 
 water which has been boiling, thus cooking them very slowh at a 
 temperature not exceeding 180 F. for ten or fifteen minutes. Eggs 
 prepared in this way are uniformly and lightly cooked, and the al- 
 bumin is coagulated in a soft gelatinous mass instead of the hard, 
 white, tough coagulum which is produced by greater heat (see 
 p. 104). 
 
 Cold meat jellies as well as simple sherry wine and lemon jellies 
 may occasionally be given, but gelatin alone is not particularly nu- 
 tritious, and, in proportion to the bulk occupied by this class of 
 foods, comparatively little benefit is derived from them. 
 
 Gelatin given with other foods, especially those of proteid com- 
 position, is assimilated much better, and makes a desirable addi- 
 
420 DIET IN DISEASE 
 
 tion to the dietary in mild cases. When added to milk in the form 
 of blancmange patients usually enjoy it. 
 
 Beef tea and chicken jelly in equal parts make an excellent com- 
 bination. 
 
 Beverages in Fevers 
 
 The Value of Water and Other Beverages. — In almost all febrile 
 affections the liberal use of water, or some beverage composed 
 chiefly of water, is to be recommended both for the relief of thirst 
 and on account of its diluent effect and of its increasing the facility 
 with which the waste matter resulting from the rapid metabolism 
 of the fever is eliminated through the kidneys. A dry mouth de- 
 stroys the appetite. It is believed by many that the toxins pro- 
 duced by the action of typhoid-fever germs or other micro-organ- 
 isms are rendered less powerful and are in some degree " washed 
 out " of the system by the imbibition of large draughts of water. 
 Patients who are extremely feeble, or who are not wholly rational, 
 niay not ask for drink although their mouths are dry and parched, 
 and it should always be the duty of the nurse to give water in proper 
 amount at regular intervals. In long-continued fevers there is a 
 tendency for an increased loss of water from the surface of the 
 lungs, and sometimes from the skin, although the kidneys may be 
 less active than normal, and if care is not taken to replace the fluid 
 in the body the effects of this loss become much more pronounced. 
 If there are profuse watery evacuations from the bowels the drain 
 of fluid from the blood, and eventually from other body tissues, is 
 considerable. 
 
 Sour lemonade constitutes one of the most useful and refreshing 
 of beverages. It is not particularly apt to disorder the stomach, espe- 
 cially if taken in the intervals between the ingestion of food, and to 
 many persons it is exceedingly grateful. It may be made efferves- 
 cing by the addition to a strong lemonade of Vichy, carbonic-acid 
 water, soda water, or ten grains of sodium bicarbonate. 
 
 Barley and rice water with a little lemon juice and sugar, or with 
 cinnamon, wine, and sugar, afford refreshing drinks to many per- 
 sons, especially children, but they contain very little nourishment. 
 Either tea or coffee may be allowed once a day in many cases of 
 fever, although this fact is often overlooked. Tea should be 
 avoided if there is marked indigestion in the stomach, and coffee 
 as well as tea should be avoided in cases where there is insomnia 
 or excessive nervousness. If there is flatulency they should be 
 given without sugar, and not with other food. Persons who ob- 
 ject to the taste of milk may take it if a tablespoonful of good 
 coffee be added to the tumblerful. Strong black coffee, moreover, 
 is useful in controlling vomiting, and is mildly stimulating in cases 
 of heart failure. Its diuretic action is also valuable in fever, but it 
 
DIET IN FEVER IN GENERAL 42 1 
 
 should be remembered that those who are not ordinarily disagree- 
 ably affected by the daily use of strong coffee may be made very 
 nervous by even small quantities given when the system is reduced 
 by the wasting processes of fever. Both tea and coffee should be 
 used, therefore, with discretion, although they may at times prove 
 valuable in relieving the monotony of a fluid diet. Other useful 
 beverages are whey, or whey and beef tea, either hot or iced, and 
 unfermented grape juice. 
 
 For the immediate relief of thirst cracked ice may be given, 
 but it sometimes parches the lips. Some patients prefer a glycerin 
 mixture. A drachm or two of glycerin and half a drachm of borax 
 or boric acid may be added to a tumbler of water and used to rinse 
 the mouth. 
 
 By sipping fluids, thirst is more relieved than if they are quickly 
 drunk. There is more satisfaction in draining a small glass than 
 in merely taking a few mouthfuls from a large tumblerful. 
 
 The question of the temperature at which milk or any form of 
 beverage should be given in fevers may safely be left, in most cases, 
 to the liking of the patient. I have elsewhere shown (p. 333) that 
 the body temperature can be but little if any affected by that of in- 
 gested fluids, and it is a matter of far more importance to give them 
 in so agreeable a form that they will not be refused. An excess of 
 cold drinks may embarrass digestion or cause stomach cramps, and 
 should be avoided, but any cold fluid slowly sipped will do no harm. 
 
 Alcohol as a Food in Fevers 
 
 The principal theory of the action of alcohol in all fevers is that 
 it serves as a food ; it is readily absorbed and carried in the blood to 
 all parts of the body, and it is believed that its combustion saves in 
 some degree the wear and tear of the tissues, as the alcohol burning 
 in a spirit lamp furnishes energy in the form of heat, and itself be- 
 comes oxidised to waste products, but spares the carbon of the 
 wick. The latter is not itself burned up or oxidised until the alco- 
 hol has been exhausted. Another theory of the use of alcohol is 
 that it possesses a positive antipyretic action by which it controls 
 the body temperature by restricting heat production. It is also 
 believed that alcohol in fevers acts upon the nervous system, 
 strengthening and supporting it, in this manner indirectly con- 
 trolling the nerve currents which preside over the activity of nutri- 
 tion, chemical change, and heat production. The subject is a very 
 broad one, and is obscured by the lack of definite knowledge as to 
 the exact nature of the chemical processes concerned in heat pro- 
 duction, which are probably very complex. It is possible that in 
 many instances alcohol may act simultaneously in all the ways sug- 
 gested, having the combined effect of a food, a nerve tonic, and an 
 
422 DIET IN DISEASE 
 
 antipyretic. This view is ably advocated by Dujardin-Beaumetz, 
 who gives an exhaustive discussion on the subject in his work on 
 alimentation in fevers (Du Regime Alimentaire dans les Maladies 
 Febriles, p. 227). 
 
 Light white wines, diluted claret, and even beer are recom- 
 mended in fevers by some writers on dietetics, especially in those 
 countries in which good water is unobtainable, or in which for other 
 reasons wine drinking is in much more common daily use than it 
 is in America, where there is an abundant supply of pure water. 
 In France and Germany light red wine is frequently allowed 
 throughout the course of mild fevers, and from five to ten ounces 
 are given daily. The fever diet in the Munich General Hospital 
 includes 150 to 300 grammes of light red wine or white wine. Beer 
 is also much used in Germany for fevers, and it contains some nour- 
 ishment. 
 
 If alcohol is not required for its stimulating effect upon the 
 circulatory or nervous systems it is better to withhold it, for in 
 continued fevers emergencies may at any time arise in which it is 
 imperatively demanded to strengthen the failing powers or aid in 
 controlling the exhaustion of delirium. Its influence will always be 
 more decided and its action can be much better controlled if spirits 
 have not previously been given, and when it is needed for any such 
 reason it is best to prescribe it in the form of brandy or whisky. 
 
 In general, it may be stated that alcohol is usually needed if the 
 temperature remains for several days above 103 F., and is always 
 required if it remains as high as 105 F. The typhoid condition 
 supervening in the course of any fever always demands it — i. e., the 
 condition characterised by great prostration, low muttering de- 
 lirium, subsultus, rapid feeble pulse, dry tongue, etc. 
 
 In the convalescence following prolonged fever the daily use of 
 liquors with meals, or in the form of toddy or punches between 
 meals, two or three times a day, is often indicated. This is particu- 
 larly the case among elderly people convalescing from pneumonia 
 and other acute febrile diseases or who have been greatly weakened 
 by some prolonged adynamic disease. In infancy also, and early 
 childhood, the use of alcohol may be demanded in the course of 
 acute fevers. 
 
 Persons who have been habitual though moderate drinkers for 
 many years, or throughout their lives, when attacked with any 
 severe acute or infectious disease possess less vitality and resistance 
 than those whose tissues have not been constantly bathed in alcohol. 
 To withhold the long-accustomed stimulation in these cases is often 
 to precipitate serious exhaustion, and the problem of properly 
 adapting the quantity of alcohol to the patients' actual needs be- 
 comes a very serious one to the physician, to which he should give 
 careful and thorough study. Caution should be given against the 
 
DIET IN FEVER IN GENERAL 423 
 
 continued use of alcohol by patients in whom there is danger of 
 inducing the alcohol habit. It not infrequently occurs that those 
 who have been addicted to excessive drinking, but who have been 
 temporarily cured of the habit, and who have taken no liquor for 
 possibly several years, acquire some acute disease in which there 
 is need of active stimulation. In such cases, having in view the 
 possible recovery of the patient, with a renewal of his alcoholic habit, 
 this stimulant should be withheld as long as possible while efforts 
 are made to sustain the enfeebled heart power by strychnine, digi- 
 talis, or diffusible cardiac stimulants, such as ether, ammonium 
 carbonate, aromatic spirits of ammonia, camphor, etc. 
 
 From the above account it appears that the question of the use 
 of alcohol in all febrile disorders should be considered from two 
 chief standpoints, embracing, first, its value as a food, with its rela- 
 tion to other foods and to nutrition ; second, its value as a stimulant 
 and the extent to which it may be replaced or re-enforced by drugs. 
 The continued use of strong alcohol always disorders digestion, and 
 since the stomach is weakened in fevers, it is more susceptible to 
 such influences, and this is an additional argument for not employ- 
 ing alcohol in a routine method, but for saving it for positive indica- 
 tions, such as asthenia. But in those cases in which the battle for 
 life must be waged largely with stimulants as much as one ounce 
 an hour (twenty-four ounces per diem) of brandy or whisky must 
 sometimes be given, and it is a curious fact that in the presence 
 of high fever patients can often tolerate such dosage without the 
 indications of alcoholic poisoning which in health would promptly 
 follow the use of a smaller quantity. 
 
 Diet in Convalescence from Fevers 
 
 Convalescents who have long subsisted solely upon fluids must 
 be careful in resuming solid diet, for the rapidity of recuperation of 
 the digestive organs varies in different persons, and taking meats or 
 other solid foods too soon may cause rise in temperature, rapid 
 heart action, and possibly visceral congestion. The first meat given, 
 therefore, should be in a finely subdivided state, such as scraped 
 beef or minced chicken. 
 
 During convalescence from protracted fevers the more easily 
 digested forms of starchy foods are found to be very useful, es- 
 pecially if there has been much loss of weight. Sago and tapioca 
 thoroughly cooked and served with cream are highly nutritious, 
 and dried bread crumbs rolled through a fine sieve may be added 
 to thicken clear meat broths. Crackers and zwieback are useful. 
 
 Other ingredients which may be added to thicken soups during 
 convalescence are panada, semolina, tapioca, and macaroni. Cus- 
 tard puddings, cooked fruit, wine and beef jellies, blancmange, or 
 29 
 
424 DIET IN DISEASE 
 
 baked custard may be allowed. " Mush," fine hominy, cornstarch^ 
 farina, and boiled rice, with beef juice, can be ordered. 
 
 The following dietary will serve as a general guide for feeding 
 convalescents from fevers of ordinary severity in which special 
 lesions of the alimentary canal are not present. It is taken from a 
 Handbook of Invalid Cooking: 
 
 "FIRST DAY 
 
 " Breakfast. — Poached egg on toast. Cocoa. 
 " Lunch. — Milk punch. 
 
 " Dinner. — Raw oysters. Cream crackers. Light wine if de- 
 sired. 
 
 " Lunch. — One cup of hot beef broth. 
 
 " Supper. — Milk toast. Wine jelly. Tea. 
 
 "SECOND DAY 
 
 " Breakfast. — Soft-cooked egg. Milk punch. Coffee with su- 
 gar and cream. 
 
 " Lunch. — One cup of soft custard. 
 
 " Dinner. — Cream-of-celery soup. Sippets of toast. A little 
 barley pudding, with cream. Sherry wine if desired. 
 
 " Lunch. — Milk punch. 
 
 " Supper. — Water toast, buttered. Wine jelly. Tea. 
 
 "THIRD DAY 
 " Breakfast. — Scrambled egg. Cream toast. Cocoa. 
 " Lunch. — One cup of hot chicken broth. 
 
 " Dinner. — Chicken panada. Bread. Light wine if desired. A 
 little tapioca cream. 
 
 " Lunch. — An eggnog. 
 
 " Supper. — Buttered dry toast. Baked sweet apples and cream. 
 Tea. 
 
 "FOURTH DAY 
 
 u Breakfast. — An orange. Oatmeal (H. O.), with cream and 
 sugar. Poached egg on toast. Baked potato. Cocoa. 
 
 " Lunch. — One cup of hot soft custard. 
 
 " Dinner. — Potato soup. Croutons. A small piece of beef- 
 steak. Creamed potatoes. Baked custard. Coffee. 
 
 " Lunch. — One cup of chicken broth, with rice. 
 
 " Supper. — Raw oysters. Banquet crackers. Graham bread,, 
 toasted. Wine jelly. Tea. 
 
 "FIFTH DAY 
 
 " Breakfast. — An orange. Coffee. Oatmeal, with cream and 
 sugar. Broiled mutton crop. Toast. 
 " Lunch. — One cup of mulled wine. 
 
TYPHOID FEVER 425 
 
 " Dinner. — Chicken soup. Bread. Creamed sweetbreads. 
 Duchess potato. Snow pudding. Cocoa. 
 
 " Lunch. — Siphon soda, with coffee sirup and cream. 
 
 " Supper. — Buttered dry toast. Orange jelly. Sponge cake 
 and cream. Tea." 
 
 A further discussion of this topic will be found in the section 
 upon Convalescence in Typhoid Fever. 
 
 While brandy and whisky constitute the best form in which to 
 give alcohol in the acute stage of fevers, in convalescence it is 
 often advisable to use some other alcoholic drink, and an occasional 
 change from one variety to another renders the patient somewhat 
 less liable to the danger of acquiring a permanent alcoholic habit. 
 For convalescence, if the patient's purse can afford it, champagne, 
 port wine, sherry, Madeira, or a good claret or Burgundy, may be 
 taken with advantage in the class of cases above mentioned. 
 
 TYPHOID FEVER 
 
 Pathological Physiology. — Careful nursing and diet regulation 
 are the life-saving agents in typhoid fever. In few diseases does 
 a closer relation exist between right feeding and symptoms. 
 
 In average cases the fever lasts a month, no matter what the 
 treatment, whether by cold bathing or otherwise, while in some it 
 continues for five or even six weeks. There is then a convalescent 
 period of at least two weeks, and often as many months, during all 
 which time constant care in feeding must be exercised. At any 
 time during the prevalence of the fever the slightest departure from 
 the strict rules for diet laid down by the physician may determine a 
 fatal issue, but it is during the period of ulceration that the greatest 
 danger is met. 
 
 The ulcers involve the Peyer's patches and solitary follicles in 
 the lower end of the ileum, but they may extend into the jejunum, 
 and even into the large intestine. They are deep and clean-cut, 
 often including the whole thickness of the muscular layers, and 
 sometimes perforating through the serous layer. An overloaded 
 intestine or a distended bowel may precipitate perforation at any 
 moment. It is therefore important to select a diet which will leave 
 but small residue. 
 
 More or less intestinal as well as gastric catarrh is often present, 
 interfering with both digestion and absorption. 
 
 The prolonged fever is itself a menace to life by the secondary 
 changes which it induces in the alimentary system. The digestive 
 secretions are altered in quality and lessened in quantity. En- 
 feebled circulation retards or inhibits absorption, and the functional 
 activity of the liver is in abeyance. 
 
 Poisonous products suspended in the blood, as well as its ele- 
 
426 DIET IN DISEASE 
 
 vated temperature, interfere with the normal rate of metabolism 
 through the body, and finally the excretory organs are overworked. 
 The typhoid bacillus has curious behavior in relation to certain 
 food materials, e. g., if cultivated in milk it prevents coagulation ; 
 whey cultures become distinctly acid, and potato cultures show 
 peculiar modes of growth. 
 
 Dietetic Treatment 
 
 There are two chief factors which should influence the selection 
 of a proper diet for typhoid fever. These are: i. The supposed 
 danger of mechanically irritating the ulcerating surfaces in the 
 intestine and the danger of overloading an intestine and stomach 
 whose digestive functions are impaired by fever. 2. The relations 
 of the chemical ingredients of the food to the increased tissue 
 change that causes or accompanies the excessive production of 
 heat. If the proper fuel can be furnished as food, the tissues are 
 spared too great self-consumption in producing heat. 
 
 Milk Diet. — In regard to the first factor the danger of mechan- 
 ical irritation of the intestinal wall is somewhat exaggerated. In 
 prescribing a milk diet for typhoid fever in order to lessen this 
 danger many overlook the fact that undiluted milk, on entering the 
 stomach, becomes almost solid, and large firm milk curds are likely 
 to prove quite as irritating to the ulcerating surfaces, or even more 
 so, than are starchy foods. 
 
 When patients are fond of milk and digest and absorb it thor- 
 oughly, there is no better diet for typhoid fever, and it answers 
 every requirement of a fever food. It contains all the essential 
 elements of nutrition, is easily digested, furnishes fluid to the tis- 
 sues, is a good diuretic, and, if properly administered, in many cases 
 it is soothing to the stomach when a mild degree of gastric catarrh 
 exists. 
 
 Those who dislike milk at first may later grow accustomed to it 
 and take it contentedly for a month or even six weeks. 
 
 Due emphasis should be given to the fact that an exclusive milk 
 diet need not and should not be prescribed in routine for all cases. 
 Within the past few years a number of writers (notably Shattuck of 
 Boston and A. G. Barrs of London) have advocated a departure 
 from the strict milk diet which had come to be the rule for typhoid 
 fever, and it is found beneficial to enlarge the dietary of some pa- 
 tients considerably by such articles as strained vegetable soups, 
 boiled rice, macaroni, soft-cooked eggs, soft cream toast, cream and 
 water, buttermilk, softened soda crackers, blancmange, wine jelly, 
 and ice cream. It is much easier to put all hospital cases of typhoid 
 fever on a routine milk diet, but it is often better to devote a little 
 study to securing suitable variation in the food. 
 
TYPHOID FEVER 427 
 
 In typhoid fever every effort should be made to maintain good 
 stomach digestion. If all food is thoroughly disintegrated before it 
 enters the intestine there need be little fear of a mechanical irrita- 
 tion of the ulcerating surfaces. P^ar more danger may occur 
 through malnutrition of the intestinal wall, which prevents absorp- 
 tion of nutriment. An accumulation of undigested food in the 
 intestine is therefore highly undesirable, and the stools should be 
 periodically examined to see that undigested milk curds do not 
 appear in them. 
 
 Milk for some persons in health is really a poison. They com- 
 pletely fail to digest it. It causes constipation with clay-coloured or 
 white stools, and fills the bowels with products of malfermentation, 
 ptomaines, and gases. They digest it even less when they acquire 
 a prolonged fever. Others, with whom the milk agrees, become 
 very tired of it after taking it exclusively for several weeks at a 
 time. 
 
 I have several times seen cases of typhoid fever with symptoms 
 which resembled scurvy, with swollen and bleeding gums and great 
 emaciation, occurring in patients who had been fed too long upon 
 an exclusive milk diet which they failed to assimilate. 
 
 Quantity of Milk Required. — If milk is the only food, enough 
 should be given, and the problem of what constitutes enough must 
 be solved in each case separately. Much harm is done by over- 
 feeding, which induces indigestion and restlessness, increases the 
 pulse rate, and aggravates the abdominal symptoms — such as tym- 
 panites, diarrhoea or constipation, haemorrhage, and abdominal pain. 
 Ingestion is very different from digestion. 
 
 There are many writers upon dietetics who give a special cau- 
 tion against the practice of overfeeding in cases of enteric fever on 
 account of the fact that more or less gastric catarrh is usually pres- 
 ent and that it is an undue tax upon the digestion of the patient to 
 have to deal with a large bulk of food. 
 
 On the other hand, underfeeding causes malnutrition, favours 
 the occurrence of complications, and prolongs convalescence. 
 
 For an exclusive milk diet the outside limits lie between one 
 and three quarts per diem, depending somewhat upon the age and 
 size of the individual, but more upon the condition of his digestion. 
 A clean tongue, a soft abdomen, and natural milk stools, not too 
 hard and without coagulse of casein or flakes of fat, indicate that the 
 milk is being well digested. 
 
 The reverse of these symptoms suggests that the milk is sup- 
 plied in too large quantity, or that it is not being digested, and one 
 or more of three things must be done : (a) The quantity must be 
 reduced ; (b) the mode of administration must be changed — i. e., 
 the milk must be predigested ; (c) other foods must be substituted, 
 either wholly or in part. 
 
428 DIET IN DISEASE 
 
 (a) When milk appears to be well digested, but the patient 
 emaciates rapidly early in the disease, he is not getting nourishment 
 enough, and the quantity must be increased or other food must be 
 added. As a general rule, from one and three fourths to two quarts 
 of milk per diem (or six ounces every two hours, day and night), 
 however diluted, is sufficient during the height of the fever to sus- 
 tain the patient properly. It is best to give as much as can be 
 thoroughly assimilated according to the symptoms above noted. 
 
 Johnston believes that from three to four ounces of milk given 
 every two or three hours is sufficient. Moore states that very few 
 patients digest over one and a half to two pints of milk, and " it is 
 scarcely ever necessary to exceed the amount of one quart of milk 
 in the twenty-four hours," or three ounces of milk in ten feedings at 
 intervals of two and a half hours. This estimate, for uncomplicated 
 cases at least, is too low. It may be necessary to reduce the allow- 
 ance to this figure if severe gastro-intestinal disturbance occurs, or, 
 in fact, with violent vomiting to temporarily discontinue the milk 
 entirely, and give only cracked ice or half-ounce doses of iced 
 champagne, but patients kept too long on as low a diet as that 
 mentioned will emaciate, grow feeble to an alarming degree, and 
 require excessive stimulation. 
 
 (b) The milk may be given raw, boiled, diluted with plain water, 
 barley water, lime water, Vichy, Seltzer, or Apollinaris, or pan- 
 creatinised according to taste and need. Gelatin, as well as gum 
 arabic, is sometimes added to milk to dilute it and prevent tough 
 curds from forming. The milk should never be skimmed. Its 
 taste may be disguised by the addition of a little strong coffee or 
 some of the extract of coffee, or a little caramel makes it agreeable 
 to the taste where patients have refused it before, or it may occa- 
 sionally be preferred with a cup of cocoa in which the milk pre- 
 dominates. If diarrhoea is present, a milk diet is especially useful, 
 and the milk should be boiled. 
 
 When vomiting occurs, it is better to use peptonised or pancre- 
 atinised milk than soda or lime water, for the latter tend to neu- 
 tralise the activity of an already enfeebled gastric juice. These 
 fluids may be given either hot or cold, according to taste. If cold, 
 the nausea is sometimes controlled, but digestion may be somewhat 
 retarded. If the vomiting is very obstinate, koumiss, kefir, or zoo- 
 lak may be given for a time with very good result in place of 
 milk. Whey or buttermilk is also used sometimes for a change for 
 a few days. A. L. Loomis recommended from four to six quarts of 
 the latter per diem. 
 
 (c) Substitutes for Milk Diet.— When milk is obviously dis- 
 agreeing and producing flatulence, I have often seen improvement 
 follow an entire change of diet for a day or two to animal broths. 
 Similar results are familiar in the treatment of infantile diarrhoea. 
 
TYPHOID FEVER 429 
 
 In cases like those above described in which, after fair trial, it is 
 found impossible to urge upon the patient the taking of milk, there 
 is no objection to giving strained broths of mutton, chicken, or 
 beef, a little clam broth for a relish, and light farinaceous arti- 
 cles, such as the prepared starchy foods, like Mellin's or Nestle's, 
 barley water, farina, arrowroot, and other gruels, custards, egg- 
 nog, or a piece of zwieback softened by soaking in milk, weak tea, 
 or bouillon. I have used gruel made from banana meal, which 
 .is palatable, highly nutritious, and easily digested (see p. 182). 
 Junket and cream are very nutritious and agreeable to the palate. 
 Egg albumin can be made very palatable by beating it with a little 
 milk and sherry. In this manner considerable variety is secured 
 .for the patient; the appetite, and in many cases the digestion, are 
 improved, and by alternating one or more of these articles with the 
 milk, a much larger quantity of nourishment will in the end be 
 taken and absorbed. Layton estimates that typhoid patients may 
 sometimes lose half a pound in weight per diem, and in that class 
 of cases in which rapid emaciation is a most alarming feature of the 
 disease these various adjuncts to the milk diet are especially useful. 
 Moreover, patients fed in this manner are not likely to become rav- 
 enous during convalescence. 
 
 It is well expressed by Henry that " it is not so much solid as 
 indigestible food that should be eschewed, and it should never be 
 forgotten that all foods except such as are predigested are solid in 
 the first stage of digestion." A pint of milk contains as much solid 
 material as a mutton chop. 
 
 The continued use of beef tea, beef juice, or meat extracts and 
 peptonoids undoubtedly produces loosening of the bowels, and such 
 substances must be avoided when diarrhoea is present ; but in cases 
 where there is a tendency to constipation this may be a decided 
 advantage. Veal and chicken broth are less apt to have a laxa- 
 tive effect than beef and mutton broth, and calf's-foot jelly is 
 allowed by some clinicians. When patients tire of the taste of beef 
 tea or broth it may be flavoured with a little celery salt or, if there 
 is no diarrhoea, with a very little tomato juice or other simple vege- 
 table extract. 
 
 Henry advocates the use of gelatin as an " albumin sparer/' 
 although it should not be given if diarrhoea is present. As much as 
 a claret-glass full may be given on alternate days, and it can be in 
 the form of simple blancmange or peptonised milk jelly, which is 
 made by adding, while hot, gelatin dissolved in a little water to pep- 
 tonised or pancreatinised milk, and flavouring with lemon or orange 
 and sherry or rum. It is eaten cold. In the stomach it is quite 
 as fluid as predigested milk. 
 
 Farinaceous Gruels. — I have alluded to the occasional advantage 
 -of giving farinaceous gruels, for, despite the fact that many writers 
 
430 DIET IN DISEASE 
 
 are opposed to them on the ground that they may excite tympany, 
 I believe them to be at times of great service. Stromeyer feeds 
 his patients largely upon oaten grits boiled for three hours with- 
 out sugar. 
 
 Da Costa recommended giving three pints of milk and one pint 
 of broth every twenty-four hours, with a midday allowance of some 
 gruel, such as arrowroot. There is a variety of enteric fever in 
 which without any noticeable complications, and even without a 
 very high temperature curve, emaciation is rapid and extreme. In 
 such cases especially the use of farinaceous gruels is indicated. 
 They must not be given too sweet, and a little cream or lemon juice 
 may be added in lieu of sugar. It is often advisable to add a table- 
 spoonful of malt extract, or one of the " prepared foods/' such as 
 Mellin's, Horlick's, Ridge's, or malted milk may be given in milk. 
 
 Sleep and Food. — In all cases of typhoid fever the question arises 
 in regard to waking the patient at night for nourishment, or to take 
 the temperature. 
 
 Some patients awaken easily, are fed, and drop off to sleep again 
 almost immediately. They may be fed every two hours day and 
 night. Others, if awakened, do not readily fall asleep again, and 
 lose half the night's rest or more, and this may considerably retard 
 their recovery. It is sometimes best to let them sleep for three, or 
 even four, hours without being aroused, for the rest may be of more 
 value to them than food. So much depends upon the temperature, 
 pulse, and general condition of each case that no rigid rule should 
 be formulated, but it is best never to let four hours pass while the 
 fever lasts without giving food. If patients are told that they have 
 a little longer interval than usual in which to rest undisturbed, they 
 will sometimes go to sleep at once. Of course, if they sleep during 
 the day there is less need of postponing feeding by night. Con- 
 stant drowsiness may indicate a need of more food. The nurse 
 should always furnish a daily record of the exact amount of milk 
 or broths actually given in twenty-four hours, making allowance 
 for dilution, and this should be compared with the quantity of urine 
 voided. 
 
 Thirst. — Thirst is a prominent symptom in typhoid fever, and 
 cool water should be given in abundance by the nurse, without wait- 
 ing for the patient to ask for it. Water favours nutrition and the 
 elimination of waste. If diarrhoea is absent it is well to acidulate 
 the water with a little dilute phosphoric or hydrochloric acid, ten or 
 fifteen drops to the tumblerful, or water flavoured with infusion of 
 orange or serpentaria. Hoppe-Seyler has washed out the stomach 
 in cases of typhoid fever, and shown that while the temperature re- 
 mains high there is little or no acid contained in the gastric juice, 
 and a mildly acidulated beverage may prove serviceable by aiding 
 digestion as well as by relieving thirst. 
 
TYPHOID FEVER 431 
 
 Relief of the latter symptom is sometimes sought by painting 
 the tongue with glycerin, which is used to prevent evaporation from 
 the surface and not because of any special virtue in the glycerin 
 itself, which, in fact, is hygroscopic and tends to abstract water from 
 the mucous surface unless it is already very much diluted, and it 
 cannot protect it sufficiently from the evaporation which occurs in 
 mouth breathing. The use of cracked ice in excess aggravates 
 thirst rather than relieves it, and it is better to sip cool water at a 
 temperature of 50 to 6o° F. rather than ice. The juice of a sweet 
 orange or a lemon is often very acceptable, and in the absence of 
 serious complications it can do no harm. Iced tea may prove 
 agreeable. As a rule, it is well to restrict the use of effervescent 
 drinks for the control of thirst on account of the danger of increas- 
 ing flatulency, and stretching the ulcerated intestinal wall. 
 
 In addition to the need of water for relieving thirst, it is of great 
 service as a diluent for washing out the waste products of the febrile 
 action from the system through the kidneys. Many clinicians, as 
 Henry, Meigs, and Beverley Robinson, make it a special feature of 
 their treatment to give large draughts of water. Henry advises 
 giving each patient eighty ounces of water (including that con- 
 tained in fluid food) per diem, and Meigs has given as much as one 
 hundred and thirty ounces with benefit, including from thirty to 
 fifty ounces of free water. Debove gives six ounces every two 
 hours. It should not be drunk too soon after the fluid food, but in 
 the intervals, so as not to dilute the gastric juice too much. In 
 mild cases a little coffee or a cup of cocoa may be drunk in the 
 morning. 
 
 Alcohol. — The question of how far alcohol serves the purpose of 
 a food and a " force regulator " in typhoid fever is very important. 
 The employment of it in excess as a routine treatment is greatly to 
 be deplored. It is seldom required at all in the first fortnight. 
 Later the heart is enervated and its muscular tissue is enfeebled. 
 In all complications which threaten life, such as severe haemorrhage, 
 sudden cardiac dilatation, hyperpyrexia (107 F.), pneumonia, or un- 
 controllable diarrhoea, alcohol must be given without stint. When 
 the complication is passed the dosage should be gradually reduced. 
 
 Patients above forty years of age usually require stimulation 
 early. 
 
 It was formerly customary to prescribe whisky in typhoid fever 
 at the rate of twenty or twenty-four ounces per diem, and in some 
 chronic alcoholic patients large quantities of alcohol may be needed 
 to prevent collapse. Sometimes delirium will disappear when ex- 
 cessive dosage of alcohol is discontinued, and I am inclined to pre- 
 scribe very much less alcohol than formerly, especially for young 
 and robust patients. Undoubtedly there are cases of greatly weak- 
 ened circulation in which its use must be pushed rapidly, and in 
 
432 DIET IN DISEASE 
 
 which it quiets restlessness, insomnia, and delirium better than 
 opium or other narcotics, but it is not to be forgotten that there 
 are other valuable cardiac stimulants. By giving small doses of 
 digitalis or strophanthus, or the two in combination, by the use 
 of caffeine, camphor, small doses of morphine, and other remedies 
 in combination with alcohol, much less of the latter will be re- 
 quired, and there is far less danger of inducing the alcohol habit. 
 Strong whisky often intensifies the stomach catarrh and interferes 
 with the natural absorption of food. One very noticeable feature 
 of the Brand cold-bath treatment is that the patients do well with 
 so little alcohol, many of them requiring none at all in the intervals 
 between the baths. 
 
 The kind of alcoholic stimulant prescribed must depend upon 
 the circumstances of the case. Brandy and whisky possess the ad- 
 vantage that the dosage is more uniform and the bulk is not great. 
 It is a matter of routine hospital practice, founded largely on eco- 
 nomical reasons, to give whisky or brandy as the only form of 
 alcoholic stimulation, but in private practice, especially among 
 women, liquors may be distasteful, and equally good results can 
 be obtained by ordering some good strong wine which is more 
 agreeable to the taste, such as one of the Hungarian wines, Malaga, 
 port, sherry, claret, etc. In Germany patients are often allowed 
 beer, but this beverage is open to the same objection as the effer- 
 vescent drinks, for there is more or less gastric catarrh usually 
 present. It is not much prescribed in this country. It serves bet- 
 ter during convalescence than while the fever is present. Brandy 
 in milk or soda or Seltzer water is best for diarrhoea, and dry cham- 
 pagne is good if there is vomiting. As the latter is used in small 
 doses — an ounce or less at a time — it is economical to place a 
 patent cork with a faucet in the bottle, so that a little may be drawn 
 at a time without losing all the effervescence. In any case in which 
 alcohol is given the best guides for the proper quantity are found, 
 as in pneumonia, in the breath, delirium, tongue, and pulse. If 
 the breath has no odour of alcohol an hour or two after the dose 
 has been taken, if delirium has subsided, if the tongue becomes 
 more moist, and the pulse becomes more full and slow, the alcohol 
 is doing good. 
 
 During convalescence a little alcohol — two ounces of whisky 
 or four or five of Burgundy a day, for example — may be needed as 
 a tonic, but should be given onlv with food. 
 
 Relation of Intestinal Antisepsis to Diet 
 
 It is said that bacilli fed on beef juice produce ptomaines which 
 act more strongly upon the nervous system than if they are fed 
 upon milk (Rachford). The starches do not make ptomaines. 
 
TYPHOID FEVER 433 
 
 The typhoid germs certainly thrive in nitrogenous media, but 
 not upon carbohydrates. Their development in the former is ac- 
 companied by the production of toxic material in the intestine, 
 which, on being absorbed into the system, produces the symptom- 
 atic phenomena of the disease. This theory, which is of compara- 
 tively recent adoption, has emphasised the possible value of anti- 
 septic treatment of the alimentary canal. While there are as yet 
 no remedies known to therapeutics which can be used in sufficient 
 strength in the intestine to be completely antiseptic or germicidal 
 to the typhoid bacilli, there is another aspect of antisepsis, or rather 
 asepsis, of the alimentary canal, which should not be overlooked — 
 that is, the prevention of those fermentative changes which accom- 
 pany indigestion in any fever. In typhoid fever the importance of 
 maintaining as nearly as possible the normal digestion and absorp- 
 tion of the food is of special urgency on account of the length of 
 the disease. Moreover, it would appear that the overdistention of 
 the intestine by flatus must have a very injurious effect upon 
 the ulcerating surfaces by stretching them. At autopsies upon 
 typhoid patients ulcers are often seen which might have been easily 
 torn by slight distention, and the prognosis of typhoid fever is more 
 grave when extreme and obstinate intestinal flatulency appears early 
 in the disease, before there has been time for either perforation or 
 peritonitis. One can do much to prevent this condition by bestow- 
 ing special care upon the whole alimentary canal. 
 
 Care of the Mouth. — The mouth should be washed very fre- 
 quently at regular intervals, and always after taking a glass of milk, 
 for nothing causes coating" of the tongue more than a milk diet, or 
 forms a better field for the development of bacteria, which are con- 
 stantly being carried down to the stomach to excite indigestion and 
 flatulency there. Listerine and hydrogen peroxid make most satis- 
 factory and cleansing mouth washes. A whalebone bent in a loop 
 forms a good " tongue scraper," and cleans its surface quite thor- 
 oughly. If patients are too feeble to rinse the mouth, the nurse 
 should swab it out for them with a bit of cotton. Nurses should 
 be made to understand the importance of this simple detail, for, 
 if properly attended to, it adds greatly to the patient's comfort and 
 appetite. When this is faithfully done, one seldom sees even in 
 fatal cases a typical " typhoid tongue " — brown, dry, hard, fissured, 
 and so stiff that it is useless to the patient. Patients can often 
 learn to use a tongue bath to advantage — that is, to hold the mouth 
 full of fluid for several minutes at a time, when much moisture is 
 absorbed by the mucous membrane. The proper care of the mouth 
 will greatly lessen the liability to parotitis and catarrh of the 
 middle ear. 
 
 The Stomach. — The dangers of overfeeding with milk have 
 already been considered upon page 427. Milk disagrees with 
 
434 DIET IN DISEASE 
 
 many patients sooner or later, and the fermentation processes of 
 which it is capable produce large quantities of gas and sometimes 
 elevation of temperature. Small doses of salicin or cerium oxalate 
 with each tumbler of milk often prevent dyspepsia, and the milk, if 
 sterilised, may be retained and digested where vomiting has been 
 extreme. If there is the least indication of ordinary milk disagree- 
 ing, it should be at once changed for some other form — peptonised, 
 or sterilized, or boiled. With a clean tongue, and with sterilized 
 milk in the stomach, much may be done to favour the further diges- 
 tion of milk in the intestine. 
 
 The Intestine. — Many typhoid patients are severely constipated 
 by an exclusive milk diet. Constipation favours abnormal fer- 
 mentation, and begets the flatulency which is so injurious. Such 
 cases should not, as a rule, be allowed to go more than forty-eight 
 hours without encouraging a movement with an enema. While it 
 is not possible to render the alimentary canal in any sense truly 
 aseptic throughout, a great deal may be done to favour the vital 
 conditions of nutrition by preventing the opposite extreme of ex- 
 cessive ingestion of bacteria of various kinds and the production 
 of malfermentation. This appears to be at present a more encour- 
 aging field for germicidal efforts than treatment directed against 
 the seat of war in the Peyer's patches. The judicious daily use of 
 rectal enemata never excites intestinal haemorrhage, but excessive 
 constipation provokes meteorism, stretches the thin ulcerating sur- 
 faces to the point of rupture, and tends to keep the temperature 
 elevated. If relapses are due to reinfection or to simple septic 
 absorption through ulcerating intestinal surfaces, there is all the 
 more reason for the prevention of accumulation of too much food 
 in the intestine. 
 
 Convalescence. — As the fever subsides, it becomes an important 
 question how soon to allow a return to solid food. Relapses are 
 very easily induced by indiscretion in this regard. 
 
 The patient's appetite is always a dangerous guide to follow in 
 this disease. After four or five weeks of an exclusive milk or milk 
 and broth diet, when the temperature subsides, and often before it 
 has become normal, he becomes ravenous. Like a long-starved 
 man, he thinks of nothing but food, and demands something new to 
 eat every day. A hospital ward containing a dozen convalescing 
 typhoid-fever patients is difficult to manage, as a bread riot is con- 
 stantly menaced. Ill-advised but sympathetic friends attempt to 
 smuggle in all manner of forbidden fruits, and the patient just ar- 
 rived at the hungry state is tempted to steal solid food from his 
 more advanced neighbour. 
 
 In the milder cases it is undoubtedly both safe and wise to 
 allow a strengthening diet at an early date, and it will greatly pro- 
 long convalescence to forbid it. Light farinaceous diet — tapioca, 
 
TYPHOID FEVER 435 
 
 rice, vermicelli, cream-toast, a cracker soaked in cream, etc. — may 
 be given with impunity in cases which have run a mild course as soon 
 as the temperature remains normal. Meat broths may be thickened 
 with rice, sago, or vermicelli. In a day or two more the soft part of 
 oysters or a chop are permissible. In cases which have presented no 
 serious complications, if there is good stomach digestion there is no 
 need of prolonging a fluid diet for fear of intestinal injury. 
 
 The following is a list of foods suitable for the different days of 
 convalescence, commencing a day or two after disappearance of all 
 fever. Milk should still be given until gradually wholly replaced 
 by solid food. 
 
 First Day. — Chicken broth thickened with thoroughly boiled 
 rice. Milk toast or cream toast once only during the day. Beef 
 juice. 
 
 Second Day. — Junket, mutton broth, and bread crumbs. Cocoa. 
 Milk toast. A piece of tender steak may be chewed but not swal- 
 lowed. One of the prepared farinaceous foods, such as Mellin's 
 or Horlick's, may be given with a cup of hot milk. 
 
 Third Day. — A small scraped-beef sandwich at noon. A soft- 
 cooked Qgg or baked custard for supper. Boiled rice or potato 
 puree strained. Arrowroot gruel. 
 
 Fourth Day. — The soft part of three or four oysters. Meat 
 broth thickened with a beaten egg. Cream toast. Rice pudding 
 or blancmange and whipped cream, or Bavarian cream. 
 
 Fifth Day. — Scraped-beef sandwich. A tender sweetbread. 
 Bread and milk. A poached tgg. Wine jelly or calf's-foot jelly. 
 Macaroni. 
 
 Sixth Day. — Mush or crackers and milk, scrambled eggs, 
 chicken jelly. Bread and butter. The soft parts of raw oysters. 
 
 Seventh Day. — A small piece of tenderloin steak or a little breast 
 of broiled chicken. Bread and butter. Boiled rice. Wine jelly. 
 Sponge cake and whipped cream. 
 
 Eighth Day. — A slice of tender rare roast beef, a thoroughly 
 baked mealy potato served with butter or mashed with cream. 
 Other foods as before. 
 
 Ninth Day. — A little broiled fresh fish for breakfast. Beefsteak 
 at dinner. Rice, macaroni, eggs. Sago, rice, or milk pudding. A 
 baked apple. 
 
 Tenth Day. — Mush and milk. A squab or breast of partridge 
 or roast chicken. Other foods as before. Ice cream. 
 
 For the next four or five days the patient may select articles 
 from the menu of the previous day, so that three good meals a day 
 are taken, besides three or four glasses of milk between meals. 
 
 It is often desirable to give a little alcoholic stimulant, espe- 
 cially if there is much difference in the frequency of the pulse 
 between lying and sitting or standing, or if the pulse rate is very 
 
43 6 DIET IN DISEASE 
 
 slow, say 56, as it sometimes is. A glass of sherry or of good 
 sound Burgundy or a tumbler of ale may be drunk, but with 
 meals only. 
 
 Rules for Feeding in Atypical Cases. — If at any time during 
 convalescence after several days of a normal temperature it begins 
 to rise above ioo° or 100.5 F. it is safest to return at once to 
 fluid diet. If the temperature falls again in a day or two, con- 
 valescent diet may be resumed. A sudden rise to 103 F., or 
 even higher, lasting but a day or two, may be caused only by 
 constipation, and it is not to be considered as a genuine relapse, 
 but until the cause is ascertained the above precaution must be 
 observed. 
 
 There is a class of patients in whom the thermometric record is 
 likely to fail as a guide for feeding unless it is correctly interpreted. 
 After a protracted fever lasting four or five weeks the temperature 
 falls to about ioo c F. and fluctuates daily up to 100.5 or 101.5 F. 
 without reaching the normal, or it may become subnormal and fluc- 
 tuate between 97.5 or 98 F. in the morning, and 101 F. in the 
 afternoon. These patients, in the absence of any sequelae to ac- 
 count for the temperature elevation, have a " starvation fever," and 
 they are usually considerably emaciated. It is necessary to give 
 them solid food cautiously to bring the temperature to normal. 
 Sometimes even then the fever lasts until they are allowed to 
 sit up. 
 
 In estimating the proper time for giving solid food, regard must 
 always be paid to the general severity of the disease. 
 
 Complications, such as an abscess or furunculosis, may protract 
 the fever, although the intestinal ulcers are completely healed, and 
 such patients should have solid food in spite of a slight elevation of 
 temperature. Very mild cases, in which the fever curve subsides 
 in ten days or a fortnight, are deceptive in that they are apt to 
 relapse, and their fluid diet should be prolonged. Patients who 
 have been very ill with repeated haemorrhage or hyperpyrexia 
 should be fed with the greatest caution during convalescence. 
 
 At the end of a fortnight of normal temperature, if the bowels 
 are moving regularly and if there is no diarrhoea, the patient may 
 usually be allowed to select his own menu, although he must be 
 warned to avoid for a long time eating food likely to leave much 
 insoluble residue, such as raw vegetables, raw apples, soft-shell 
 crabs, berries, green corn, old peas, beans, cabbage, tough meats, 
 dried fruits, etc. He must be instructed also not to excite diar- 
 rhoea by eating too much fresh fruit. With any attack of indiges- 
 tion he must return for a few days to a very simple diet. I have 
 seen a second distinct relapse occur on the twentieth day after the 
 first, but such cases are fortunately quite exceptional. 
 
TYPHUS FEVER 437 
 
 Typhoid Fever in Children 
 
 Typhoid fever in young children is rare. When it occurs in in- 
 fants between two and five years of age they must be fed, if possi- 
 ble, exclusively upon milk in some form, predigested if necessary, 
 but in each case sterilised or Pasteurised. Children usually take 
 koumiss well and thrive upon it. 
 
 If milk is refused, and emaciation threatens in consequence, 
 some concession should be made in the rigour of the diet, but of 
 course no solid food can be allowed. Beef juice, beef, mutton, or 
 chicken broths (not thickened), and beaten egg albumin sweetened 
 and flavoured with a few drops of sherry, may be substituted for 
 milk or alternated with it. Children take junket extremely well. 
 When stimulants are required, from ten drops to a teaspoonful of 
 brandy or whisky, well diluted, should be given. 
 
 If they refuse this, a little Tokay, champagne or wine whey 
 may be tried. As a rule they need no alcohol unless they are very 
 feeble, or if complications arise. The nurse must offer water freely. 
 Barley water with a little lemon juice is useful to relieve thirst. 
 
 It must be remembered that the temperature curve of typhoid 
 fever in children is often very regular, and a fall to near the normal 
 must not be regarded as justifying an allowance of solid food at 
 once, and no matter how clamorous the child may be for it, exactly 
 the same rigid rules must be enforced as in the case of adults, and 
 for the same length of time during convalescence. 
 
 TYPHUS FEVER 
 
 In general the dietetic treatment of typhus fever should be the 
 same as that of typhoid fever, but as intestinal ulceration is absent 
 from the former, the extreme care of the alimentary canal is less im- 
 perative. The fever is high and the patient is usually delirious, 
 hence an exclusive milk diet is best during the height of the fever, 
 provided it is well digested. The duration of this fever is much 
 shorter than that of typhoid fever, and some of the objections to a 
 milk diet are therefore less apt to arise. From four to six ounces of 
 milk may be given every two hours. 
 
 If the milk is not well assimilated it may be alternated with or 
 supplemented by broths, custard, raw eggs, farinaceous gruels, etc. 
 
 Abundant water should be offered, and the prominent tendency 
 to ataxic symptoms and stupor may be counteracted by strong 
 black coffee, alcohol, etc. 
 
 Convalescence. — During convalescence the precautions ob- 
 served in the treatment of typhoid fever are not necessary, and 
 patients may return much sooner to a solid diet ; but some alcoholic 
 stimulant, such as ale or porter, will be needed with the meals. The 
 
43§ DIET IN DISEASE 
 
 directions given in the section on Diet in Fever in General (p. 
 417) may be observed; for, although any severe fever may leave the 
 digestive organs somewhat enfeebled, there is no unusual danger 
 of this kind in typhus fever, and relapses are not occasioned by 
 dietetic errors. 
 
 SMALLPOX 
 
 The invasion of smallpox is usually abrupt, and the tempera- 
 ture may reach 104 F. on the first day. There are anorexia, thirst, 
 vomiting, and prostration, in addition to other symptoms. The 
 fever continues for three days, or until the eruption has fully devel- 
 oped, after which it subsides. During the febrile stage a light fluid 
 diet should be given, such as is recommended for fever in general — 
 milk, broth, gruel, etc. (p. 417). The thirst is usually consider- 
 ably relieved by taking cool liquids in abundance, such as water, 
 iced lemonade, Seltzer water, etc. If there is much eruption in the 
 throat, there may be considerable dysphagia. 
 
 During the suppurative stage of the eruption the patient re- 
 quires an abundant supporting diet, and as much milk, eggs, whisky, 
 and stimulating meat broths should be prescribed as can be di- 
 gested. The patient should be fed at least once every two hours, 
 and must be awakened three or four times at night for food. Vom- 
 iting is not to be dreaded after the onset of the disease. The com- 
 bined effect of the irritation of so large a cutaneous eruption, and 
 of the secretion of so much pus from the pustules, which may 
 amount to many ounces, is exhausting to the last degree, and ear- 
 nest effort must be made to counteract it. This is especially true of 
 all confluent cases. A dozen eggs, three quarts of milk, and ten 
 or twelve or more ounces of whisky or brandy is not too much to 
 order for an adult. These materials may be given alone or in com- 
 bination, as eggnog, milk punch, etc. If the stomach rebels against 
 so much food, the rectum must be utilised for part of the work. 
 
 This supporting treatment should in all severe cases be com- 
 menced early, even in the vesicular stage of extensive eruption, 
 without waiting for signs of exhaustion, which are otherwise certain 
 to follow. If strong liquor is not tolerated, champagne or other 
 wine must be substituted. 
 
 Convalescence occupies from one to four weeks, according to 
 the severity of the attack. The diet should be slowly increased, and 
 should comprise abundant animal food, meat, milk, and eggs, and 
 alcoholic stimulants, such as ale, porter, or Burgundy. 
 
 SCARLET FEVER 
 
 In mild cases of scarlet fever the temperature subsides in a few 
 days, and after that time, during the period of desquamation, spe- 
 
MEASLES 439 
 
 cial care in the diet is unnecessary unless nephritis is present. 
 While the fever lasts the diet should be of fluid character, and milk, 
 koumiss, soups, broths, and farinaceous gruels of arrowroot, farina, 
 etc., are to be given. In all cases there is liability to renal irrita- 
 tion, and desquamative nephritis may occur ; and in order to elimi- 
 nate the scarlatinal poison and waste products of the fever from 
 the system as rapidly as may be, it is advisable that the patient 
 take as little nitrogenous food as possible, except milk, and drink 
 large quantities of fluid. Dryness of the mouth and thirst are prom- 
 inent symptoms, and there is often difficulty in swallowing, owing 
 to the inflamed condition of the throat. Water, effervescing waters 
 (Seltzer, Apollinaris), barley water, orange juice in Vichy, and sour 
 lemonade may be drunk in considerable quantities. 
 
 In mild cases a little plain vanilla ice cream is much enjoyed by 
 children. It is nutritious, cooling, and grateful to the parched 
 throat. 
 
 If the fever is high, four or five ounces of fluids must be given 
 every hour. In severe cases there is gastric derangement, and the 
 diet must be restricted to milk in some form, as koumiss or pepto- 
 nised milk. If nephritis is present, the milk diet should be con- 
 tinued, and all other nitrogenous food must be withheld (see Albu- 
 minuria). Jaccoud maintains that scarlatinal nephritis can be usu- 
 ally averted by keeping the child upon a strict milk diet from the 
 commencement and continuing it for several weeks. 
 
 Convalescent children who have had very mild attacks are often 
 hungry, but it is best to control their diet carefully for two or three 
 weeks, even if albuminuria is not detected. They may be given at 
 first such articles as junket, rice pudding, crackers, farina, corn- 
 starch or sago with cream, milk toast, cream toast, baked custard, 
 blancmange, wine and beef jelly, mush, baked apples, stewed 
 prunes, oranges. The resumption of animal fare should be very 
 gradual in all cases, and fish, oysters, chicken, or eggs should be 
 given before meat. 
 
 MEASLES 
 
 The diet in ordinary cases of measles does not require special 
 care beyond that described under the section on Diet in Fever in 
 General. The appetite is usually wanting in the prodromal and 
 eruptive stages, and milk with farinaceous gruels answers every 
 requirement. Thirst is prominent, and cool water or lemonade may 
 be offered, or orange juice or unfermented grape juice in Vichy. 
 Alcoholic stimulation is only needed if the patient is very feeble, or 
 if severe complications arise. The resumption of a solid diet must 
 be gradual, but it may begin as soon as the fever and catarrhal 
 symptoms disappear. 
 
 When nursing or hand-fed infants have measles they should be 
 30 
 
440 DIET IN DISEASE 
 
 fed somewhat oftener than usual, and must be given less food at 
 each feeding. A child of eight or ten months of age should be fed 
 on diluted milk like one two or three months younger. 'In this 
 manner any existing catarrh of the stomach is less likely to cause 
 serious indigestion and vomiting. It is particularly necessary to 
 give water, and half an ounce should be offered at least every two 
 hours, or oftener, while the infant is awake. 
 
 If there is much gastric irritation or catarrh, it may prove best 
 to suspend milk feeding for a day or two and substitute meat juice 
 or beef or mutton broth. 
 
 MUMPS 
 
 For mumps no special diet is required beyond the necessity of 
 giving fluids or soft food while the swelling of the parotid glands 
 and fever last. The suggestions for the dietetic treatment of ton- 
 sillitis apply to this disease. Anaemia is apt to be extreme during 
 convalescence, and meats should therefore be plentifully supplied. 
 Cod-liver oil is very appropriate in protracted convalescence. 
 
 WHOOPING COUGH 
 
 In whooping cough the paroxysms of coughing are so severe as 
 to give rise to vomiting, and in bad cases they are excited by taking 
 food which does not have an opportunity to become assimilated, 
 and nutrition may suffer very seriously in consequence, adding to 
 the general exhaustion which accompanies the disease. All food 
 must be made easily assimilable. It is best to give food regularly 
 in moderate quantity at each time, and it should be predigested 
 if necessary. Pancreatinised milk, koumiss, the prepared amyla- 
 ceous foods, cream toast, eggs, junket, chicken broth, malted farina- 
 ceous foods, custard, milk puddings, gruels thickened with meat 
 extracts, and stimulants in the form of Qgg albumin in sherry, egg- 
 nog, or milk punch, are recommended for patients who vomit solid 
 food. The worst cases require nutrient enemata, as exhaustion be- 
 comes critical. 
 
 INFLUENZA 
 
 Symptoms. — Influenza is an acute and moderately infectious 
 fever of microbic origin which is recognised by catarrhal inflam- 
 mation of the mucous membranes of the upper air passages, and by 
 symptoms referable to the nerve centres. In many cases the symp- 
 toms are mild and of short duration, and no special dietetic treat- 
 ment is required beyond that common to febricula, but a large 
 number of cases are accompanied by a variety of serious complica- 
 tions or they present sequelae. In the majority of instances the 
 mucous membranes of the air passages are the principal seat of the 
 
INFLUENZA 44 1 
 
 inflammation, but in others the gastro-intestinal mucous membranes 
 are similarly attacked, giving rise to pronounced digestive dis- 
 orders, nausea, vomiting, and diarrhoea. The fever, commonly of 
 moderate severity (103 to 103. 5 F.), persists for three or four days 
 or a week. There is usually great depression of spirits, with ex- 
 treme malaise, muscular pains, enfeebled circulation, and almost 
 total loss of appetite. As an adjunct to other treatment, absolute 
 rest in bed is imperative in all severe cases, not only for the pur- 
 pose of maintaining a uniform temperature and of protecting the 
 body from draughts, but to guard against syncope from debilitated 
 heart action. 
 
 Dietetic Treatment. — While the fever lasts, the stomach is usu- 
 ally irritable, and the diet must be fluid and restricted. Food should 
 be given in very small quantities, according to the rules applicable 
 in cases of extreme debility. 
 
 In severe cases it is necessary to prescribe an exclusive milk diet 
 for the first two or three days, and two and a half quarts should 
 be drunk if possible. Later the patient may be given nourishing 
 beef, mutton, or chicken broths, with beaten eggs added, milk toast, 
 custards, eggnog, and milk punch. As soon as solid food can be 
 eaten, scraped-beef sandwiches, oysters, tender breast of chicken, 
 eggs poached or scrambled, and light farinaceous articles with which 
 cream is taken, are appropriate. 
 
 As a stimulant, champagne is particularly serviceable in relieving 
 both the physical and mental depression which is so characteristic 
 of nearly all phases of this disease. 
 
 Convalescence is frequently prolonged, and debility, muscular 
 weakness, irritability of the heart, and enfeeblement of digestion are 
 often present to a degree which appears wholly disproportionate 
 to the intensity and duration of the febrile attack. The diet must 
 therefore still be carefully supervised, while every exertion of either 
 body or mind must be prohibited. The food should be of a highly 
 nutritious character and served in an appetising and palatable man- 
 ner, and as abundant as the condition of the stomach will allow. 
 (See Convalescence from Typhoid Fever, p. 434.) 
 
 Patients with whom milk usually agrees do well to take it in 
 quantities amounting to a quart a day, in addition to abundant solid 
 nitrogenous food, roast beef, beefsteak, chicken, eggs, etc. 
 
 Alkaline waters should be drunk. If the appetite flags and return 
 of strength is delayed, tonics and possibly change of air may be 
 required. 
 
 When convalescence is protracted it is advisable to continue 
 alcoholic stimulation, and milk punches, plain whisky and water, or 
 a glass of sound Burgundy may be given two or three times a day, 
 as a tonic, with the meals. Malt liquors may also be indicated in 
 some cases. 
 
44 2 DIET IN DISEASE 
 
 DIPHTHERIA 
 
 Symptoms. — Diphtheria is an acute, infectious disease charac- 
 terised by croupous inflammation of mucous membranes which 
 particularly affects the pharynx and upper air passages. Clinic- 
 ally the disease presents fever of an irregular type, with great 
 debility, and frequently albuminuria. Anaemia and rapid, loss of 
 flesh and strength are characteristic. The mortality is high, espe- 
 cially among children, whom the disease chiefly attacks, and death 
 may result from toxaemia, sudden heart failure, obstruction to the 
 entrance of air caused by accumulation of the diphtheritic mem- 
 brane, the extension of the inflammation down the air passages, or 
 exhaustion from inability to swallow food. Recovery is uniformly 
 slow, and may be still further retarded by paralysis or other sequelae. 
 Owing to the extent to which the throat is involved, with conse- 
 quent difficulty in swallowing, and to the general weakness and pros- 
 tration, there are few diseases in which greater care in regard to 
 dietetic treatment becomes imperative. There is anorexia, and the 
 sense of taste is lost; nausea is frequently present as well as con- 
 stipation. The cervical lymphatic glands are more or less swollen 
 and give rise to pain or soreness on opening the mouth. Albumin 
 may appear in the urine as early as the second day. 
 
 Dietetic Treatment. — " Alimentation occupies the first place in 
 the general treatment " (Trousseau). Throughout the active stage 
 of the disease while the fever lasts, there is difficulty in swallowing. 
 All food must be given in fluid form, of which milk is the best, or 
 if, as sometimes happens, semisolid material is more easily swal- 
 lowed, the food must be thickened with cream, gelatin, eggs, or 
 farinaceous articles ; or beef meal, Mellin's food, malted milk, etc., 
 may be added for this purpose to other foods. The diet should con- 
 sist chiefly of nutritious beef or chicken broth and beef tea, ^gg 
 albumin, eggnog, milk, and milk punch. Plain vanilla ice cream 
 is nutritious, and if not too sweet it is well borne, and is frequently 
 very grateful to the inflamed throat. Simple farinaceous foods, such 
 as arrowroot, thoroughly cooked rice, soft cream toast, and gruels, 
 may be taken. Continued disgust for food is a very bad prognostic 
 sign, and every effort must be made to counteract it by offering 
 variety. When the child is unable to swallow on account of pain 
 or accumulation of membrane in the throat, forced feeding with a 
 nasal or stomach tube may be better than nutrient enemata. 
 
 Intubation and Tracheotomy 
 
 When intubation of the larynx has been performed the child 
 sometimes experiences great trouble in swallowing without drawing 
 food into the trachea. It is difficult to close the epiglottis with the 
 
DIPHTHERIA 443 
 
 tube in position, or to draw up the larynx beneath the root of the 
 tongue to the extent which should occur in normal deglutition, and 
 hence fluid food particularly is liable to trickle through the tube into 
 the trachea, exciting violent dyspnoea and spasms of coughing. 
 Semisolid food or solid food, such as junket, mush, or eggs, is more 
 liable to glide over the instrument without being sucked in through 
 it during inspiration. Patients usually require considerable nourish- 
 ment to support their strength, so that the difficulties of feeding may 
 be serious. 
 
 Very young infants, who are dependent upon a milk diet, can 
 swallow best if laid upon the back across the nurse's lap with the 
 head downward supported below her knees. While in this position 
 the bottle is given. Regurgitation through the nose may occur, 
 but that is of little moment compared with the accident of inhaling 
 the milk through the tube into the lungs. 
 
 In older children, when proper precautions are taken in regard to 
 the position of the head in swallowing and the avoidance of inspira- 
 tion at the same time, these dangers may be reduced to a minimum, 
 or they may be overcome by the passage of an oesophageal tube, 
 though this irritates the throat and may spread the diphtheritic 
 membrane along the oesophagus. Intelligent children can learn to 
 swallow well with a little practice and care while wearing the intuba- 
 tion tube. Some even swallow easier than before its insertion by 
 reason of the relief of dyspnoea, which always makes deglutition 
 difficult. In other cases the tube may be temporarily removed, if 
 the dyspnoea is not extreme, while the child takes nourishment ; but 
 this requires skilled attendance, and, as the patient must be very 
 frequently fed, it possesses great disadvantages. As a rule, the 
 longer the tube remains in position, the better the patient acquires 
 facility in swallowing. In some cases it may be well to resort to 
 rectal alimentation for a day or two to obviate the necessity of swal- 
 lowing while the tube is worn. 
 
 The late Dr. O'Dwyer said : " Solids and semisolids, when there 
 is an appetite for such food, and when the patients can be induced 
 to take it, are swallowed much better than fluids, and do not enter 
 the tube, as far as I am aware " ; and he added that a bolus of food 
 tends to press the epiglottis down over the tube, while fluid tends 
 to raise it, or slip in under it, although he modified the head of the 
 tube by giving it a concave surface to fit the epiglottis. 
 
 It should not be forgotten with very young children that a failure 
 to take food may be due to loathing or nausea, and not to physical 
 inability to swallow with the tube in situ. O'Dwyer wrote : " I always 
 instruct children who are old enough to understand, to drink as 
 rapidly as they can, and then cough to expel any fluid which may 
 have entered the tube, instead of coughing after each deglutition, 
 as they usually do." He discountenanced the theory that food may 
 
444 DIET IN DISEASE 
 
 enter the tube and excite pneumonia by reaching the deeper por- 
 tions of the lungs, and said : " I do not believe — and there is no 
 evidence so far to prove — that any of the fluid entering the tube 
 ever reaches the bronchi, for it is promptly expelled by coughing." 
 He cited cases in support of this statement, one being that of a 
 woman who wore the laryngeal tube for over ten months continu- 
 ously, and enjoyed good health. He said that vomited food enters 
 the tube even less often than swallowed food. 
 
 TRACHEOTOMY 
 
 The operation of tracheotomy is performed for obstructions of 
 various kinds, such as accumulation of diphtheritic membrane in the 
 larynx, oedema of the glottis, laryngeal new growths, etc. The con- 
 ditions which require this procedure are usually among those which 
 interfere to a greater or less extent with swallowing, although the 
 presence of the tracheotomy tube in the trachea is well borne and 
 does not necessarily conflict with deglutition in any manner. No 
 special precautions in feeding are necessitated by the presence of 
 the tube, as in the case of intubation. 
 
 Post-Diphtheritic Paralysis 
 
 In post-diphtheritic paralysis the soft palate is oftenest affected, 
 but the muscles of the tongue and pharynx, or even the oesophagus, 
 may also be involved, in which case deglutition is hindered and the 
 patient must be fed through a catheter or stomach tube (see Gavage) 
 or by enemata. (See Food Enemata.) Meltzer has shown that in 
 man and the horse the mylo-hyoid muscles contract upon fluids so as 
 to squirt them down into the oesophagus at a rate exceeding that of 
 ordinary peristaltic motion, or several feet a second ; hence, in paral- 
 ysis affecting these muscles fluids can scarcely be swallowed. W. B. 
 Cannon and A. Moser, by means of the X ray, studied the swallow- 
 ing of capsules of bismuth, and found that " solids and semisolids are 
 slowly carried through the entire oesophagus by peristalsis alone." 
 
 The phenomenal success of antitoxin inoculations in reducing 
 the mortality of diphtheria to less than one third of its former degree 
 have made sequelae of this nature very infrequent. 
 
 CEREBRO-SPINAL MENINGITIS 
 
 Symptoms. — Cerebro-spinal meningitis is an infectious disease of 
 microbic origin, in which the chief lesions are an inflammation of 
 the meninges of the brain and spinal cord. This inflammation of the 
 membranous coverings of the nervous system results in the produc- 
 tion of a variety of symptoms, including fever, disturbances of the 
 nervous and muscular systems, nausea, vomiting, and constipation. 
 
ERYSIPELAS 445 
 
 The symptoms vary greatly in severity and duration, lasting from 
 a few days to several months. In mild cases convalescence is estab- 
 lished at the end of a week, but in severe and protracted cases the 
 nervous symptoms increase m severity. The stage of excitement 
 and irritation of the nerves with active delirium is succeeded by 
 profound prostration and coma, with progressive emaciation, a vari- 
 able temperature, and paralysis of the sphincters, with involuntary 
 evacuations. Such cases as a rule prove fatal, but they are not 
 necessarily hopeless, and recovery may occur at any time. Much, 
 therefore, depends upon the careful nourishment of the patient, and 
 every effort should be directed towards maintaining strength and 
 promoting nutrition. 
 
 Dietetic Treatment. — In mild cases a liquid diet of milk, broth, 
 meat, and egg albumin, with, perhaps, a little toast or crackers, may 
 be given while acute symptoms last. In protracted severe cases, and 
 especially where convulsions, delirium, and coma are present, the 
 patients must be fed with great care, and all nourishment must be 
 given in frequent small doses and in an easily assimilable form. 
 Huebner sometimes employs forced feeding with the stomach tube. 
 Pancreatinised meat broth, pancreatinised milk, albumoses, and beef 
 juice must be ordered, if necessary, every fifteen minutes. Brandy 
 or whisky is required when hyperaemia is succeeded by exhaustion. 
 If given too early, alcohol may increase the delirium. In extremely 
 feeble patients such fluids must be administered in teaspoonful doses, 
 or even in smaller quantities, with a medicine dropper, by which 
 they are passed between the closed teeth. It will be also advisable 
 to employ rectal alimentation. There is seldom any lesion of the 
 alimentary canal present, and consequently in those cases in 
 which larger quantities of fluid nourishment, or even solid food, 
 can be taken there is no objection. If the patient is able to eat 
 and swallow properly, milk toast, scraped beef, eggs, custard, 
 wine jelly, farina, Bavarian cream, blancmange, etc., are indicated. 
 Water may be given ad libitum to relieve the thirst, which is often 
 severe. 
 
 Convalescence will be promoted by giving abundance of food. 
 Five or six meals a day may be taken. The appetite is frequently 
 good from the commencement of convalescence. Beefsteak, chops, 
 roast beef, mutton, or chicken, bread and butter, oatmeal, por- 
 ridge, hominy, and rice with cream, may be allowed as soon as 
 the patient's digestion admits. A milk punch, or glass of claret 
 should be ordered three times a day. 
 
 ERYSIPELAS 
 
 Symptoms. — Erysipelas is an infectious disease caused by a spe- 
 cific micrococcus, and characterised by high fever and intense local 
 
446 DIET IN DISEASE 
 
 inflammation of the skin and contiguous mucous membrane. There 
 is usually more or less prostration and enfeeblement of the heart 
 and circulation. 
 
 Dietetic Treatment. — The indications for dietetic treatment are 
 to support the strength by stimulants and nutritious foods, which 
 must be adapted for easy digestion. When the temperature is high, 
 and nausea and vomiting exist, nourishment should be taken in 
 small quantities — an ounce or two at a time every hour. In ordi- 
 nary cases, pancreatinised milk, beef peptonoids or albumoses and 
 beef juice, eggnog, milk punch, and farinaceous gruels are recom- 
 mended. Alcohol is needed and it is well tolerated, for it seems to 
 be consumed in the system without intoxicating effects. From 
 eighteen to twenty ounces of brandy or whisky may be given within 
 twenty-four hours. In extreme cases an ounce an hour may be 
 taken, or if allowance is made for sleep the individual doses may 
 be increased. The liquor should be diluted with plain water, or with 
 Vichy or carbonic water, or soda water. Aged or debilitated per- 
 sons and young children especially need vigorous alcoholic stimula- 
 tion. After the local inflammation subsides the period of convales- 
 cence requires a very nutritious diet, and fluids may gradually be 
 replaced by beef, soft-cooked eggs, toast, bread and butter, and light 
 farinaceous foods with cream. 
 
 If the disease invades the pharynx, an exclusive milk diet is 
 necessary, and alcoholic stimulants as well as medicines, except those 
 designed for local treatment, should be given per rectum to avoid 
 increasing the local irritation. 
 
 Heuter favours the drinking of large quantities of hot tea to 
 induce perspiration, but it is doubtful whether this in any way affects 
 the cutaneous lesion. 
 
 CHOLERA 
 
 Dietetic Prophylaxis.— Cholera is a zymotic disease, the germs 
 of which can only enter the system by the mouth, and they are 
 spread chiefly through the agency of contaminated water used for 
 drinking or washing purposes. All raw foods and cooking utensils 
 washed in such water are liable to become infected. 
 
 No raw food or drink of any kind whatsoever should be taken. 
 In many cities it is customary for the local health boards to pro- 
 hibit the sale of raw fruits while a cholera epidemic is in progress. 
 It is a standard rule to cook all food and boil the drinking water. 
 
 Tea, coffee, chocolate, and cocoa should be made only with water 
 previously sterilised by boiling. Sterilised water only should be 
 used for cleansing the teeth. Water should not be cooled by direct 
 contact with ice, or the latter should be newly made from distilled 
 water. No beer, ale, soda water, or artificial mineral waters should 
 be used if there is any chance of contaminated river or well water 
 
CHOLERA 447 
 
 having entered into their manufacture. Milk may become infected 
 from washing the milk cans in impure water. 
 
 Acid beverages should be freely drunk, for the cholera germs 
 do not thrive in acid media, and if accidentally introduced into the 
 stomach they may perish there if the gastric contents always have 
 an acid reaction. Sour lemonade made with ten or fifteen drops 
 of dilute sulphuric acid has an excellent reputation as a prophylactic 
 against cholera. Vinegar, sour pickles, or lime juice may be taken 
 for the same purpose. 
 
 Indigestion, perhaps because it promotes alkaline fermentation 
 in the stomach, favours infection, and hence during the prevalence 
 of an epidemic it is desirable to eat only plainly cooked, wholesome 
 food, and to avoid all excesses in eating and drinking. All foods, 
 such as pastry, fried dishes, etc., having the reputation of easily 
 disagreeing should be eschewed. 
 
 During the prevalence of an epidemic of cholera it is highly 
 important to avoid eating anything likely to produce diarrhoea, and 
 all indigestible substances, such as meat, eggs, fish, or milk not 
 strictly fresh, unripe or overripe fruit and vegetables, must be abso- 
 lutely forbidden. 
 
 Symptoms. — The symptoms of cholera are usually divided into 
 four typical periods, which are those of— 
 
 i. The premonitory diarrhoea. 
 
 2. The period of profuse serous diarrhoea. 
 
 3. The algid stage, or that of collapse or asphyxia. 
 
 4. The reactionary stage. 
 
 The dietetic treatment varies with each of these stages of the 
 disease. It is imperative that the patient be kept absolutely quiet 
 in bed throughout all the active phase of the disease. 
 
 First Period. — There is alkaline watery diarrhoea with frequent 
 profuse stools, nausea and, usually, vomiting. The stomach is too 
 irritable to retain food, and undigested broths and milk only furnish 
 culture media for development of the cholera bacilli and production 
 of toxins. 
 
 During this period only light fluid food in very small quantity 
 should be eaten. Nothing can be worse than overeating. Whey, 
 gruels, bouillon, or pancreatinised milk only are permissible. 
 
 The contents of the stomach should still be kept acid, and sour 
 lemonade, lime juice, dilute acid phosphates, dilute vinegar, and 
 dilute hydrochloric acid, twenty or thirty drops in a half tumblerful 
 of water, or diluted aromatic sulphuric acid in similar dosage, are 
 to be swallowed from time to time. The acids should be given 
 through a glass tube to spare the teeth. 
 
 Hyperacidity of the stomach artificially produced favours the 
 passage of a portion of the acid stomach contents into the small 
 intestine, so that its normal alkalinity is, to some extent, neutralised. 
 
44§ DIET IN DISEASE 
 
 The duodenum indeed may temporarily acquire an acid reaction, 
 which is inimical to the development of cholera germs. 
 
 Second Period. — The stools become more frequent and serous. 
 They are almost continuous, and enormous quantities of fluid are 
 rapidly drained from the system, in which whitish flakes of desqua- 
 mated intestinal epithelium are suspended. Sometimes they contain 
 blood. As much as two quarts of fluid may be discharged in a single 
 evacuation. Nausea and epigastric distress occur with projectile 
 vomiting of fluid, which exceeds in quantity that which is drunk. 
 Intense abdominal cramps follow and extend down the legs. The 
 patient rapidly emaciates, and the feebleness and prostration are ex- 
 treme. There is a cold clammy perspiration, and in a few hours 
 the victim passes into collapse. Active efforts must be made to 
 stop the vomiting and diarrhoea. The abdomen must be incased in 
 flannel, and turpentine stupes are of service if the cramps are severe. 
 A mustard paste may be placed over the epigastrium, and a hypo- 
 dermic injection of morphine is required. Cracked ice, cold lime 
 water, iced champagne and carbonic-acid water, iced fresh lime juice 
 in Vichy, weak cold brandy and Seltzer, or plain soda — are all good 
 remedies which should be offered in very small doses every five or 
 ten minutes. Strong black coffee may be tried. The thirst may be 
 assuaged by dilute hydrochloric acid or lemon juice in water. A 
 little fluid held in the mouth for a few minutes sometimes affords 
 more relief of this symptom than larger quantities swallowed. It 
 is worse than useless to attempt to give even predigested milk while 
 the vomiting and diarrhoea continue. 
 
 Third Period. — In both the second stage and in the third stage 
 of collapse the best results are obtained by the method of hypoder- 
 moclysis — that is, of hypodermic injections into the thighs and sides 
 of the abdominal wall of large quantities of normal salt solution 
 made by dissolving 60 grains (a scant teaspoonful) of salt to the 
 pint of boiled water. The injections are given at the temperature 
 of the blood, and the entire quantity may be used in the course of 
 half an hour. The salt solution replaces to some extent the fluid 
 drained by the serous diarrhoea and emesis, restores the blood pres- 
 sure and equilibrium of the circulation, and almost immediately re- 
 lieves the thirst. 
 
 Fourth Period. — If vomiting ceases and the symptoms of col- 
 lapse abate, a little fluid nourishment must be very slowly and cau- 
 tiously tried. A teaspoonful or two of pancreatinised milk, koumiss, 
 Liebig's or Valentine's meat extract, or fresh beef juice is first given. 
 If this is retained, the dose is to be repeated and continued by in- 
 creasing the quantity and diminishing the frequency of administration 
 as the patient improves. The stomach remains feeble and irritable 
 for many days, and for a week or two it may be necessary to limit 
 the diet to predigested milk, beef albumoses, nutritious broths, egg 
 
YELLOW FEVER 449 
 
 albumin in diluted brandy, and champagne. The further dietetic 
 treatment may be conducted in the manner of that of the convales- 
 cence of typhoid fever (p. 434). 
 
 YELLOW FEVER 
 
 Symptoms. — Yellow fever is an acute, infectious disease charac- 
 terised by a sharp febrile paroxysm, gastric haemorrhage, jaundice 
 and suppression of urine. The nature of the symptoms is exceed- 
 ingly acute and intense. In those patients who die very soon after 
 the invasion of the disease no definite lesions are found. In other 
 cases hyperemia and visceral degenerations are noted. These im- 
 portant changes are found in the liver and gastro-intestinal mucous 
 membrane, and during the active progress of the infection digestion 
 becomes almost impossible. The liver presents the lesions of paren- 
 chymatous hepatitis. The hepatic cells here and there are rilled with 
 granular material and oil globules. Many of them are distended or 
 fused and have indistinct or absent nuclei. The small bile ducts are 
 filled with degenerated epithelium, and the functional activity of the 
 liver is therefore almost completely suspended. The whole alimen- 
 tary canal presents the picture of acute catarrh, but the stomach par- 
 ticularly is softened, swollen, and ecchymotic, and it may be eroded. 
 
 The disease presents three different stages, the dietetic treatment 
 of each of which is important, and it will therefore be necessary to 
 briefly describe them. These stages are : 
 
 1. The cold period, followed by febrile reaction. 
 
 2. Remission or " stage of calm." 
 
 3. Second exacerbation, a uraemic condition or else collapse. 
 The first stage begins with almost immediate vomiting and great 
 
 prostration. The ejecta consist first of mucus, then bile in increas- 
 ing amount, and finally, if the retching continues and muscular 
 straining is severe, the irritability of the stomach in this period be- 
 comes greater than in almost any other disease. The slightest pres- 
 sure over the epigastrium excites projectile vomiting. Constipation 
 is present from the inability to retain fluids ; the mouth becomes dry 
 and the gums sore and swollen, and thirst is extreme. The urine 
 is much diminished in volume as the changes in the liver progress, 
 and the bile ducts are blocked with degenerated epithelium ; the bile 
 enters the blood, and the skin and conjunctivae become decidedly 
 jaundiced. 
 
 After several days — usually four or five — these symptoms sub- 
 side and the second period is reached. The duration of this period 
 seldom exceeds two days, and it may continue but a few hours. It 
 is a condition of calm, in which all symptoms are abated ; the fever, 
 which may previously have existed, subsides and the gastric irrita- 
 tion is lessened. 
 
450 DIET IN DISEASE 
 
 The third period promptly succeeds the second, and in it the 
 symptoms of the first period return with renewed severity, and in 
 addition a condition of uraemia develops. Haemorrhage of the 
 stomach, known as " black vomit," is present in about one third of 
 the fatal cases. The vomited material ejected during the course of 
 the disease consists, first, of whatever food the stomach may con- 
 tain, then of bile-tinged mucus, and finally of a deep brown or 
 black acid semifluid substance resembling coffee grounds, which 
 consists of red blood-corpuscles, pigment granules, degenerated 
 mucus, epithelial ceils, leucocytes, fatty matter, and serous fluid. 
 The action of the gastric juice upon the extravasated blood pigment 
 turns it dark brown or black. The quantity of this fluid may reach 
 several pints. It is acrid and irritating to the fauces and mouth. 
 The blood from the passively congested surface oozes freely from 
 the capillary walls of the gastric mucous membrane. The intestinal 
 mucous membrane may be similarly affected, in which case the stools 
 are black and diarrhceal. The urine becomes very scanty, and may 
 be entirely suppressed. There is haematuria. 
 
 Should recovery result, the jaundice continues for some days, but 
 the other symptoms subside gradually and convalescence is always 
 slow and may be retarded by various complications, among the most 
 serious of which are an exceedingly irritable stomach and intestine. 
 Errors in diet have been known to cause fatal haemorrhage from 
 the stomach as long as a fortnight or three weeks after beginning 
 convalescence. The heart action after such a severe ordeal is always 
 feeble, and reparative and nutritive processes advance slowly. Irri- 
 tability of the stomach may even persist for several months after the 
 subsidence of all other symptoms. This brief account of the more 
 important features of the disease emphasises the necessity for most 
 careful dietetic management. 
 
 Treatment of the First Period. — The patient must be immediately 
 put to bed and kept absolutely free from excitement. Rest in a 
 recumbent position must be carefully enjoined, and the patient must 
 not be allowed to even raise the head to drink. Medicine and fluids 
 must be given through a tube or with a teaspoon. If the patient is 
 seen promptly, and there is a probability of undigested food being 
 present in the stomach, that organ should be unloaded by an emetic, 
 and as little medicine as possible should be ordered. If constipation 
 is present the bowels should be emptied by a purgative enema. It 
 is generally considered that profuse perspiration is an advantage. 
 This object can be accomplished by covering the patient with blank- 
 ets and giving a hot lemonade or hot toddy, such as hot whisky and 
 water. 
 
 As the vomiting becomes more and more severe, efforts may be 
 made to relieve it, but if all measures fail, it will be best to let the 
 stomach have absolute rest, which is secured by hypodermic injec- 
 
YELLOW FEVER 45 1 
 
 tions of morphine, mustard paste over the epigastrium, and the use 
 of the rectum for all medication. Among the various means at com- 
 mand for the relief of the vomiting are cracked ice, light acidulated 
 and effervescing draughts, such as acid lemonade, Vichy, Seltzer, 
 or carbonic water, strong coffee, plain lime water in frequent half- 
 ounce doses given cold, besides dilute hydrocyanic acid, cerium 
 oxalate, etc. Iced champagne, very dry Mumm or Pommery sec, 
 or acid lemonade with bitartrate of potassium, will sometimes be 
 retained. With the supervention of uraemic symptoms, or when 
 there is suppression of urine, there is urgent need of getting more 
 fluid into the body. The lumbar region should be cupped or poul- 
 ticed or covered with a mustard paste. If aerated waters are not 
 tolerated by the stomach, three or four pints of salt water should 
 be injected into the rectum every two hours, or it is suggested 
 that hypodermoclysis might prove of service after the manner 
 employed in cholera (p. 448). While the fever lasts, or through- 
 out the first period, it is usually best not to attempt to give 
 food at all, for the stomach is almost certain to reject or fail to 
 digest it. 
 
 Cochran dissents somewhat from the prevalent practice of allow- 
 ing no food during this stage, and believes that an attempt should 
 be made to supply a little nourishment per os, to fortify the system 
 against the future drain upon it which is certain to follow. He says : 
 " I have seen infants at the breast pass through attacks of yellow 
 fever to prompt recovery, throwing up black vomit frequently and 
 freely, and nursing as regularly and heartily as if there was nothing 
 the matter with them." 
 
 Many cases of yellow fever occur among previously healthy 
 people who can withstand the absence of food for a day or two 
 without serious loss, provided exhausting symptoms can be held in 
 check. In many instances, however, prostration and exhaustion 
 occur with extraordinary rapidity, and in an hour the patient may 
 be too feeble to articulate or move. Active stimulation by the 
 rectum and hypodermically is then necessary. For this purpose 
 whisky is best. It should be obtained pure and injected hypoder- 
 mically with a sterilised syringe in quantities of one to three 
 drachms. The injections may be made beneath the skin on the 
 outer surface of the thigh and arms in four or five places. Two 
 ounces of whisky diluted in an equal part of water may be injected 
 per rectum. 
 
 Treatment of the Second and Third Periods. — During the interval 
 of the second period abatement of the fever and of the gastric irri- 
 tation may admit of a little nourishment being taken by the stomach. 
 Some patients recover without passing into the third period, but 
 because many do not, extreme caution must be observed and food. 
 if taken at all, must be in very minute quantities. The same rules 
 
45 2 DIET IN DISEASE 
 
 in regard to diet and stimulants apply to the third period which have 
 been prescribed for the first, and the main reliance for nourishment 
 should be through rectal alimentation. When the paroxysm is over 
 and the symptoms have abated, the greatest care must still be exer- 
 cised in regard to diet even if the patient is hungry, as sometimes 
 happens. In the worst cases no solid food should be permitted for 
 at least ten days or a fortnight, and it must be remembered that fatal 
 relapses have been precipitated by not observing this rule. When 
 the vomiting and epigastric pain have ceased, half-teaspoonful or 
 teaspoonful doses may be given once in fifteen minutes of pancre- 
 atinised milk, koumiss, Liebig's or Valentine's meat extract, iced 
 dry champagne, or good Rhine wine. If such foods are retained, 
 they may be followed after some hours by a few spoonfuls of pressed 
 beef juice, salted, and later still by warm, nourishing beef broths, 
 chicken broths, gruels, or buttermilk. Stimulating or nutrient ene- 
 mata should still be ordered, because in the early stages of convales- 
 cence the stomach will not tolerate all the food which the impover- 
 ished tissues require. Any epigastric fulness or distress, or tym- 
 panites, should be regarded as a warning, and food should be again 
 withheld until the difficulty is corrected by antacids or antifermen- 
 tatives. 
 
 It is to be noted that children usually require rectal feeding and 
 stimulation even earlier than adults. Large doses of opium given 
 to aid the retention of nutrient or stimulating enemata should be 
 avoided on account of the tendency to suppression of urine. In 
 mild cases, after four or five days, and in severe cases after a fort- 
 night, solid food may be occasionally given, commencing with milk- 
 toast, crackers, junket and cream custard, farina and boiled or broiled 
 chicken, soft-cooked eggs, wine jelly, boiled rice, scraped beef, and 
 similar nourishment. 
 
 Fruits and vegetables should not be allowed for several weeks. 
 
 SEPTICEMIA 
 
 In all septic conditions the diet must be made as nutritious as 
 possible, and alcoholic stimulation may be required, brandy or 
 whisky being the best forms. As a rule, the diet must be fluid, but 
 in very chronic cases and those accompanied by prolonged local 
 suppuration easily digestible solid food — such as broiled fish or 
 beefsteak or chicken, oysters, toast, light bread and butter, and 
 light farinaceous articles with cream — may be allowed. The di- 
 rections given in the article upon the Diet of Fever in General 
 (p. 417) and convalescence are applicable here, and if the patient 
 improves, the stimulating diet recommended for some cases of 
 tuberculosis (see Dietetic Treatment of Tuberculosis, p. 457) is 
 recommended. 
 
TETANUS 453 
 
 MALARIA 
 
 Intermittent Fevers. — The dietetic management of malarial fevers 
 consists of the treatment during the paroxysms and of that between 
 them. In intermittent fever the paroxysms, although severe, are 
 comparatively brief. Vomiting often accompanies the chill. If the 
 patient is disinclined to take food there is nothing to be gained by 
 urging it upon him, and the stomach may be allowed to rest for 
 a day. Otherwise a glass of milk or a cup of broth may be given. 
 When the paroxysm is over, if the appetite returns, solid food may 
 be given without much restriction. If a patient has had several 
 attacks at brief intervals he is usually both anaemic and constipated, 
 and the subsequent diet should contain a liberal proportion of ani- 
 mal food to counteract the former condition, and of fresh fruits and 
 green vegetables for the latter. Beyond these general directions 
 but little is usually necessary. 
 
 Remittent Fevers. — In the continued malarial fevers, indigestion 
 or feeble digestion may be a prominent symptom, requiring a milk 
 diet while the fever is at its height. The reader is referred to the 
 article upon the Diet of Fever in General (p. 417), which will cover 
 the ground for these cases. 
 
 Patients with malarial fever are inclined to resort too freely to 
 the whisky bottle, and overstimulation in the continued fevers is a 
 common fault. Only the severer forms of Southern and tropical 
 agues, bilious remittent fever, etc., require much alcohol. The die- 
 tetic treatment of the latter corresponds with the directions given 
 for that of yellow fever (p. 450). 
 
 TETANUS 
 
 Symptoms. — Tetanus is an acute infection produced by a bacillus 
 which enters the body through an abraded surface, develops toxins 
 in the system, and causes greatly exaggerated irritability of the 
 central nervous system. With the heightened reflexes, tetanic con- 
 traction of the voluntary muscles occurs, especially of those of the 
 jaw, face, and the extensors of the back. The ordinary reflex action 
 from peripheral excitation is so far intensified that the slightest 
 pressure on the surface of the body, or change in surrounding tem- 
 perature, or even a loud sound, may throw the patient into violent 
 convulsions and painful tonic spasms. Efforts in swallowing may 
 induce them. The muscles of the jaw are often set in a condition 
 of rigid contraction, making it impossible for the patient to open 
 the mouth to take food, and forcible efforts to separate the teeth 
 excite convulsions. It is necessary to support the strength by every 
 available means, for tetanus is not invariably a fatal disease, al- 
 
454 DIET IN DISEASE 
 
 though, according to Gowers, death results in about 90 per cent of 
 all cases. 
 
 Dietetic Treatment. — Food can only be given in liquid form, but 
 if a front or side tooth is absent a soft-rubber catheter may be passed 
 in between the set teeth and fluid can be conveniently poured into 
 the mouth through it. Milk, egg albumin, eggnog, nutritious beef, 
 mutton, or chicken broths, malted gruels, wine, brandy, and whisky 
 should be given as frequently as the condition of the patient will 
 admit. If possible, from two to four ounces should be administered 
 every hour. The spasm does not affect the involuntary muscles, so 
 that food is swallowed if it can be placed far back in the pharynx. 
 Alcoholic stimulation and nourishment can also be given by the 
 rectum, but this method is as apt to excite convulsions as mouth 
 feeding. If severe convulsions are induced by every attempt to feed 
 the patient, it becomes necessary to put him under primary anaes- 
 thesia by the inhalation of chloroform, and then a tube may be 
 passed into the stomach, through which twelve or sixteen ounces 
 of soup or predigested milk, eggnog, and stimulants may be poured. 
 By this means he is disturbed much less often and larger quantities 
 of nourishment are taken at one time. In a recent case of tetanus 
 which came under my observation, and in which tetanus bacilli were 
 found, the muscular spasms were intense and almost continuous for 
 over five weeks. The difficulty in feeding the patient was extreme, 
 and emaciation was very pronounced. He complained incessantly 
 of thirst, and often of hunger, but he was able to swallow milk broths 
 and stimulants given between the closed teeth in very frequent doses, 
 and his final recovery was attributable mainly to persistent efforts 
 at careful feeding, chloroform anaesthesia having been several times 
 successfully employed to relax spasm. 
 
 RABIES 
 
 In feeding a patient with rabies, substantially the same plan is 
 to be followed as that above described for tetanus. In some cases, 
 however, even in the early stages, all efforts to swallow fluid food 
 excite violent general convulsions. Osier suggests that this spasm 
 may be lessened by application of cocaine to the throat, so that the 
 patient can swallow. Failing this, nutrient enemata must be relied 
 upon, but they also sometimes excite convulsions. In this case it is 
 justifiable to produce primary anaesthesia with chloroform, and to 
 seize the moment of temporary relaxation for feeding. 
 
 TUBERCULOSIS 
 
 Causation. — Tuberculosis is an infectious disease, due to the 
 presence in some part of the body of the Bacillus tuberculosis. The 
 
TUBERCULOSIS 455 
 
 disease may be either acute or chronic, but fever is present when- 
 ever there is an exacerbation of the symptoms. The latter are both 
 local and general, and vary with the particular organ or organs 
 affected, but the lungs constitute by far the most frequent site for 
 the development of the germs. The bacillus produces from the tis- 
 sue or " soil " in which it grows a toxin or poisonous substance 
 which enters the circulation by absorption and which modifies nutri- 
 tion, causing pyrexia and an increased production of tissue waste, 
 with more or less rapid emaciation. 
 
 Several factors combine to disturb the digestive system. These 
 are : 
 
 1. The fever itself. 
 
 2. The impoverished condition of the blood, which affects the 
 quality and quantity of the digestive juices. 
 
 3. In pulmonary tuberculosis, after the expectoration becomes 
 considerable it is often ropy and tenacious, and some of it is liable 
 to adhere to the surface of the mouth or pharynx, and be swallowed 
 with the food or saliva, with the result of exciting gastric and intes- 
 tinal catarrhs, or possibly of locally infecting the mucous mem- 
 brane of the intestine with the bacilli, which produce ulceration 
 with further impairment of digestive functions and absorption. 
 
 The prognosis of a given case depends very largely upon the 
 digestion. 
 
 General Consideration of Dietetic Treatment. — Proper dieting is 
 unquestionably one of the most important factors in the prophy- 
 lactic as well as the active treatment of pulmonary tuberculosis, and 
 in prescribing a regimen many things must be taken into considera- 
 tion besides the mere classification and selection of food. The dis- 
 ease may be exceedingly protracted, lasting for years, with intervals 
 in which the patient enjoys a comparative degree of health and 
 comfort, which temporarily emancipate him from dietetic restric- 
 tions. But even then he should see to it that his food is ample for 
 his bodily needs. Malnutrition at any time may permit the renewed 
 activity of a latent tubercular process, and, on the other hand, an 
 increase in body weight is accompanied by marked improvement in 
 the symptoms of the disease. 
 
 The disease being very chronic the pecuniary circumstances of 
 the patient must be considered. By ordering him to abandon his 
 only means of livelihood or to undertake a long and expensive 
 journey he may be so impoverished that he cannot afford to procure 
 the best food, which is so essential both to repair the tissue waste, 
 which sooner or later is a prominent feature of the disease, and to 
 supply energy ; and good climate is of little use unless it helps him 
 to acquire a better appetite and easier digestion. 
 
 The appetite, too, must be consulted. It is sometimes better to 
 humour whims than to seek to combat them, and inflexible rules 
 31 
 
456 DIET IN DISEASE 
 
 can no more be enforced for dieting- than for medication. The ap- 
 petite is often very poor or capricious, and the physician's dietetic 
 expedients will be severely taxed to devise suitable foods which 
 meet all requirements. The patient should be given a list of foods 
 which he can regularly eat, foods to be avoided, and foods which he 
 may have as an occasional indulgence. 
 
 Young phthisical girls especially may long for sweets and 
 confectionery, and despise the more wholesome animal food ; in 
 fact, some writers regard this as a symptom of the disease in such 
 cases. If they cannot have what they crave they will refuse what 
 they are allowed, and much tact and persuasion is required to in- 
 duce them to eat rationally. 
 
 Since so much depends upon sustaining the nutrition and 
 strength of tuberculous patients, it is of the utmost importance to 
 keep the stomach and bowels in the best possible condition. 
 
 Patients should be warned never to swallow 7 the sputum, for 
 this always excites dyspepsia, and sooner or later gastric catarrh. 
 The occurrence of the latter is also favoured by the habit, which 
 many patients acquire, of perpetually taking cough medicines and 
 patent " sure cures," many of which contain potassium iodide and 
 other gastric irritants. In advanced cases the catarrh may be a 
 sequel to enfeebled circulation. 
 
 All food should be fresh and carefully selected, and the cooking 
 should be as simple as possible without monotony. Viands should 
 be savoury, and served in a manner to tempt the palate. 
 
 The most important articles of diet for the consumptive are the 
 animal foods, and milk, beef, and fats and oils should form the 
 essentials, rather than too much meat; but in ordinary cases any 
 variety of properly cooked animal food may be eaten. Starches 
 and sugars are allowable in milder cases, but never to the ex- 
 clusion of nitrogenous aliments, and not at all if gastric catarrh 
 exists. 
 
 In phthisis there often seems to be a failure to assimilate amy- 
 laceous and saccharine food, which is beyond that which is ex- 
 plainable by the presence of catarrhal conditions. These substances, 
 which ordinarily furnish a large proportion of the energy of the 
 body, in tuberculosis appear to do so less readily than the fats and 
 proteids. Growing children, however, require more carbohydrates 
 than do adults. Malt is especially valuable as a tonic in tuberculo- 
 sis, and the diastase aids assimilation of farinaceous foods. 
 
 Great diversity exists among different phthisical patients in the 
 power of assimilation of food, and even in individual cases during 
 the progress of the disease. 
 
 Bauer says : " One not infrequently sees phthisical patients who 
 consume the full hospital diet without any visible ill effects, al- 
 though their evening temperature oscillates between 102 and 
 
TUBERCULOSIS 457 
 
 104 F. With such patients one need feel no anxiety as to the choice 
 of foods, provided their nutritive value be the same." 
 
 Rest is important in its relations to digestion, and patients 
 should not eat when fatigued. Great benefit is often derived by 
 lying down and quietly resting, even without sleeping, for half or 
 three quarters of an hour before dinner and supper. It is best to 
 take the principal meal in the middle of the day unless there is 
 fever at that time or soon after it, in which case a hearty breakfast 
 and a light lunch will be better borne. 
 
 If much hectic fever is present, it is desirable to employ the 
 intervals when the temperature is low for feeding, and it often hap- 
 pens that a hearty meal taken between 7 and 10 a. m. may be better 
 digested than at any other time of day. 
 
 Patients should avoid eating more food at any one time than 
 they can comfortably digest, and it is often best to give food five 
 or six times in twenty-four hours, to avoid overworking the 
 stomach. If the digestion is feeble, it is best to give only one 
 article of food at a time, or else only such varieties of food as 
 require the same length of time for digestion (p. 346), and 
 patients often do better when they eat all their animal food at one 
 meal and vegetable food at another, having regard to the separate 
 action performed by the stomach and intestines upon these dif- 
 ferent food classes. If there is stomach catarrh, or if the gastric 
 juice is feeble, the quantity of fluid taken with meals should be 
 restricted to a minimum, excepting in very advanced cases, in which 
 the diet may be necessarily entirely fluid. But half a pint of very hot 
 water may be taken with advantage half an hour before each meal, 
 to cleanse and stimulate slightly the gastric mucous membrane. 
 
 A. L. Loomis wrote : " When the pressure of food in the stomach 
 excites cough, or when paroxysms of coughing have induced vomit- 
 ing, the ingestion of food must be delayed until the cough ceases, 
 or an appropriate sedative may be employed. In those extreme 
 cases where every attempt at eating excites nausea, vomiting, and 
 spasmodic coughs, excellent results are attained by artificial feed- 
 ing through the soft-rubber stomach tube." 
 
 Meats. — Raw beef is extolled by many physicians, especially 
 among the French, as possessing peculiar nutritive and even cura- 
 tive value for tuberculosis, and in the popular mind its blood-red 
 colour and scarlet juice seem to suggest an intimate connection 
 with blood formation. It is true that blood and muscle have great 
 similarity of composition. The red wines are erroneously regarded 
 by laymen in the same light. It has yet to be demonstrated that raw 
 meat possesses any advantage over rare steak or underdone roast 
 beef beyond the fact that the scraping and mincing process to which 
 it is usually subjected prepares it somewhat better for solution by 
 the gastric juice. 
 
458 DIET IN DISEASE 
 
 Patients will often take scraped raw-meat balls contentedly for 
 several days, and then acquire a distaste for them. This may be 
 overcome by seasoning with a little aromatic herb, such as thyme, 
 parsley, or marjoram. Yeo suggests that when made into small 
 balls the meat may be covered with powdered sugar or gum, and 
 swallowed with a sip of wine or brandy, or the mouth may be rinsed 
 with claret to remove the after-taste. 
 
 Both scraped beef and the various preparations of beef powder, 
 beef meal, etc., are useful to re-enforce broths, hot milk, milk 
 punch, or light soups of vermicelli, tapioca, etc. According to Pro- 
 fessor Chittenden, the nutritive value of lean beef being placed at 
 ioo, that of beef peptonoids is 140 and that of Mosquera's beef meal 
 is 400. If preferred, from one to five ounces of beef meal may be 
 eaten daily, spread like jam upon bread and butter. Insomnia may 
 be often prevented by taking on retiring a cup of hot bouillon, clam 
 broth, or gruel, with a cracker or two. 
 
 Beef juice, extracted by a small meat press, may be ordered two 
 or three times a day. It may be seasoned and drunk like bouillon, 
 or eaten as a luncheon upon dry toast, crackers, or boiled rice. 
 
 H. P. Loomis gives the following useful details in regard to 
 the preparation of this important food : " To obtain from the meat 
 the maximum amount of juice, a meat squeezer is absolutely essen- 
 tial. There are a number of good ones in the market, which range 
 in price from one to three dollars. The best kind of meat from 
 which to squeeze the juice is a thick round steak free from fat. 
 This should be seasoned with pepper and salt, broiled over a brisk 
 fire, cut in pieces two inches square, and then put into the meat 
 squeezer. About eight ounces of juice can be obtained from each 
 pound of meat. No further direct heat should be applied to the 
 juice, as the albumin would be at once coagulated and the juice 
 rendered worse than useless. If the juice becomes cold and it is 
 advisable to heat it, this can be best accomplished by placing 
 the cup in hot water. Freshly squeezed beef juice is the best 
 of the artificial preparations of meat known, and the trouble of 
 preparing it is well repaid by the marked improvement in the 
 patient." 
 
 It is often desirable to give dilute hydrochloric acid and a little 
 pepsin after the ingestion of meat or other animal food unless it 
 has been predigested. 
 
 Eggs. — Eggs are not well borne if there is dyspepsia or decided 
 gastric catarrh. Otherwise they are nutritious and wholesome. 
 They may be given raw, beaten, or very lightly cooked in hot water, 
 but never hard boiled. They may also be eaten scrambled or as an 
 omelet if lightly made. Egg albumin may be well digested when 
 the yolk proves too rich. " A raw egg sucked from the shell will) 
 often relieve an irritable condition of the larynx " (H. P. Loomis). 
 
TUBERCULOSIS 459 
 
 Cereals. — Cereals may be used in the early stage of the disease, 
 before the alimentary canal is much disturbed, and such foods as 
 corn mush, farina, oatmeal, wheaten grits, or germea may be al- 
 lowed with cream. If cream and sugar disagree, they may be eaten 
 with lemon juice. 
 
 Fruits. — The succulent fruits are well borne in mild cases, and 
 are very wholesome and nutritious. Baked and stewed apples may 
 be given with cream. 
 
 Fats and Oils. — Fats and oils are indicated in tubercular disease, 
 and especially in pulmonary phthisis, in as large amounts as the 
 patient may be able to digest. Crisp fat bacon, butter, cream, 
 whole milk, egg yolk, cod-liver oil, and olive oil all furnish desira- 
 ble forms of fat when the intestine absorbs them. Russell's emul- 
 sion of mixed fats is a very digestible preparation by which to 
 administer this class of food. 
 
 While fat is being taken it is well to occasionally observe the 
 stools to see that none passes away undigested, and if any one fat 
 disagrees and causes dyspepsia its use must be restricted, or tem- 
 porarily withheld while another is tried. As a rule, cream butter 
 and cod-liver oil will prove the best. If a patient can take one 
 quarter pound of butter a day it furnishes about one half of the 
 necessary heat units. Fats, well digested, seem in some instances 
 to have an almost curative power, so greatly do nutrition and body 
 weight improve during their use. 
 
 Cod-liver Oil. — The use of cod-liver oil in phthisis should be 
 determined by the condition of the digestive organs and the general 
 nutrition of the patient. Wherever the digestion is fairly good, in 
 the absence of gastric catarrh, the oil is of great nutritive value, and 
 it is usually well borne when properly administered. If there is 
 much gastric catarrh, or if the stomach is irritable and nausea is 
 easily excited, persistence in the use of the oil will only make mat- 
 ters worse. It should be at least temporarily discontinued, though 
 in the chronic forms of tuberculosis unaccompanied by fever, in 
 which debility and emaciation predominate, cod-liver oil is often 
 well tolerated. It is on the whole more satisfactory for children than 
 adults, particularly in cases of tuberculosis in which the bones or 
 glands are enlarged. 
 
 The presence of diarrhoea is to be regarded as a contraindication 
 for the administration of cod-liver oil, but unless it is given in large 
 quantities it has very little if any laxative effect upon adults, and it 
 may usually be continued in doses of a drachm two or three times 
 a day, with no ill effect, and, in fact, by improving the nutri- 
 tion it may sometimes benefit diarrhoea. Ringer suggests that 
 for this class of patients a teaspoonful or more of the oil given 
 at night before sleep may be better borne than at any other time 
 in the day. 
 
460 DIET IN DISEASE 
 
 Commonly it is best to give the oil pure and uncombined if it 
 can be tolerated. It may be given in capsules, although they are 
 not always dissolved at the proper time in the stomach. Patients 
 who require alcohol may take the oil in whisky. For the many dif- 
 ferent methods of administering it and of disguising its taste the 
 reader is referred to the section on Cod-liver Oil (p. 201). The 
 isolated active principle of the oil, called gaduin, has been employed 
 with some degree of success (p. 200). 
 
 Alcohol. — Alcohol is not believed to possess any specific action 
 in phthisis, and in many cases it is positively harmful. As a rule, if 
 patients have a fair appetite and are improving in strength its use 
 is contraindicated. When alcohol is required as a food and tonic 
 rather than as a stimulant, the best form in which to give it is that 
 of malt liquor or light wine. One or two pints daily may be pre- 
 scribed of beer, stout, or porter, or half a pint of claret or sound 
 Burgundy is useful if anaemia is marked. The light Hungarian, 
 Italian, or Greek wines may be used by those whose purse places 
 them within reach. One of the Tokay wines, with cocoa, may be 
 prescribed. Sweet wines, sherry, port, Madeira, and champagne 
 are not as useful. They are liable to disagree and cause dyspepsia 
 and headache. 
 
 The promiscuous habit of daily drinking rum, whisky, or other 
 strong liquors in tuberculosis is to be condemned. 
 
 No class of patients exhibits more painfully and rapidly the in- 
 roads of the disease than those who for a long time have been hard- 
 ening their own tissues, like pathological specimens, with daily 
 draughts of strong alcohol. The cirrhotic changes which occur in 
 various organs are the best possible preparation for the advance- 
 ment of tubercular processes. If the exhibition of alcohol increases 
 the temperature and the pulse rate, and is followed immediately by 
 greater weakness, it is doing harm. Advanced cases of tubercu- 
 losis show great toleration for alcohol, but it does not follow that 
 it is proportionately benefiting them. When in the course of an 
 ordinary case the hectic fever becomes high and exhausting, the 
 pulse feeble and rapid, and the digestion fails, it may be best to 
 lessen the quantity of food and give more stimulation. Usually 
 three or four, but seldom more than six, ounces of whisky, brandy, 
 or rum may be required daily for this purpose. Special pains should 
 be taken to use only such liquors as are strictly pure and of the best 
 quality. 
 
 Diet in Mild Cases 
 
 The following liberal menu will furnish abundant variety from 
 which to select the dietary for tubercular patients in whom the 
 progress of active lesions is in abeyance or completely arrested, 
 and in whom there is little or no gastric catarrh. Patients should 
 
TUBERCULOSIS 46 1 
 
 eat all they can digest, especially of milk, eggs, and butter, and 
 should allow five hours' interval between meals. 
 
 FOODS ALLOWED IN NON-ACTIVE CASES WITHOUT GASTRIC 
 
 CATARRH 
 
 Soups and broths : Mutton, oyster, clam, barley, vermicelli, bou- 
 illon, chicken with rice. 
 
 Purees of peas, beans, tomatoes, celery. It is often well to add 
 to them meat extracts, peptonoids, beef meal, etc. 
 
 Milk or cream in any form, including buttermilk and koumiss, 
 clotted or Devonshire cream, whipped cream, etc. 
 
 Shellfish : Oysters or clams, either raw, roasted, or broiled (the 
 livers or " soft parts " only). 
 
 Fish of any kind if fresh, either boiled or broiled (never fried), 
 sardines (if they " agree ") for the sake of the oil. 
 
 Eggs, preferably raw or very lightly cooked, or in eggnog or cus- 
 tard, also poached, scrambled, or in plain omelet (never hard-boiled). 
 
 Meats : Beefsteak, rare roast beef, scraped-beef sandwiches or 
 meat balls, lamb or mutton, roasted or boiled; chops; chicken, 
 capon, turkey, either roasted, boiled, or broiled. 
 
 Game : Partridge, squab, woodcock, snipe, prairie chicken, quail, 
 roasted or broiled. 
 
 Meats, especially beef and mutton, should predominate. Gelatin 
 may be used, but it is not very nutritious. It should be combined 
 with meal or meat preparations. 
 
 Entrees: Sweetbreads. 
 
 Fats and oils (as much as can be digested) : Good fresh butter, 
 olive oil on lettuce or raw tomatoes, cod-liver oil, the fat of beef or 
 mutton (if it " agrees "), cream (on everything with which it can 
 be appropriately eaten), a little fat bacon. Pancreatin or pancreatic 
 emulsions will aid the digestibility of fats. 
 
 Vegetables : Baked potatoes, tomatoes stewed or raw, very 
 young green peas, string beans, spinach, celery (stewed), onions, 
 boiled asparagus, lettuce, cauliflower. 
 
 All vegetables to be eaten in moderation. 
 
 Cereals : Whole-meal bread, wheaten or rye, only if stale or 
 toasted, zwieback, rusk, milk-toast, cream-toast, crackers, malted 
 bread and biscuit, rice in any form, mush, hominy, farina, cracked 
 wheat, wheaten grits, oatmeal, macaroni, spaghetti. 
 
 Some authors recommend lentil flour, on the ground that it 
 contains both iron and phosphorus. Oatmeal contains considerable 
 fatty matter, and maize has still more. All cereals are to be eaten 
 sparingly. 
 
 Fruits : Apples, baked or stewed, oranges, shaddock, grapes, 
 pears, peaches, plums, strawberries, blackberries, olives. 
 
462 DIET IN DISEASE 
 
 Desserts: Wine jelly, custard, blancmange, rice pudding, bread 
 pudding, junket and cream, Bavarian cream. 
 
 Avoid fried foods, rich sauces, pastry, cakes, hot breads, ra- 
 gouts, beans, carrots, turnips, cabbage, confectionery, puddings, 
 dried foods, salt fish or meats (except as specified above). 
 
 Beverages Allowed. — Water, tea, coffee, cocoa, milk, koumiss, 
 zoolak, buttermilk, milk punch, lemonade or orangeade, Vichy or 
 other aerated water, non-fermented grape juice, malt extracts. 
 
 Alcohol : Beer, ale, porter, wines, liquors, are permissible only 
 if needful for special symptoms — that is, if desirable for food or to 
 aid digestion and promote exercise. 
 
 H. P. Loomis gives the following useful sample diet, with the 
 appropriate intervals for taking food. A glass or two of milk may 
 be added at night with advantage : 
 
 " On Awakening. — Eight ounces of equal parts of hot milk and 
 Seltzer, taken slowly through half an hour. 
 
 " Breakfast. — Oatmeal or cracked wheat, with a little sugar and 
 an abundance of cream, rare steak, or loin chops with fat; soft- 
 boiled or poached egg, cream-toast, half pint of milk, small cup of 
 coffee. 
 
 " Lunch, 10 a. m. — Half pint of milk or small teacup of squeezed 
 beef juice, with stale bread. 12, noon : Rest or sleep. 
 
 " Midday Meal, 12.30. — Fish, broiled or stewed chicken, scraped- 
 meat ball, stale bread, and plenty of butter, baked apples and cream, 
 two glasses of milk. 
 
 " Lunch, 4 p. m. — A bottle of koumiss, raw scraped-beef sand- 
 wich, or goblet of milk. 5.30 p. m. : Rest or sleep. 
 
 " Dinner, 6 p. m. — Substantial meat or fish soup, rare roast beef 
 or mutton, game, a slice of stale bread, spinach, cauliflower, or other 
 fresh vegetables in season (sparingly)." 
 
 At 9 p. m. half an ounce of cod-liver oil should be taken, or an 
 ounce of peptonised cod-liver oil and milk. At 2 a. m., or there- 
 about, if the patient awakens, a glass of milk, zoolak, or diluted 
 cream should be drunk, or a scraped-beef sandwich may be eaten. 
 
 Diet in Advanced Cases 
 
 It not rarely happens that patients who have suffered much 
 from indigestion in the earlier stages of phthisis finally reach a 
 condition in which, although greatly emaciated and prostrated, they 
 seem able to eat and digest a much larger variety and quantity of 
 food than before. As these cases are utterly hopeless, it is often best 
 to let such patients select their own diet, providing only that it is 
 nutritious and of a quality which does not excite cough or diarrhoea. 
 
 If the bowels are not too loose, fresh fruit, especially oranges, 
 may be allowed, and proves very refreshing. 
 
TUBERCULOSIS 463 
 
 In very advanced cases, and in all cases during acute exacerba- 
 tions of severity, with marked prostration, the patient must have 
 food every two or three hours, and the intervals of feeding should 
 never be longer than the latter. A diet consisting very largely of 
 milk or milk and cream is best, but broths and pancreatinised meat 
 preparations, albumoses, and tgg albumin may be added. 
 
 Milk Diet. — Milk is a food which is especially adapted for con- 
 sumptives, many of whom do best when living upon it almost ex- 
 clusively, while others should drink it freely in connection with 
 other nourishment. It is fattening, is assimilated without over- 
 taxing the digestive organs, and taken hot, either alone or with an 
 equal part of Vichy, it is soothing to the throat and ameliorates 
 the cough. 
 
 Advanced cases of tuberculosis living upon full milk diet should 
 take between two and a half and four quarts a day, but not over 
 eight ounces at once. It should be sipped, or really eaten, and not 
 drunk, for it then will coagulate by slow degrees in the stomach 
 and not form large indigestible curds. This should be insisted 
 upon and ten minutes should be occupied in drinking half a pint. 
 If the milk disagrees at first it may be modified in any one of the 
 ways suggested on p. 74, but it is best not to give it in connection 
 with beef juice. 
 
 In this country cow's milk is preferred, but elsewhere the milk 
 of other animals serves equally well. Goat's milk, drunk largely in 
 Switzerland, contains more salts of lime and is good for cases of 
 tubercular diarrhoea, and sometimes ass's or mare's milk proves 
 more digestible. The latter varieties are principally used in Russia. 
 
 Lebert's Milk Cure (from Bauer). — " Lebert directs the patient 
 to drink slowly three hundred to five hundred grammes of milk 
 every morning and evening between five and six o'clock, fasting. 
 He prefers it freshly drawn from the cow, and if, in consequence of 
 having stood for some time, a separation of the cream has already 
 begun, recommends it to be skimmed off. 
 
 " During the continuance of the milk treatment the patient is 
 allowed a substantial dinner, at least of soup, roast meat, young 
 vegetables, stewed fruit, etc., and a little beer or wine. At the dis- 
 cretion of the physician a proper breakfast may be taken an hour 
 after the morning's milk of a cup of tea with plenty of milk and 
 biscuits and, perhaps, one or two light-boiled eggs, and again in 
 the evening a good soup, as well as, when possible (i. e,, in the 
 case of non-febrile patients), some more roast meat. If milk is 
 well borne, the regular breakfast and supper may be supplemented 
 by further doses of one hundred to two hundred grammes of 
 milk." 
 
 Whey or koumiss may be drunk instead of milk. For those 
 who can digest it, cream is an excellent food. With some patients 
 
464 DIET IN DISEASE 
 
 cream diluted with an equal bulk of hot water agrees even better 
 than milk. The taste, if complained of, may be modified by a very 
 little tea or coffee, or salt or sugar. Yeo sometimes adds a tea- 
 spoonful of rum or brandy or aromatic spirits of ammonia. Some 
 patients can take a quart of cream besides a quart and a half of milk 
 per diem with profit. 
 
 SURALIMENTATION 
 
 Suralimentation, called also " superalimentation," or " forced 
 feeding," is based upon the theory that the best method to com- 
 bat the symptoms of phthisis is by " stuffing " the patient with all 
 the food which he can possibly digest. More food is needed than 
 in health to counterbalance rapid tissue waste. The appetite is not 
 always a reliable indication of the strength of the digestive organs, 
 and, acting upon this fact, Debove introduced the plan of feeding 
 by means of the oesophageal tube. It is only necessary to use this 
 method when a patient loses all appetite, or acquires a positive dis- 
 gust for food, and rapidly emaciates in consequence. The tube is 
 employed in the manner described for feeding cases of insanity, and 
 any form of desirable fluid food is introduced through it. It is 
 sometimes only necessary to pass the tube to the level of the 
 oesophagus, and the first few times that it is used it may be well 
 to brush the pharynx with a two-per-cent solution of cocaine. The 
 meals may be given three or four times a day, or a patient whose 
 appetite is not wholly lost, but is inadequate, may prefer to eat 
 part of his food himself and have other meals furnished through 
 the tube. 
 
 The following are the foods most suitable for tube feeding: 
 1. Milk and its preparations; cream. 2. Raw eggs, eggnog. 3. 
 Meat extracts, beef meal or powder. 4. Leguminous purees and 
 cereals, thoroughly cooked and made fluid by predigestion with 
 malt extract. A quart may be given at a time. If gastric catarrh 
 is present the gavage should be preceded by lavage. 
 
 Debove, speaking of his method, says : " A patient who has no 
 appetite, or who has a decided disgust for all food, will digest per- 
 fectly a large meal introduced by the tube, and even at the end of 
 a certain time will recover appetite." 
 
 His method is first to wash out the stomach with cold water, 
 and then pour in through the tube a litre of milk, one hundred 
 grammes of fine meat powder, and an egg. 
 
 He adds that with suralimentation night sweats, cough, and ex- 
 pectoration are all reduced or disappear completely, while there is 
 considerable gain in weight and strength and improvement in the 
 physical signs in the chest. 
 
 Suralimentation may also be conducted without the stomach 
 tube in patients who are able and willing to eat. They may be 
 
TUBERCULOSIS 465 
 
 given five or six meals a day. This applies to patients who are 
 not having severe hectic fever, and in whom gastric catarrh is not a 
 prominent symptom. Should vomiting occur during the treatment, 
 it will be necessary to suspend it until the stomach is again in 
 order. As a rule, in such instances it is better to discontinue medi- 
 cines than food, if both are being taken. The presence of moderate 
 fever — one or two degrees — is not in itself alone a contraindica- 
 tion for forced feeding, or for keeping the patient confined to bed. 
 The gain of appetite which often accompanies removal to a favour- 
 able climate may be utilised to promote forced feeding. 
 
 The following diet recommended by Solis-Cohen serves as a 
 good illustration of the proper regimen in the cases under discus- 
 sion : 
 
 "Diet for Forced Feeding 
 
 " The patient is to take a pint of hot water in the early morning 
 to stimulate the stomach and cleanse it of mucus accumulated over- 
 night. 
 
 " A half hour after the morning bath, milk punch and beef meal 
 or peptonoids. 
 
 " Breakfast, a half hour later, consisting of rare steak or chop, 
 eggs, sliced tomatoes, bread with plenty of butter, or cracked wheat 
 and cream. In two hours, koumiss or soup, milk, bread and but- 
 ter, celery salad, broth, and peptonoids. 
 
 " Dinner, 1 p. m. — Bouillon, rare beef, greens, Burgundy, beer, 
 fruits. 
 
 " 3 or 4 p. m. — Koumiss, cream, or milk punch, peptonoids, malt 
 extract. 
 
 " 7 p. m. — Supper, like breakfast. 
 
 " 9 or 10 p. m. — Cream and cocoa or coca wine, milk, and pep- 
 tonoids." 
 
 The patient should keep milk, or peptonoids, or some nutritious 
 beverage by the bedside to be drunk if he awakens in the middle 
 of the night. 
 
 Another diet well suited to some patients is thus outlined by 
 Weber in his Croonian Lectures : 
 
 " 7 a. m. — While still in bed, a cup of milk with a dessertspoon- 
 ful of Cognac or lime water, or a cup of tea or cocoa, with bread 
 and butter. 
 
 " 8.30 to 9 a. m. — After dressing, milk and tea or coffee, bread 
 and butter, fish, ham, or bacon. 
 
 "11 a. m. — Milk, koumiss, or broth, or a sandwich and glass of 
 wine. 
 
 " 1 to 1.30 p. m. — A substantial meal of meat, poultry, fish 
 or game, fresh vegetables, a light pudding, fruit and a glass 
 of wine. 
 
466 DIET IN DISEASE 
 
 " 4 p. m. — Milk or koumiss, tea or coffee, with bread and but- 
 ter or biscuit. 
 
 " 7 p. M. — Another meal like that at I p. m. 
 
 " 9.30 to 10 p. m. — A cup of milk, bread and milk, or milk or 
 cream and farinaceous food, such as Hart's, Liebig's, Nestle's, or 
 Mellin's. A glass of brandy if there are night sweats." 
 
 The question may properly be asked whether it is not possible, 
 to overfeed patients in this manner? This will happen when the 
 increase in body weight exceeds the breathing capacity of the lungs 
 — in other words, when the facilities for oxygen supply are dispro- 
 portionate to the bulk of tissue to be supplied. The symptoms will 
 be a coated tongue with dyspepsia and biliousness, increased pulse 
 frequence, and possibly increased dyspnoea on exertion, all occur- 
 ring without aggravation of the local physical signs. The food 
 must then be reduced in amount. Both fluids and solids are to be 
 restricted, and fish may replace meat temporarily. 
 
 Aids to Dietetic Treatment 
 
 It is not within the scope of this work to discuss the details of 
 hygiene, but they should be at least mentioned as important ad- 
 juncts to dietetic treatment. In those cases especially in which 
 forced feeding is recommended it is desirable to promote oxidation 
 in every way. Patients should live in the open air all they can, 
 sleep with the windows open, and, if possible, should go to a 
 climate which enables them to be outdoors all day long. They 
 should wear flannel undergarments, but should avoid dressing too 
 warmly, and keep the feet warm and dry. Habits of moderate exer- 
 cise, instruction in proper methods of breathing, cold bathing, mas- 
 sage, and reasonable mental diversion and good cheer are all useful 
 factors in improving the digestion and assimilation of food. Worry 
 and nervous strain of every kind should be avoided. Nine hours 
 should be nightly allotted for sleep. 
 
 Of the long list of medicinal remedies which have from time to 
 time won favour or notoriety for the treatment of tuberculosis, 
 those which have best withstood the test of practical experience 
 are the ones which, like creosote, act mainly by maintaining asepsis 
 and preventing malfermentation in the alimentary canal. It is im- 
 material whether cod-liver oil be considered as a medicine or as a 
 food. It has already been discussed as a food. In a negative 
 way it should be stated that one of the best aids to digestion con- 
 sists in preventing the patient from disordering the stomach and 
 the appetite with all manner of cough mixtures and ill-advised 
 tonics. 
 
 Such medicines as may from time to time be required for emer- 
 gencies will be much better absorbed if the stomach has not been 
 
THE RESPIRATORY SYSTEM 467 
 
 long kept in a state of dyspeptic irritability. In patients with con- 
 stipation appetite and digestion will be improved by catharsis. 
 
 Diet " Cures" for Phthisis 
 
 Many special forms of dietetic treatment have been devised and 
 extensively practised for the cure of pulmonary tuberculosis. The 
 details of these " cures " are elsewhere described. The principal ones 
 are the "Milk Cure" (p. 719), the " Whey Cure" (p. 721), the 
 " Koumiss Cure " (p. 82), practised chiefly in the steppes of south- 
 eastern Russia, and the " Grape Cure " (p. 724), conducted at Me- 
 ran, Montreux, and elsewhere in the months of September and 
 October. Aside from climatic influences and the effects of good 
 hygienic surroundings, their benefits are attributable only to the 
 fact that the patient is encouraged to take a large quantity of 
 easily digestible food and live constantly in the open air. Patients 
 with chronic phthisis are notoriously sanguine as to the possibilities 
 of their ultimate recovery, and it is also true that their mental state 
 reacts to a greater degree upon their physical condition than in 
 almost any other disease. 
 
 All manner of absurd foods, such as fish roes in Germany and 
 snails in the south of France, have achieved fame with credulous 
 persons as possessing specific virtues in the cure of phthisis. It 
 should be as much the duty of the physician to protect them from 
 the chagrin, disappointments, and expense of following dietetic illu- 
 sions as to encourage them in every reasonable effort for improve- 
 ment. Beyond the requirements of a good, nourishing, easily diges- 
 tible diet, there is no specific food " cure " for tuberculosis, as there 
 is no medicinal cure. 
 
 DIET IN DISEASES OF THE RESPIRATORY SYSTEM 
 
 Laryngismus Stridulus 
 
 • In children who are subject to spasmodic croup the attacks are 
 often precipitated by dyspepsia caused by overfeeding and nurs- 
 ing, by improper food, or by constipation. The diet must therefore 
 be regulated according to the rules laid down under the heading 
 Infant Feeding. The habit of night feeding especially should be 
 much restricted after the first month of life. This can usually be done 
 after two or three trials. If the infant awakens crying" at night it 
 must be offered a little cool water, and it may presently drop 
 asleep. Up to the fourth month six meals a day, three hours apart, 
 are all that are allowed, and from that time on until the second 
 year five meals must suffice. 
 
 Between the attacks the milk should be lessened in amount, and 
 
468 DIET IN DISEASE 
 
 so modified as to insure more perfect digestion. Children over six 
 months of age should be given from one to three tablespoonfuls of 
 pressed beef juice in a day. 
 
 Older children had better be kept upon a fluid diet of meat 
 broths, milk, and egg albumin, solid food being withheld until the 
 seizures abate. Cod-liver oil should be given in most cases. 
 
 Tubercular Laryngitis 
 
 In tubercular laryngitis intense pain is excited by the act of 
 deglutition. Nutritious but non-irritating food is therefore required. 
 Thick soups and gruels, purees, cream, beaten raw eggs, scraped 
 rare beef, raw oysters, junket, can all be swallowed more readily 
 than very fluid or solid food. Strong condiments, vinegar, and salt 
 must be avoided, for they increase the pain. 
 
 The difficulty experienced in deglutition is considerably relieved 
 by the method proposed by Wolfenden, which is to have the patient 
 lie prone on a lounge, and with his face protruding over the lower 
 edge he is to suck through a glass tube semifluid food from a tum- 
 bler on the floor. Sajous advises the patient to lean over forward 
 when eating, which, he says, " causes the food to pass down along 
 the pyriform sinuses, thus avoiding the upper portion of the larynx, 
 contact with which causes the severe pain experienced by advanced 
 cases during the act of deglutition." 
 
 HEMORRHAGE OF THE LUNGS 
 
 Haemorrhage of the lungs, or rather from the bronchial mucous 
 membrane, when occurring suddenly and in considerable amount, 
 greatly reduces the strength, and naturally alarms the patient and 
 excites the nervous system. Absolute quiet must be immediately 
 secured by rest in bed without a pillow, so that the body may lie 
 flat, and the head and arms should on no account be raised. The 
 room should be kept quiet and the patient must not be allowed to 
 speak or to feed himself. A reliable and quiet nurse should be 
 secured for him, and he should be fed upon a nutritious diet, which 
 requires no effort in eating. Small quantities only of fluid should 
 be given at one time through a glass tube or by a teaspoon, so that 
 the head need not be raised. If nausea occurs, every effort must 
 be made to control it, for the violent muscular action and the tem- 
 porary circulatory and respiratory disturbances occasioned by the 
 act of vomiting might excite further haemorrhage. It is desirable 
 to reduce the blood pressure in the lungs as much as possible in 
 order to allow coagulation of the blood to occur over the oozing 
 surface of the bronchial mucous membrane, and therefore large 
 quantities of fluid should not be given at first. The patient is usu- 
 
THE RESPIRATORY SYSTEM 469 
 
 ally thirsty from the loss of blood and temporary drying of secre- 
 tions. The thirst may be relieved by crushed ice and small quan- 
 tities of cold acidulated drinks, such as very dilute phosphoric acid 
 or sour lemonade, and if the stomach is in normal condition, plain 
 milk may be given or else pancreatinised milk and strong beef 
 broth in quantities not exceeding two or three ounces in as many 
 hours. 
 
 It is customary to administer all fluids cold, but the advantage 
 of this is overrated. Warm fluids have a somewhat more stimulat- 
 ing effect upon the heart, and are more rapidly absorbed, but the 
 idea sometimes advanced that the cold of iced fluids taken into the 
 stomach is ever sufficient to constrict the bleeding bronchial ves- 
 sels, even by supposed reflex action, does not appear rational. For 
 a full discussion of this question the reader is referred to experi- 
 ments reported upon p. 333. 
 
 If coincident gastric disorder is present with bronchial haemor- 
 rhage, to forestall vomiting it may be better to resort to nutrient 
 enemata. 
 
 In cases where exceptionally large quantities of blood have been 
 lost, the blood pressure may be greatly reduced and the danger of 
 death from heart failure may appear imminent. It then becomes 
 necessary to give a larger quantity of fluid, and the rules in regard 
 to the dietetic treatment of severe and sudden haemorrhage taking 
 place anywhere from the body must be observed. Salt and water, 
 a teaspoonful to the pint, may be injected into the rectum, or even 
 beneath the skin. Most cases, however, are more mild, and after a 
 few hours of rest and quiet, furthered, perhaps, by the hypodermic 
 injection of morphine, the patient will be able to retain a little sim- 
 ple semisolid food, such as milk toast, a beaten egg, junket, etc. 
 
 If there is no return of the haemorrhage in a day or two, the 
 diet should be increased and anaemia consequent upon the bleeding 
 must be treated by an abundant meat diet. As a rule, alcoholic 
 stimulants should be avoided, on account of the relation of blood 
 pressure to the bleeding, or they should be given in moderation, 
 unless the danger of heart failure is imminent. 
 
 Acute Capillary Bronchitis 
 
 In acute capillary bronchitis in infants and children a wholly 
 fluid diet of the simplest but most nutritious kind must be enforced. 
 In young infants milk alone, in older children milk, meat juice, 
 meat broths, and beaten eggs or egg albumin, should be fed at 
 least every two hours in such quantities as the stomach will bear. 
 It may be best to pancreatinise all food. Very feeble children will 
 require food oftener, and sometimes a teaspoonful only should be 
 ordered once every fifteen or twenty minutes. If the child refuses 
 
470 DIET IN DISEASE 
 
 food or vomits constantly, nutrient enemata (p. 408) must be pre- 
 scribed once in three or four hours. 
 
 Chronic Bronchitis 
 
 The diet for chronic bronchitis is substantially the same as that 
 recommended for the earlier stages of pulmonary phthisis, to which 
 the reader is referred (p. 455). 
 
 The cough is often momentarily relieved by drinking hot lemon- 
 ade, hot milk and Seltzer or Vichy, glycerin and whisky, and some- 
 times by sucking a raw Qgg through the perforated shell. 
 
 Asthma 
 
 Spasmodic bronchial asthma is believed to be occasioned by 
 temporary spasm of the bronchial muscles which narrows the lumen 
 of the tubules and obstructs the free entrance and exit of air. It is 
 also attributed to hyperemia and swelling of the bronchial mucous 
 membrane, and possibly, in some cases, to a reflex spasm of the 
 diaphragm and other muscles of inspiration. Asthmatic patients 
 soon find from experience that errors in diet are liable to precipitate 
 an attack, and overloading the stomach or eating particular kinds 
 of food, which are unwholesome or against which the individual 
 possesses some idiosyncrasy, may excite dyspnoea. Aitkin showed 
 a true appreciation of the importance of diet in this disease when 
 he wrote : " More is to be done for asthmatic patients on the side 
 of the stomach than in any other direction," and " the asthmatic 
 can never with impunity eat and drink as other people." 
 
 Accumulation of large quantities of undigested and fermenting 
 food results in the production of gas in both the stomach and intes- 
 tines, which become distended and by pressure interfere with the 
 movements of the diaphragm and abdominal muscles in free respira- 
 tion. The chemical irritation of undigested food may be a cause 
 of reflex spasm of various muscles, and may possibly affect those 
 of respiration. It is therefore necessary for asthmatics to exercise 
 care in the selection of their food and to keep the digestive organs 
 in as normal a condition as possible. All food which is constipating 
 or which is liable through fermentation to evolve large quantities of 
 gas should be shunned. In general, fats and sweets should be 
 given up, and starchy food, if eaten at all, must be very thoroughly 
 cooked and slowly masticated, in order that the salivary digestion 
 of it may be as complete as possible. Pork, veal, and cheese must 
 never be eaten, and elaborate cooking and desserts are forbidden. 
 No water should be allowed with meals or until at least three hours 
 thereafter. A cup of very hot water may be drunk an hour before 
 each meal and again at night. 
 
THE RESPIRATORY SYSTEM 471 
 
 In most persons the asthmatic attacks are worse at night, and 
 in many they only occur at that time. It is consequently better 
 for them to take the principal meal of the day at noon and to eat a 
 light supper, so that gastric digestion may be finished before going 
 to bed. 
 
 The following diet may be offered as giving a general idea of 
 the regimen for somewhat advanced cases : 
 
 Breakfast. — Bread and milk or well-cooked oatmeal porridge or 
 wheaten grits without sugar (lemon juice may be added instead). 
 A chop or a little broiled fresh fish, coffee without sugar. 
 
 Dinner (not later than 2 p. m.). — Beef or mutton, bread, one or 
 two green or succulent vegetables, such as spinach, stewed celery, 
 stewed or raw tomatoes. Blancmange or custard (not sweetened), 
 or a little rice pudding. Fresh fruit in season, such as a peach or 
 baked apple. 
 
 Supper (6 p. m.) — A soft-cooked &gg or a little cold fowl or 
 game, stale bread, toast, or zwieback, milk, stewed fruit (without 
 sugar). 
 
 Patients should eat very moderately, masticate thoroughly, and 
 take their meals with punctuality. 
 
 Among beverages, coffee without sugar is better borne than 
 tea. Loomis believed that " not infrequently a paroxysm of asthma 
 can be warded off by taking two or three cups of strong coffee im- 
 mediately upon the accession of the first asthmatic symptom." 
 
 During an attack non-alcoholic patients may take a hot strong 
 lemonade with whisky or a hot brandy and soda. Malt liquors are 
 forbidden. 
 
 Emphysema 
 
 Patients suffering from emphysema have more or less engorge- 
 ment of the venous circulation, and hence are liable to catarrh of 
 the stomach and intestines. The dyspnoea from which they suffer 
 on exertion is considerably aggravated by flatulency, and their diet 
 must be regulated to prevent this occurrence. In general, starchy 
 and saccharine foods are to be avoided, as constipation must be 
 prevented. For a discussion of these principles, the reader is re- 
 ferred to the articles upon Gastric Dyspepsia and Constipation. 
 
 The patient must be particularly warned against too rapid eating 
 and overeating. Condiments, sauces, fried and greasy food, and 
 all obviously indigestible articles, must be shunned. Fluids should 
 not be taken with solid food, and should be used in moderation. 
 Water may be drunk an hour before meals, but not for three hours 
 after. In the early stages a nourishing diet, consisting chiefly of 
 animal food, meat, fish, milk, cream, eggs, and good butter, should 
 be taken. If dyspnoea predominates with frequent asthmatic at- 
 tacks, it will be best to substitute milk largely for other foods, and 
 32 
 
472 DIET IN DISEASE 
 
 in the later stages, with a feeble heart and increasing congestion of 
 the abdominal viscera, the diet should consist solely of milk and 
 meat broths. Cod-liver oil is an excellent food in emphysema. 
 
 Pneumonia 
 
 Symptoms. — Pneumonia is an infectious inflammatory disease of 
 the lungs, accompanied by grave constitutional disturbances, such 
 as fever and rapid and enfeebled heart action. The mortality at 
 some seasons of the year, and especially among debilitated or alco- 
 holic patients, is very great, and since no known remedy can limit 
 the disease, it is exceedingly important to maintain the strength of 
 the patient through the few days during which the fever lasts, or 
 until the crisis by which it terminates has been reached. All danger, 
 however, is not then over, and convalescence in all cases, and espe- 
 cially in aged persons, must be promoted by careful dietetic treat- 
 ment. The onset of the disease is acute, and the fever is often 
 high, reaching 104 or 105 or more on the first day. The duration 
 of the fever varies from five to seven or nine days on the average, 
 when it subsides by a sudden fall. The rate of respiration is greatly 
 accelerated, with or without subjective dyspnoea. More or less 
 cough accompanies the fever, and there is frequently delirium. 
 
 Dietetic Treatment. — The indications for treatment are to give 
 a light diet, which will not excite the cough in swallowing or in- 
 crease dyspnoea by distention of the stomach, or augment the en- 
 feeblement of the heart action by overtaxing the digestive powers. 
 Vomiting should be especially guarded against, and if nausea exists, 
 efforts should be made at once to control it. It is not necessary to 
 keep the patient upon a rigid milk diet, but if milk is well borne, it 
 is advisable to give nothing else while the acute symptoms last ; 
 otherwise, whey, meat juice, broths, and egg albumin may be 
 allowed. Starchy and saccharine food must be withheld. Cold 
 drinks are both acceptable and beneficial to the patient, and water, 
 plain or aerated, such as Apollinaris or soda water, may be drunk in 
 considerable quantity. It is believed by some authorities that the 
 activity of the kidneys may be thus promoted, and that the poisOn 
 which occasions the constitutional symptoms of the disease may be 
 better eliminated. There are cases, however, among persons with 
 robust circulation in which the onset is very sudden and violent. 
 The pulse is full and bounding, and the heart is greatly overworked 
 by the effort to propel a large volume of imperfectly aerated blood. 
 In such instances the addition of large quantities of fluid to the cir- 
 culation, besides what is actually required for nutrition, may have 
 the effect of still further straining the heart. 
 
 It is stated that carbonated waters reduce the viscidity of the 
 sputum, which is often very tenacious. 
 
THE RESPIRATORY SYSTEM 473 
 
 The diet should be kept fluid until defervescence has occurred, 
 with a normal temperature and commencing disappearance of the 
 exudation — in fact, it is well to prolong the fluid diet tor three or 
 four days after the temperature has become normal, in order to 
 make sure that a relapse of the fever is not likely to follow. In 
 those cases in which resolution is postponed and the patient be- 
 comes more and more feeble, although the temperature may be 
 nearly or quite normal, it may be desirable to give a little properly 
 prepared solid food somewhat earlier, and scraped beef, milk toast, 
 or a soft cooked tgg may be added to the milk diet. 
 
 During the entire period of convalescence the diet must be very 
 nourishing and of easy digestion ; milk may still be given, and after 
 slowly returning to the regulation three meals a day (see Convales- 
 cent Diet, p. 435) patients do well to take milk punch, or egg- 
 nog, or a glass of wine and a biscuit three or four times a day in 
 the intervals. 
 
 Alcohol is exceptionally well borne, and it undoubtedly serves 
 both as a food and as a support to the overworked heart. The fact 
 that it is thoroughly oxidised in the circulation or tissues is dem- 
 onstrated by the large quantities which patients can often digest 
 and absorb without toxic symptoms. Doses may be thus tolerated 
 which in health would ordinarily produce drunkenness. In alco- 
 holic subjects who have been drinking up to the time of the onset 
 of the disease it is indispensable to continue the use of alcohol, for 
 the sudden withdrawal of its stimulating effect on the organism may 
 give rise to rapid collapse. In aged and constitutionally weak per- 
 sons it is also important that its use should be begun early in con- 
 siderable quantities. 
 
 In extreme cases as much as an ounce every two hours, or twelve 
 ounces in the day, may be given with benefit, but ordinarily from 
 six to eight ounces will suffice. There are other cases found among 
 robust subjects who do not need such stimulation, and possibly may 
 not require alcohol at all. The custom now in vogue of prescribing 
 other forms of cardiac stimulants, such as strychnine, and vaso- 
 dilators, like nitroglycerin, makes the employment of excessive 
 doses of alcohol less imperative. It should always be remembered 
 that it is undesirable to produce toxic symptoms of alcoholism in 
 pneumonia as well as in any other disease. So long as the pulse is 
 slowed and its force strengthened the use of alcohol may be re- 
 garded as beneficial ; but if delirium is increased and the odour of 
 whisky or brandy is strong in the breath an hour or two after it 
 has been given, it is an indication that the patient is receiving 
 more than is desirable, and the dosage should be reduced. From 
 its serving as a fuel, and thereby saving tissue waste in the 
 muscles, the free use of alcohol in pneumonia undoubtedly saves 
 many lives. 
 
4/4 DIET IN DISEASE 
 
 Broncho- Pneumonia 
 
 Symptoms. — Broncho-pneumonia is common at the extremes of 
 age, in the very old and very young. The mortality is greatest in 
 children under two years of age. It is the sequel to many of the 
 acute diseases of childhood, and is also produced by the tubercle 
 bacillus and by the inspiration of particles of food or fluid which are 
 drawn through the larynx to the bronchi by inhalation during the 
 act of swallowing. The latter variety may occur as a result of draw- 
 ing seeds or other hard substances into the bronchi ; from operations 
 about the mouth and upper air passages after tracheotomy ; and from 
 the conditions which impair the normal sensitiveness of the larynx 
 and the reflex action of the epiglottis and vocal cords, such as pro- 
 found uraemia or apoplectic or alcoholic coma, and post-diphtheritic 
 or laryngeal paralysis. A few cases have been produced by careless- 
 ness in the passing of the oesophageal catheter into the larynx and 
 pouring liquid food into it. 
 
 Dietetic Treatment. — Broncho-pneumonia is always a very crit- 
 ical disease and the utmost care is required in nursing and feeding. 
 The diet should consist of such articles as meat juice, predigested 
 milk, and egg albumin. Stimulation is early required and in con- 
 siderable quantity. Brandy or whisky sweetened with a little sugar 
 and cold water should be systematically given, especially to young 
 children, who are unable to make their want of drink known. Hot 
 milk and Vichy, in the proportion of one part of Vichy to two of 
 milk for older children, or half-and-half for young infants, may 
 have the effect of loosening the tenacious mucus and easing the 
 cough. If there is any tendency to flatulency, aerated waters had 
 better be avoided. 
 
 When the disease occurs in children the diet should be adapted to 
 foster the strength and tax the digestive organs as little as possible. 
 At first food should be given every two hours, and milk is usually 
 all that is required. Later it may be alternated with or supple- 
 mented by egg albumin, expressed meat juice, plain beef or mut- 
 ton broths, arrowroot, or other gruels. 
 
 Pleurisy 
 
 Of the various forms of pleurisy, those which are chiefly influ- 
 enced by diet are pleurisy with effusion and empyema. In pleurisy 
 with effusion the objects to be attained are to preserve the strength 
 of the patient and promote the reabsorption of the fluid in the pleu- 
 ral sac. A diet is therefore advised which shall consist of nutritious 
 solids with a minimum amount of fluid, in order that the blood may 
 become more dense and that favourable osmosis may occur from 
 
THE RESPIRATORY SYSTEM 475 
 
 the pleuritic cavity into the blood vessels ; at the same time free 
 action of the kidneys should be promoted. To still further favour 
 the absorption of fluid, a special dry diet has been recommended in 
 which, as in case of aneurism, the patient is encouraged to take as 
 little fluid as possible and to eat table salt by the teaspoonful, the idea 
 being to increase the density of the blood both by withholding fluid 
 and adding salt, and that the latter may also promote osmosis. This 
 treatment has been attempted in several of the New York hospitals 
 and elsewhere, but has not met with success, mainly, no doubt, on 
 account of the difficulty of overcoming the thirst of the patient, 
 which is doubly aggravated by the lack of fluid and the supply 
 of salt. 
 
 An extreme dry diet known in Germany as " Schroth's Method " 
 has been indorsed by Niemeyer, Pimser, and others. The patient 
 is fed upon lean roast veal and stale rolls {Butterbrod) without 
 fluid of any kind but a little water until the third day, when half a 
 pint of red wine is given. At the end of a week a pint is allowed. 
 Very few patients will submit to such treatment in this country, and 
 it certainly is severe. A reasonable abstinence from fluids, espe- 
 cially water, is all that can be expected. Practically, many patients 
 are found to go on reabsorbing pleuritic exudation while continuing 
 a milk or other fluid diet which is necessitated by some complica- 
 tion in the digestive system. 
 
 Several French writers, as Serre and Eloy, advocate an exclusive 
 milk diet, giving from three pints to three quarts daily, to be sipped 
 in small quantities every hour or two. They rely upon the diuretic 
 effect of the milk, and give it in any form most agreeable to the 
 patient. The treatment is continued for a week or more after the 
 exudation has been absorbed, and return to a solid diet must be 
 gradual. 
 
 This method is obviously directly opposed to the dry diet, and 
 possesses no advantages over it, excepting sometimes in cases com- 
 plicated by chronic valvular heart disease, gastric catarrh, or ad- 
 vanced anaemia. In England and Europe thoracentesis appears to 
 be much less practised than in this country, whefe it is performed 
 with but little hesitation. 
 
 If the pleuritic exudation accumulates in sufficient quantity to 
 severely embarrass respiration or the action of the heart, it is so 
 easy to absolutely withdraw it by the aspiration needle when anti- 
 septic precautions are taken that annoying the patient by experi- 
 mental dietetics is hardly justifiable, and I have found solid diet 
 with reasonable restriction to be, on the whole, the most satisfac- 
 tory. Patients who are fairly robust will naturally endure privation 
 of food and drink better than the feeble and anaemic. 
 
476 DIET IN DISEASE 
 
 Empyema 
 
 The dietetic treatment of empyema is based upon the need for 
 nutrition to supply the drain on the system of the constant excre- 
 tion of pus, and fatty food, such as butter, cod-liver oil, and cream, 
 should therefore fill a large portion of the dietary. The general 
 supporting treatment prescribed for the early stages of pulmonary 
 tuberculosis is recommended (p. 461). 
 
 DIET IN DISEASES OF THE CIRCULATORY SYSTEM 
 
 AND BLOOD 
 
 Diseases of the Heart 
 
 The proper dietetic treatment of advanced heart disease deserves 
 careful consideration, for on it to a great extent depends the pa- 
 tient's comfort, if not the prolongation of his life. It cannot be said 
 that the several conditions of cardiac enlargement, valvular disease, 
 fatty degeneration, etc., demand different forms of treatment per se, 
 but there are certain general principles which should be observed 
 in any case when particular symptoms arise. The dietetics of car- 
 diac diseases may, accordingly, be conveniently reviewed together. 
 
 Pathological Physiology. — The general conditions involved are 
 largely physical, or rather mechanical — perhaps more so than in any- 
 other form of disease. 
 
 1. We have to deal with a pump whose action is impaired by 
 more or less weakness of its walls, or leakage or obstruction of its 
 valves, or which is overworked by the imposition of increased re- 
 sistance. 
 
 2. The balance of food pressure in the vessels is usually disturbed 
 and the rate of blood flow is altered. 
 
 3. As the disproportion increases between the driving force or 
 the resistance of the vessels and the volume of the fluid to be pro- 
 pelled, there is apt to be leakage of serum in various situations, 
 producing dropsies or general anasarca. Or these conditions may 
 result from a diminution in the vitality of the peripheral blood ves- 
 sels or changes in the composition of the blood itself. 
 
 4. The rate of absorption of the materia alimentaria by osmosis 
 depends as much upon the activity of the circulation — i. e., upon the 
 rapidity of renewal of the layer of blood in the capillaries of the 
 absorbing surface — as upon the density and composition of the 
 blood, the action of individual cells, or any other factor. A feebly 
 beating heart or an obstructed vascular system promptly checks 
 absorption. Moreover, the reabsorption of transuded serum will 
 depend upon the reversal of the conditions which originally caused it. 
 
 5. The elimination of waste and the various processes of secre- 
 
THE CIRCULATORY SYSTEM AND BLOOD 477 
 
 tion depend upon almost identical conditions with absorption, and 
 while not due merely to filtration, they are nevertheless controlled 
 very promptly by alterations in blood pressure and in the velocity 
 of the current. 
 
 Bearing in mind these elementary principles, the first question 
 which arises in the dietetic treatment of advanced cardiac disease 
 must concern the administration of fluids. 
 
 Fluids. — An additional pint of fluid beyond the needs of the 
 system may be sufficient to overtax the heart, alter the balance 
 of blood pressure, disturb a temporary compensation, and precipi- 
 tate anasarca, renal congestion, pulmonary oedema, or other symp- 
 toms. On the other hand, with too little fluid the blood pressure may 
 fall to a dangerous degree or there may not be water enough in 
 the vascular system to maintain the free diuretic action which is so 
 desirable. It is a well-known physiological fact that the heart, like 
 any other muscle, does better work if it has reasonable resistance 
 to overcome. Such are the problems, briefly stated, which must 
 be met by the comparison from day to day of the amount and qual- 
 ity of the urine, the degree of arterial tension, the force of the heart 
 beat, and the possible presence of oedema. 
 
 Dietetic Treatment. — It is difficult to formulate any but the most 
 general rules for the dietetic treatment of chronic valvular disease 
 of the heart. These cases often extend through a period of many 
 years, and the variety of secondary symptoms which may appear is 
 very great. The forms of valvular disease which are most apt to 
 result in disturbances of digestion are those in which obstructed 
 venous circulation results in local engorgement of the abdominal 
 viscera, producing nausea, vomiting, and great distaste for food. 
 Constipation and more or less chronic gastric and intestinal catarrh 
 may be among the symptoms. The hypostatic congestion of the 
 liver retards the activity of that organ, and the ingredients of the 
 food which are brought to it by the portal system are no longer 
 properly elaborated, so that general nutrition and assimilation suffer 
 in consequence. A depleting diet is, therefore, sometimes to be 
 recommended, and concentrated food is required to prevent over- 
 burdening the circulation. If gastric catarrh necessitates the use of 
 fluid food, the quantity of beverages taken in addition should be 
 considerably restricted. When acute attacks of indigestion super- 
 vene in the course of chronic valvular disease, the bowels should 
 be kept thoroughly open, and a diet of milk, beaten eggs, and 
 broths, taken once in three hours, must be prescribed for a few 
 days, after which boiled fish, broiled chicken, scraped beef, beef- 
 steak, or rare roast beef may be added. Fats, farinaceous foods, 
 and sugars should not be allowed, owing to their tendency to pro- 
 duce flatulency and aggravate existing symptoms. The use of 
 alcoholic stimulation may at times become necessary, and whisky 
 
478 DIET IN DISEASE 
 
 diluted in some non-effervescing water is perhaps the best. Beer 
 should be particularly avoided, and recommendation of the regular 
 use of stimulants, in this as in other forms of chronic disease, should 
 be made with great caution lest the alcoholic habit be acquired and 
 become permanent. Patients with sudden cardiac dilatation, such 
 as sometimes occurs during convalescence from typhoid fever, need 
 to return to a milk diet. 
 
 When acute symptoms of palpitation, dyspnoea, etc., develop, the 
 patient should never eat very much food at one time. It is better 
 to take four or five meals a day, if necessary, and eat only small 
 quantities. A large meal always distends the stomach considerably 
 for several hours, causing this organ to elevate the diaphragm and 
 displace somewhat the heart, which lies upon it, and diminishing the 
 vertical diameter of the chest. The heart may become irritated by 
 the mechanical pressure to which it is subjected by a moderate 
 degree of displacement, and it is indirectly affected by the greater 
 difficulty of breathing, as well as by reflex irritation from the 
 disordered stomach. All food which is liable to ferment in the 
 stomach, such as sugar and indigestible starches and fats, must be 
 particularly avoided. Gastric catarrh is readily excited and aggra- 
 vated by coarse or fermenting food. On this account also the use 
 of strong alcohol should be forbidden except in the case of aged 
 and feeble persons, to whom light wine or diluted spirits may be 
 given. The regular use of tobacco should be prohibited, and tea 
 and coffee, if permissible, are to be taken only in very dilute form. 
 The tendency to constipation can be overcome by attention to diet, 
 and a moderate amount of fruit, such as baked or stewed apples, 
 stewed prunes, and grape fruit, may be allowed between meals. 
 
 CARDIAC VALVULAR DISEASE IN CHILDREN 
 
 Children who have chronic valvular disease or enlargement of 
 the heart, but who are not strictly confined to bed, should be closely 
 supervised in regard to their habits of eating. They should eat 
 slowly and moderately, and have their meals at regular intervals, 
 taking the principal meal at noon, and a light supper two hours 
 before bedtime. In general, animal food is better for them than 
 vegetables, but they may eat the lighter fresh vegetables, such as 
 spinach, tomatoes, or stewed celery in season, and sometimes a little 
 roast or mashed potato. Rice and macaroni may be given. Bread 
 should be only eaten dry or toasted. Sweets should not be allowed, 
 except very rarely, when a taste of jam or preserves may be given. 
 Such substances are apt to cause flatulency and palpitation, if not 
 more serious disturbances, and everything depends upon saving the 
 heart from excitation or strain. All food should be very simply 
 cooked, and too great variety is harmful. 
 
THE CIRCULATORY SYSTEM AND BLOOD 479 
 
 In acute endocarditis it is very important to avoid all food likely 
 to cause dyspepsia. Raw eggs with brandy, broths, and chiefly milk 
 must be prescribed, and if the stomach is weak and irritable, a part 
 of the nutriment may be given per rectum (p. 408). 
 
 DIETETIC TREATMENT OF THE SENILE HEART 
 
 In persons past middle life the heart may become enfeebled from 
 a variety of causes independent of inflammatory conditions or valv- 
 ular lesions. Fatty degeneration is a very common cause of such 
 weakness, and in other cases the heart muscle may gradually lose 
 its normal strength and " tone " from strain, or a disturbance of 
 balance between its' power and the peripheral resistance to be over- 
 come. In the aged the arterial walls become less and less resilient, 
 if not actually rigid, from fibrosis or calcareous deposit, and, more- 
 over, the heart suffers no less than other organs from impaired nutri- 
 tion. In such cases the prolongation of the patient's life as well as 
 the maintenance of his comfort may be fostered by attention to 
 dietetics. 
 
 A weak heart implies impaired circulation in the gastric vessels, 
 and hence the gastric juice becomes poor in quality and lessened in 
 quantity. Digestion is consequently retarded, and absorption of 
 food products is less active than it should be. The heart and the 
 stomach being both supplied by branches of the vagus nerve, it is 
 easy to understand how gastric irritation, caused by products of 
 malfermentation, organic acids, accumulated undigested food, or 
 gaseous distention, may affect the heart through reflex action. Me- 
 chanically, too, a stomach distended by gas presses upon and irri- 
 tates the heart. Balfour (The Senile Heart) says : " If the heart 
 is weak the discomfort induced by such irregularities is after mid- 
 dle life more apt to be felt in connection with that organ than 
 in the stomach itself." The result is intermission in the pulse rate, 
 unevenness in force and frequency of the heart beat, its " fluttering " 
 action, and sensations of palpitation, precordial distress, fulness or 
 constriction, and dyspnoea. In order to avoid these symptoms as 
 far as possible, the patient must have his diet carefully supervised. 
 A sufficient interval — fully five hours — must always elapse for the 
 complete digestion of one meal before a second is taken, and be- 
 cause the gastric juice is feeble it is best not to allow more than 
 four or five ounces of fluid of any kind to be taken with the meals. 
 While sufficient variety of food may be allowed to maintain a fair 
 appetite, it should never be so great as to entice the patient to eat 
 too freely. 
 
 Balfour summarises excellent rules for dieting to be followed by 
 patients whose cardiac action is enfeebled by any cause, but espe- 
 cially for the condition described as " the senile heart." 
 
4^0 DIET IN DISEASE 
 
 Balfour s Rules for dieting for Weak Hearts 
 
 " I. There must never be less than five-hour intervals between 
 meals. 
 
 " 2. No solid food is ever to be taken between meals. 
 
 " 3. All those with weak hearts should have their principal meal 
 in the middle of the day. 
 
 " 4. All those with weak hearts should have their food as dry as 
 possible." 
 
 A good typical menu is given by the writer above quoted : 
 
 Balfour s Diet for the Senile Heart 
 
 " Breakfast, 8.30 a. m. — Dry toast, one small piece — one or one 
 and a half ounce — with butter ; one soft, boiled egg, a small piece 
 of whitefish ; three to five ounces of tea or coffee with cream and 
 sugar, or an infusion of cocoa nibs, or milk and hot water, or cream 
 and Seltzer. Sometimes oatmeal porridge is permissible, but not 
 over three or four ounces should be taken. 
 
 " Principal Meal, 1.30 or 2 p. m. — Fish, such as haddock or sole, 
 or meat and pudding. Two courses only are allowed. No soups, 
 pickles, pastry, or cheese. Whitefish and short-fibred meat only 
 are allowable. The fish may be boiled in milk. A little spinach or 
 one potato may sometimes be eaten, or a half pound of fruit, such 
 as pears, apples, or grapes. Four to five ounces of hot water may 
 be drunk with each meal, but no more. 
 
 " 5 to 6 p. m. — Three to four ounces of tea (one teacupful) infused 
 for four minutes may be drunk, but absolutely no solid food is to be 
 taken with it. If desirable, a teaspoonful of Liebig's extract of meat 
 may be stirred in with the tea. 
 
 " Supper, 7 p. m. — Whitefish and a potato or toast and pudding, 
 or milk pudding, or bread and milk, or revalenta made with milk or 
 Liebig's extract. 
 
 " Bedtime. — Four to five ounces of very hot water, sipped, helps 
 the patient to fall asleep." 
 
 Upon this very limited regimen the patient, if heavy and water- 
 logged, at first loses weight by absorption of " cedematous soakage," 
 or if much wasted he may gain in weight. In this manner the natu- 
 ral equilibrium of the body is re-established. 
 
 In not too critical cases a little more latitude is permitted, and 
 such vegetables may be occasionally eaten as asparagus, onions, 
 leeks, tomatoes, lettuce, cress. The heavier, coarser vegetables (like 
 cabbage, sprouts, turnips, parsnips, carrots, beets, legumes), pastry, 
 nuts, dried fruits, and sweets of all kinds are forbidden. 
 
 Equal care mut be given to the selection of proper beverages. 
 If there is much palpitation, tea, coffee, and chocolate must be pro- 
 
THE CIRCULATORY SYSTEM AND BLOOD 48 1 
 
 scribed. In many cases Balfour allows a little weak tea, made by 
 infusing a teaspoonful (about one hundred grains) in four or five 
 ounces of water for only three or four minutes. Alcathrepta may 
 be drunk. The two latter beverages may be taken at 5 p. m. or 
 on retiring, when the stomach is empty. They must not be made 
 too sweet. 
 
 No champagne or effervescing drinks are allowed, and all alco- 
 holic beverages should be given only in moderation. If more than 
 two ounces (a claret-glassful) of one of the stronger wines is taken, 
 it excites acid dyspepsia, and claret, Burgundy, or hock should not 
 be allowed in greater measure. A small glass of port or sherry may 
 be drunk twice a day ; but, as Balfour observes, there is so much 
 idiosyncrasy in the digestibility of wines that in general plain liquor 
 is better for these cases and in the small quantity recommended in 
 the menu given above. Alcohol is by no means a necessity, and 
 many patients are better without any. He has great faith in the 
 stimulating properties of hot water, slowly sipped, and says : " This 
 will be found to have quite as good an immediate effect upon the 
 heart as alcohol. " 
 
 It has been elsewhere shown that the frequent acts of degluti- 
 tion performed in sipping any fluid tend to increase the pulse rate 
 slightly through reflex stimulation of the vagus branches which 
 are concerned in the act. 
 
 As the heart becomes more and more feeble, the inactive circu- 
 lation, perhaps aided by alteration in the composition of the blood 
 or by albuminuria, results in the production of localised cedema or 
 general anasarca. 
 
 In referring to the use of dry diet for these conditions as occur- 
 ring in connection with the senile heart, Balfour says : " When there 
 is anasarca, or any evidence of soakage in any dependent part of 
 the body, it is of the greatest importance to place the patient, for 
 a time at least, on the driest possible diet, and not too much of 
 it. ... I have seen a considerable amount of cedema of the lower 
 limbs disappear within twenty-four hours before there had been 
 time for any change in the heart, which was feeble and dilated." 
 His dry diet is as follows : 
 
 Breakfast. — A single slice of dry toast, without butter. A cup of 
 tea (infused only four minutes). 
 
 Dinner. — Two lean chops, or their equivalent in chicken or fish. 
 No vegetables. Dry toast ad libitum. Half an ounce of brandy, 
 whisky, or Hollands in three ounces of water. 
 
 Supper. — As much dry toast as desired. Half an ounce of 
 liquor, as at dinner. 
 
 Nothing else is allowed ; but if the patient is thirsty, very hot 
 water may be sipped between meals. This, Balfour maintains, is an 
 excellent cardiac tonic. 
 
482 DIET IN DISEASE 
 
 ANGINA PECTORIS 
 
 The only indication to be met in the dietetic treatment of angina 
 pectoris is to reduce the arterial tension. A vegetable diet with re- 
 stricted fluids, and no alcohol, is to be recommended. These pa- 
 tients often are subjects of the gouty diathesis, and the directions 
 for diet in that condition are to be observed. (See Gout.) 
 
 CARDIAC PALPITATION 
 
 The dietetic treatment of cardiac palpitation is sufficiently indi- 
 cated under the heading of Flatulent Dyspepsia. Overeating should 
 be avoided, as well as all stimulating foods and beverages. Tea, 
 coffee, and tobacco should be forbidden — at least temporarily. Ef- 
 fervescing drinks of all kinds, from their tendency to produce flat- 
 ulency, should also be proscribed, as well as all sweets and much 
 starchy food. Laxative foods, especially fruits, will be found useful. 
 
 ARTERIO-SCLEROSIS 
 
 In those cases in which renal inadequacy is a pronounced feature 
 it will be well to put the patient upon a milk diet for several weeks. 
 In general a non-stimulating diet is requisite, with a minimum of 
 butcher's meat, and no strong condiments, richly cooked dishes, or 
 alcohol should be allowed. 
 
 ANEURISM 
 
 In aneurism of the larger arteries the vessel wall is dilated and 
 thinned, and rupture is liable to occur at any time from increase 
 of the blood pressure or obstruction to the circulation produced by 
 sudden movement, or otherwise. The most favourable result of 
 treatment which can be anticipated is thickening of the diseased 
 vessel by the deposit of coagulated fibrin from the blood. The co- 
 agulability of the blood varies with its composition, and is favoured 
 by increased density of the blood and by structural changes in its 
 albuminous ingredients. To a limited extent this process can be 
 aided by diet. The object to be attained in the dietetic treatment 
 of aneurism is to reduce the volume, and consequently increase the 
 density of the blood. The latter does not necessarily increase its 
 coagulability, however. This method of treatment was originally 
 formulated by Bellingham and Joliffe Tufnell, of Dublin, and it is 
 now described by the latter's name. It is only less rigid than the 
 very old method of Valsalva, who gave half a pound of pudding 
 morning and evening, and nothing else — practical starvation ! In 
 conjunction with the dietetic treatment absolute rest of the patient 
 is enjoined ; he should lie horizontally in his bed, and not be per- 
 
THE CIRCULATORY SYSTEM AND BLOOD 483 
 
 mitted to make exertion of any kind, and mental strain and emotion 
 should be carefully guarded against. He should be fed by a nurse, 
 and not allowed to sit up at any time. By rest alone the rate of the 
 heart beat is materially slowed, and this is favoured also by the re- 
 duced diet. The artery, in consequence, is distended less and less 
 often and is submitted to less pressure. The exact treatment recom- 
 mended by Tufnell is as follows : 
 
 TufnelVs Diet 
 
 Breakfast. — Two ounces of bread with a little butter and two 
 ounces of milk. 
 
 Dinner. — From two to three ounces of meat without salt and 
 four ounces of milk ; for a portion of the milk an ounce or two of 
 claret may be substituted. 
 
 Supper. — The same as the breakfast. 
 
 This extremely rigid diet is apt to be rebelled against by most 
 patients, but it serves as a basis for the commencement of other 
 treatment, and if it be found impracticable to adhere to it, the quan- 
 tity of food will have to be slightly increased. It may be necessary 
 to double the quantity of milk and increase the amount of bread 
 or vary it with crackers or some light form of starchy diet. The 
 fluid, however, is in all cases to be restricted as much as possible. 
 Patients usually complain bitterly of thirst, and while it is more 
 desirable to restrict the fluids than the solids in the dietary, the 
 thirst may be alleviated somewhat by the use of acidulated drinks, 
 such as sour lemonade, dilute phosphoric acid in cinnamon water, 
 etc. The danger which menaces the patient and the object of his 
 treatment should be clearly explained to him and his co-operation 
 secured in the effort for his relief. It is customary to employ iodide 
 of potassium and morphine in moderation for their sedative action 
 upon the circulation and the system generally. Many cases are of 
 syphilitic origin, and they are particularly benefited by the potas- 
 sium iodide. Upon this reduced diet improvement in physical signs 
 of the aneurism — such as diminished pulsation and intensity of bruit 
 and lessened pain — is occasionally quite decided. In favourable 
 cases improvement may be looked for at the end of a week, and if 
 the dietetic treatment is persisted in for six weeks, the benefit may 
 be considerable. Tufnell himself reports several cases in which the 
 aneurismal sac became lined with a thick coating of fibrin. 
 
 There are many cases of aneurism outside the province of surgi- 
 cal treatment which are incapable of relief from any diet, but the 
 method above described is decidedly worth a trial in an otherwise 
 hopeless condition. I have several times known it to produce con- 
 siderable lessening of pain, dyspnoea, and other symptoms, but it 
 requires firmness and perseverance to carry it out successfully. The 
 
484 DIET IN DISEASE 
 
 curative results have, unfortunately, not verified Tufnell's original 
 claims, and as pointed out by Loomis, if the method is too rigidly 
 and too long enforced — for six or eight weeks — an extreme degree 
 of anaemia may develop and leave the patient worse off than before. 
 If the Tufnell diet is not prescribed, non-stimulating food only 
 should be allowed, consisting chiefly of simply cooked fresh vege- 
 tables and fruits, with but little meat. Anything likely to produce 
 flatulency or gastric dyspepsia should be carefully avoided, and 
 strong alcohol must be forbidden. 
 
 Anaemia — Chlorosis 
 
 Pathological Physiology. — The proper nutrition of all the tissues 
 of the body is directly dependent upon the quality of the blood 
 plasma and of the amount of oxygen conveyed by the corpuscles. 
 A very slight departure from the average composition of these ele- 
 ments will sooner or later result in diminishing the nutrition and 
 functional activity of all the organs in the body, notably those of 
 the digestive system. 
 
 Anaemia, whether acute and due to haemorrhage or disease, or 
 chronic from any cause, by depleting the cellular elements of the 
 blood, interferes with the proper oxidation of food after absorp- 
 tion. On the other hand, a diet which is insufficient in amount 
 or inappropriate in quality, if long continued, is certain to pro- 
 duce an impoverished condition of the blood with a diminution in 
 the number of corpuscles ; hence there is a double relation exist- 
 ing between the power of the blood to insure complete absorption 
 and metabolism, and of the food itself to maintain the normal bal- 
 ance of the ingredients of the blood. Anaemia, therefore, demands 
 special feeding, the basis of which should be an effort to restore as 
 soon as possible the proper number of red corpuscles and the nor- 
 mal quantity of other ingredients of the blood by a diet which is 
 nutritious and abundantly rich in nitrogenous food given in some 
 easily assimilable form. When proteid food is excluded from the 
 diet for some weeks the haemoglobin of the red blood corpuscles 
 is considerably reduced in amount and hydraemia ensues, but the 
 pigment is always increased by an excess of nitrogenous food. 
 
 Anaemia and chlorosis are most common at the age of puberty, 
 and immediately thereafter, among young girls who are growing 
 or who are overworked at school or in factories while beginning 
 menstruation, and who are improperly fed. The diversion of consid- 
 erable nervous energy for other functions than those of the circula- 
 tion at this time may interfere somewhat with the nervous mechan- 
 ism of digestion and absorption. In other cases there is a con- 
 stitutional or hereditary weakness of the digestive system, which 
 is aggravated by an exceptional strain or overwork of the nervous 
 
THE CIRCULATORY SYSTEM AND BLOOD 485 
 
 system. The phenomena of growth and development of the differ- 
 ent organs necessitates the consumption of a relatively larger quan- 
 tity of good food than is needed later in life for merely maintaining 
 the equilibrium of the tissues and restoring the balance of material 
 used in the production of energy. Growth implies the building up 
 of new material and a renewal of the old as well. At the period of 
 growth, therefore, there are always unusual demands upon the 
 nervous system, and overstrain at this time is to be especially 
 guarded against. 
 
 Symptoms. — Among the many symptoms referable to the nerv- 
 ous system which occur in the course of protracted anaemia are 
 languor, vertigo, various forms of neuralgia and megrim, with in- 
 definite muscular pains, which to some extent are produced by en- 
 feebled circulation, which allows waste material produced by mus- 
 cular action to accumulate in the tissues. Depression of spirits and 
 drowsiness are also observed, and palpitation is easily excited. The 
 poor circulation may result in the production of fainting, or of 
 oedema in the lower extremities. In advanced anaemia it is found 
 that not only is the normal rate of tissue metabolism impaired, but 
 there may be modifications in the relative consumption of certain 
 foods by the tissues. A large excess of urea is commonly observed, 
 which indicates an active combustion of nitrogenous substances. 
 The view is widely held that owing to the small number of the red 
 disks, or oxygen carriers, the final oxidation of fatty matter is re- 
 tarded, and it is for this reason that anaemic subjects very often 
 appear plump or even corpulent from the deposition of a large 
 amount of fat derived from incomplete combustion of fats and 
 starches, whereas their muscles, from the increased nitrogenous 
 waste, are reduced in size and are weak. Van Noorden, Kraus, 
 Bohland, and others dissent from this argument and believe that 
 chlorotic patients feel tired, sleep long, and are disinclined to ex- 
 pend energy in muscular exertion, and less energy than usual goes 
 into heat production, and as they sometimes eat abundantly of 
 sugars and starches, they necessarily store up fat. 
 
 Rest, Exercise, and Air. — In many cases of extreme anaemia, 
 found especially among young chlorotic girls, the dietetic treatment 
 must be accompanied by careful regulation of all hygienic condi- 
 tions. Sufficient rest for the tissues, and especially for the digestive 
 organs, must be secured. These patients, who appear so well 
 nourished, may in reality be quite feeble, and it is a great mistake 
 to compel them to rise early and perform tasks and indulge in 
 exercises of the same character and degree with those of healthy 
 children. For many patients it is well to insist on prolonged and 
 continuous rest in bed. For others it will suffice to restrict the ac- 
 tivities of the day by permitting the patient to rise shortly before 
 noon, and to insist upon rest being taken on a lounge both before 
 
486 DIET IN DISEASE 
 
 and after meals in order to secure more perfect digestion. These 
 patients must be cautioned against allowing themselves to become 
 unduly fatigued. They are often able, under the influence of stim- 
 ulants and excitement of various sorts, to perform feats of exercise 
 or endurance which are equal to those of healthy persons, but a 
 strong reaction is certain to follow, and a steady but slow progress 
 will often be checked for several weeks by infringement of neces- 
 sary regulations. In such cases, however, as soon as decided im- 
 provement is evident, and in all the milder cases, it is desirable to 
 enforce rules for gentle exercise in the open air, and the patient 
 should be outdoors nearly all the time whenever the weather per- 
 mits. The exercise should be supervised and slowly increased in 
 stout subjects, so that they gradually consume their superfluous fat. 
 If the climate is unfavourable the cure will be much more rapid 
 if the patient can be moved to a more salubrious locality. Fresh air 
 is more important than exercise, for an abundant oxygen supply 
 increases the appetite and distinctly favours the assimilation of the 
 food. 
 
 Dietetic Treatment. — The dietetic treatment of anaemia requires, 
 in the first place, that the most nutritious food should be supplied ; 
 secondly, care must be taken to insure its complete digestion and 
 absorption. In all cases of anaemia the impoverished and watery 
 condition of the blood reacts unfavourably upon the character of 
 the digestive secretions and diminishes their organic elements. The 
 secretions are therefore unable to digest the food with the necessary 
 vigour, and it is often desirable to re-enforce them by the use of 
 artificially prepared ferments or to give predigested food, making 
 use of pancreatin, in the preparation of animal food, and diastase 
 or malt extracts for the predigestion of amylaceous food (see pp. 
 
 353, 354)- 
 
 At the commencement of treatment rest and a small amount of 
 food may be required, but with improvement of the digestive organs 
 the quantity of food must be rapidly increased, and four or five 
 meals a day may be given. At first, if milk is well borne by the 
 enfeebled digestive system, and if it is not distasteful to the patient, 
 it should be the principal food. It may be drunk between meals, 
 and especially at night on going to bed. Some of these patients 
 who cannot digest milk with facility are able to take a mixture of 
 equal parts of cream and hot water with ten grains of bicarbonate of 
 soda and a teaspoonful of brandy to the tumbler (Yeo). Eggs in 
 all forms which are of fairly easy digestion are an excellent food 
 for anaemic subjects, and rare meat should be given in consider- 
 able quantities two or three times a day. Sandwiches made with 
 pounded meat or beefsteak almost raw, which is placed between 
 thin slices of bread and butter, may be taken with meals, or as a 
 light lunch in the middle of the morning and afternoon. Inserting 
 
THE CIRCULATORY SYSTEM AND BLOOD 487 
 
 a crisp lettuce leaf in each sandwich makes it still more palatable 
 and wholesome. Patients of this class often object very strongly 
 to eating meat, and prefer pastry and sweets, but with tact and per- 
 suasion they can usually be induced to take it in some form. Meat 
 broths and consommes may be thickened with scraped meat, or raw 
 scraped beef may be added to chocolate or Burgundy, or may be 
 eaten in any manner agreeable to the patient. In this way large 
 quantities of meat in an easily digestible form may be taken with- 
 out tiring of it, as fat anaemic women are very apt to do. Young 
 chlorotic girls should receive at least five or six ounces of albumin 
 per diem. See gives as much as fourteen ounces of raw meat daily 
 in some cases of chlorosis, and finds it especially serviceable for those 
 patients whose weak stomachs rebel against the use of the different 
 preparations of iron. 
 
 Anaemic patients often feel worse during the first half of the day. 
 They then complain most of headache, languor, and anorexia, but 
 they should be encouraged to begin the day early with nourish- 
 ing albuminous food to counteract this condition. Van Noorden's 
 system at the Berlin Charite is excellent, and he describes it as 
 follows : 
 
 " I recommend chlorotic girls to drink slowly half a litre of milk 
 of the best quality while they are yet in bed in the morning. They 
 must take time, and occupy at least a quarter of an hour in con- 
 suming this quantity. They ought to rise half an hour later, and 
 they should be rubbed briefly with a dry rough woollen towel. This 
 is to be followed by the breakfast, consisting of a small cup of tea, 
 one or two slices of buttered toast, and plenty of meat. I con- 
 sider it extremely desirable — the physiological reasons for this are 
 easy to defend — that these patients should take in at breakfast, 
 before the daily work commences, as much albumin as possible. 
 Two and a half hours later some bread and butter and two eggs 
 are to be eaten, followed immediately afterwards by drinking a 
 quarter of a litre of milk. If considered advisable for special 
 reasons, a small glass of sherry is now permissible." 
 
 If the large quantities of meat recommended are not perfectly 
 digested and absorbed, it is well to prescribe some preparation of 
 pepsin with dilute hydrochloric acid. A concentrated meat diet al- 
 most always produces constipation if this condition does not al- 
 ready exist as a result of the anaemic and atonic condition of the 
 intestinal wall, or the giving of iron. It is well to counteract this 
 tendency by the use of draughts of hot water and of purees of fresh 
 vegetables, whole-meal bread, oatmeal, and such fruits as stewed 
 prunes, apples, and the juice of oranges and grape fruit. (See Con- 
 stipation.) 
 
 The various Italian pastes, such as macaroni, vermicelli, and 
 polenta, with meat gravies, are suggested by Yeo. But with those 
 
 33 
 
488 DIET IN DISEASE 
 
 patients in whom there is a tendency to overproduction of fat, 
 withholding of hydrocarbons from the diet is highly desirable. 
 
 For others who, besides being anaemic, are thin and poorly 
 nourished, it is well to add some simple forms of starchy food and a 
 good deal of fat with the meals. Van Noorden says : 
 
 " For a well-nourished, moderately fat, chlorotic girl, weighing 
 sixty kilos, I would consider the following diet as eminently suitable : 
 
 " 120 grammes albumin = 492 calories. 
 
 60 " fat = 558 
 
 270 " carbohydrates = 1,110 " 
 
 Total 2,160 
 
 (i. e., 36 calories per kilo of body weight.)" 
 
 The eating of fats is to be encouraged to the limit of toleration. 
 Cream and large quantities of butter are recommended when easily 
 digested, and they can be made to replace cod-liver oil when the 
 patient is unable to take this form of fat. Many patients can digest 
 broiled fat bacon with ease. Two or three eggs beaten with boiling 
 water or milk, with the addition of sugar and spices and a table- 
 spoonful of brandy or sherry, make a useful form of eggnog, which 
 can be given two or three times during the day between meals. 
 
 The use of glycerin extracts and of emulsions of bone marrow 
 has been advocated for anaemia, but the results have not been mark- 
 edly satisfactory. The method of preparation of the marrow is 
 described on p. 196. 
 
 The condition most improved is chlorosis, but it is claimed 
 that some cases of pernicious anaemia have been helped. 
 
 Most anaemic patients have no appetite, or lose it, during the 
 early part of the day, and careful attention should therefore be 
 given to making all their food as agreeable to them as possible in 
 taste and manner of serving. Meat should be prepared so as to 
 require the least possible effort in mastication, and much more food 
 can be consumed in a fluid and semisolid form. 
 
 Condiments are serviceable, for they render simple food more 
 agreeable and stimulate the enfeebled gastric secretion. Moleschott 
 insists on the free use of salt by chlorotic patients on account of its 
 supposed favourable action in restoring the blood corpuscles and 
 plasma. Vinegar, pickles, gravies, and sauces should be avoided. 
 
 Alcohol is not indicated for all, but there are some patients who 
 are benefited by its use, and the best form of alcoholic tonic for an 
 anaemic patient is a good rich claret, Burgundy, or Madeira. Some of 
 the milder cases, especially in women in whom the digestive organs 
 are not particularly disturbed, do very well on porter or stout, or 
 one of the various malt preparations, which may be taken with the 
 noondav meal or at bedtime with a few crackers or a raw-beef sand- 
 wich. The latter is a prescription very serviceable in those cases in 
 
THE URINARY SYSTEM 489 
 
 which insomnia is a harassing symptom. There is no apparent con- 
 nection whatever between the absorption of alcohol and the forma- 
 tion of new blood cells, although there is a popular idea to the effect 
 that red wine produces red blood. Alcohol, however, often does 
 promote the accumulation of fat, and this is most undesirable in 
 anaemic subjects who already possess that tendency. 
 
 PERNICIOUS ANAEMIA 
 
 Hunter argues for the use of an exclusively farinaceous diet for 
 pernicious anaemia, on the ground that in health a proteid diet 
 causes more extensive destruction of the corpuscular elements of 
 the blood than a farinaceous one, and in this disease, on account 
 of putrefaction in the intestine, the blood destruction is increased 
 by nitrogenous diet. This theory is in opposition to all others, and 
 the most satisfactory and rational treatment consists in giving pre- 
 digested milk, eggs, beef broth and juice, etc., in as large quan- 
 tities as both stomach and rectum will absorb. 
 
 There is defective assimilation of proteid foods, and hence they 
 should be thoroughly predigested (see p. in). 
 
 DIET IN DISEASES OF THE URINARY SYSTEM 
 
 Modifications in the Urine caused by Food 
 
 The quantity as well as the composition of the food eaten exer- 
 cises an important influence over the composition of the urine. 
 Animal food increases the acidity of the urine and naturally also 
 its nitrogenous elements, urea, uric acid, and urates, and vegetable 
 food increases the carbonates and earthy salts. A concentrated 
 diet restricted in fluids as well as solids reduces the water of the 
 urine, and makes it relatively more acid, although the absolute 
 quantity of acid may not be increased. Conversely, watery foods, 
 milk, succulent fruits and vegetables, and all beverages increase 
 the quantity of urinary fluid and tend thereby to lessen its acidity 
 and density. Cantani dissents from the common view that the or- 
 ganic acids, such as fruit acids, form carbonates which promote 
 alkalinity of the urine, and says that this is true of small quantities, 
 but that larger amounts or the continued administration of these 
 acids makes the urine strongly acid. Phosphatnria or the excessive 
 deposit of phosphates in the urine is best treated dietetically by the 
 use of meats, eggs, cheese, cereals, and legumes. Potatoes, fresh 
 green vegetables, and fruits should be avoided. 
 
 A diet rich in fatty food, or an excess of cod-liver oil, may some- 
 times give rise to fat in the urine, or lipuria. The volatile fatty acids 
 may similarly be present. The presence of the fat makes the urine 
 
490 DIET IN DISEASE 
 
 somewhat turbid, and oil globules and fat crystals may sometimes 
 be seen under the microscope. 
 
 A milk diet makes the urine alkaline, and increases the indican. 
 
 Foods producing oxaluria are described under Oxaluria. 
 
 The odour of asparagus in the urine is explained on p. 172. 
 
 Acute Nephritis 
 
 Symptoms. — Acute nephritis is an inflammation of the kidneys, 
 which is principally caused by exposure to cold and wet, by certain 
 medicinal poisons, or by the toxins developed in the course of acute 
 infectious fevers, especially the exanthemata and diphtheria. It is 
 unnecessary to discuss its varieties here, as the dietetic treatment is 
 the same for all. 
 
 Among the important symptoms are anaemia and a scanty secre- 
 tion of urine containing abundant albumin with casts and blood. 
 Anasarca and effusion into various serous cavities, such as those of 
 the pleura and peritonaeum, may occur. The arterial tension is 
 increased. The patient must be kept in bed to insure a uniform 
 temperature of the body, and facilitate the use of measures to pro- 
 mote perspiration. 
 
 Dietetic Treatment. — The dietetic treatment must be adapted 
 to prevent overloading the digestive organs, which are easily de- 
 ranged, and to prevent overworking the kidneys. A light diet is 
 therefore necessary. The patient will do best to live exclusively 
 upon milk for some days, until the functional activity of the kid- 
 neys is restored. The importance of this should be explained to 
 him and insisted upon. Between four and seven pints are to be 
 taken daily, diluted with Vichy or carbonic-acid water. If the 
 bowels are loose, lime water may be added instead ; or if con- 
 stipated, magnesia solution. If the liver seems inactive, skimmed 
 milk or buttermilk may agree better. Milk sometimes causes gas- 
 tric oppression. If sipped slowly, or taken with a teaspoon, this 
 may be overcome, for it is then diluted with the saliva. 
 
 If milk is strenuously objected to or actually disagrees with the 
 patient, other simple foods may be allowed, such as koumiss, but- 
 termilk, and gruels of oatmeal, groats, rice, barley flour, or arrow- 
 root. These forms of starchy food should be prepared without 
 much sugar, but a little cream may be added or, if preferred, the 
 juice of a lemon, but no vegetables are permitted. If the patient is 
 feeble, strong beef tea or beef or chicken broth are sometimes to be 
 recommended, but, in general, so long as the symptoms are at all 
 acute it is necessary to withhold all meat preparations from the 
 diet. This is especially true in the case of young children. Animal 
 broths dissolve substances from meat which may develop into toxins 
 and irritate the kidnevs. 
 
THE URINARY SYSTEM 491 
 
 When the kidneys become more active and the character of the 
 urine improves, the diet may be increased by such articles as bread 
 and butter, plain puddings, lettuce, or water cress with plain French 
 dressing, stewed apples, grapes, oranges, etc., but whenever pos- 
 sible the food should consist largely of milk for a long period. 
 Later, eggs and even meat broths may be allowed, and finally a 
 little white meat of poultry. 
 
 Any return of the albuminuria should be immediately met by a 
 reduction in the diet to its original simplicity — chiefly milk. 
 
 A patient may lose thirty or forty grains of albumin in twenty- 
 four hours without serious harm, but if three hundred to four hun- 
 dred grains are lost the condition is in itself alarming, for he is 
 losing from one fifth to one fourth of his total albuminous food 
 through leakage of the kidneys — i. e., he is passing daily in the 
 urine one twelfth of the nutrient matter of his blood (Granger 
 Stewart). A pint of milk supplies about an ounce of albumin and 
 casein, thus replenishing the waste. 
 
 The lactose of milk is sometimes given separately for its diuretic 
 action. See gives it up to three ounces in twenty-four hours, to be 
 drunk in two quarts of water, and he believes it acts best when car- 
 diac dropsy is also present and the quantity of albumin is not large. 
 I have found it difficult to push its use to such a degree without 
 causing dyspepsia and a decided dislike for it. Milk is undoubt- 
 edly a good mild excitant of renal activity, but this is due to its 
 water as much as to any other ingredient, and the diuretic effect of 
 lactose is much overrated. 
 
 Should vomiting occur at any time, the diet must be again re- 
 duced, or it may be advisable to give the stomach complete rest for 
 ten or twelve hours. To increase the activity of the skin and wash 
 the casts and debris of granular matter and blood corpuscles from 
 the renal tubules, the blood volume must be raised by the ingestion 
 of abundant fluid, provided the tendency to dropsical effusions is 
 not great. Water, alkaline, mineral, or effervescing waters, soda 
 lemonade, or cream-of-tartar lemonade should be drunk freely, the 
 latter especially if there is constipation (Dickinson). Osier rec- 
 ommends the following: A drachm of cream of tartar in a pint of 
 boiling water with the addition of the juice of half a lemon and a 
 little sugar. To be drunk cold. 
 
 It is a general rule to exclude all foods and drinks which may 
 in any way irritate the kidneys, and the following are especially 
 forbidden : Grills, roasts, sauces, pastry, spices, very acid foods, 
 strong alcoholic drinks, tea and coffee. Strong wines, sweet wines, 
 and all sorts of liquors are absolutely prohibited. If alcohol 
 seems necessary for the stimulation of the heart, a little weak claret, 
 white wine, or diluted whisky and some effervescing water may 
 be given. 
 
492 DIET IN DISEASE 
 
 ACUTE NEPHRITIS IN CHILDREN 
 
 When the disease occurs in children, as often happens during or 
 after acute infectious diseases, such as scarlatina and diphtheria, the 
 diet must consist wholly of milk. During the most acute stage of 
 nephritis the milk may be diluted one half with Vichy or water for 
 its diuretic influence. It should be given in moderation, but often 
 — say at least once in two hours. As the acute symptoms subside 
 milk is to be ordered in full strength. 
 
 Gradually other articles may be added, such as crackers, toast, 
 porridge, rice pudding, cornstarch, junket, and blancmange. Orange 
 juice may be taken freely, and an occasional baked apple with cream 
 or a few stewed prunes will act favourably upon the bowels. 
 
 It is best, as in the case of adults, to forbid meat broths, and 
 eggs and meat in any form must be withheld for three or four weeks 
 after the urine has regained its normal composition. Subsequently 
 a menu may be composed from such articles as a chop, the breast 
 of a chicken or partridge, a little broiled whitefish, a poached egg, 
 oysters, custard, a baked mealy potato with fresh butter, stale bread, 
 wine jelly, and fresh ripe fruits. 
 
 Albuminuria — Functional Albuminuria 
 
 Pathological Physiology. — Albuminuria may be produced by al- 
 terations in the composition of the blood and by structural or 
 functional changes in the kidney itself, or by both. The albumin 
 is derived from the blood serum, which in turn comes from the 
 protein of the food. Under ordinary circumstances proteid matter 
 in passing through the body undergoes several transformations 
 which affect its degree of solubility and its ability to osmose or go 
 through animal membranes such as line the alimentary canal, the 
 blood vessels, and the tubules of the kidney. Most protein taken 
 into the body as food is not readily absorbed until converted into 
 some form of peptone or albumose. These substances diffuse 
 very easily, and their presence in the blood would render them 
 liable to constant osmosis from the vessels into the lymph spaces 
 or tissues almost immediately after absorption, but in their transit 
 through the intestinal villi they are reconverted into serum albu- 
 min, which does not osmose easily, and which therefore remains 
 in the vascular system. A certain amount of albuminous mate- 
 rial, however, must pass by osmosis from the blood vessels into 
 the lymphatic channels, and thence into the tissues which surround 
 them or which they penetrate. For serum albumin to pass into 
 the urine it must osmose through two layers of cells — namely, the 
 capillary wall of the blood vessel and the epithelial lining of the 
 tubules of the kidney. Variations in the density of these, walls, and 
 
THE URINARY SYSTEM 493 
 
 probably also alterations in the functional activity of the epithelial 
 cells which compose them, will modify the rate of osmosis so that 
 it may be completely checked, or it may be allowed to take place 
 unhindered. The conditions of osmosis also depend upon the rela- 
 tive density of the fluids on either side of the membrane, hence al- 
 terations in the composition of the blood plasma may allow of the 
 osmosis of serum albumin into the tubules of the kidney. It is im- 
 portant to observe that the presence of serum albumin in the urine 
 in excess not only indicates a functional or structural weakness in 
 the kidneys themselves, or in the composition of the blood, but it 
 represents actual loss of substance from the body — i. e., of material 
 which is not yet converted into waste matter, but which is capable 
 of furnishing nutrition to the tissues — in other words, there is a leak 
 of nutrient matter from the kidneys. 
 
 From the foregoing statements it might seem feasible to disre- 
 gard the leakage and increase the amount of nitrogenous food suf- 
 ficiently to counterbalance the loss sustained. The same plan might 
 theoretically be thought to be of benefit in cases of diabetes, where 
 it would seem quite possible to counterbalance the loss of saccha- 
 rine material from the kidneys by ingestion of much larger quantities 
 of starches and sugars ; but this is a fallacious comparison, for ex- 
 cess of sugar is really a foreign body in the blood, while albumin 
 is not (Granger Stewart). Clinically, however, it has been found 
 that when either of these conditions of loss of substance from the 
 blood exists in the kidneys it is better to withhold as much as possi- 
 ble the particular variety of food which is leaking through them 
 and reduce the work of these organs, hoping by rest, combined 
 with other appropriate means of relief, to cure the faulty condition. 
 
 Functional Albuminuria. — Temporary functional albuminuria is 
 now recognised as occurring in many individuals without the signifi- 
 cance of any structural or organic lesion of the kidney. This sub- 
 ject has been exhaustively investigated by the medical examiners 
 of life-insurance companies, for it is of great importance not only 
 to discover the presence of albuminuria early, but to assign the 
 proper significance to its presence. It is not many years since the 
 detection of albumin in the urine was regarded as an infallible indi- 
 cation of some form of renal disease, but the fact is now established 
 that errors in diet and faulty assimilation produced by mental and 
 nervous strain, overwork, and worry, and more particularly by the 
 exhaustion of very rapid growth of the body in the later years of 
 childhood and early youth, may occasion albuminuria. 
 
 A solution of meat albumin experimentally transfused into the 
 venous circulation of a dog, injected either subcutaneously or into 
 the rectum, reappears unaltered in the urine, but serum albumin 
 similarly injected is retained by the blood and does not cause albu- 
 minuria, although the percentage of albumin in the blood plasma 
 
494 DIET IN DISEASE 
 
 has been considerably raised above the normal. Moreover, if a 
 man in health eats eight or ten raw eggs in the course of five or 
 six hours, traces of serum (not egg) albumin may appear in the 
 urine. The matter is of interest in connection with the diet for 
 chronic Bright's disease (p. 497). Albuminuria thus produced is 
 purely temporary, and is directly dependent on the nature of the 
 food. So much of this proteid has been eaten that a portion of it 
 is absorbed directly into the blood without the formation of inter- 
 mediate products of digestion. Similarly this albumin will os- 
 mose through the kidney. But if the digestive activity in the stom- 
 ach is very great, a large number of raw eggs may be eaten, and 
 as many as nineteen have been taken in thirty-six hours (Dolradin) 
 without the appearance of albuminuria. It is no doubt true in such 
 an instance, as suggested by Yeo, that the vigour of the digestion 
 converts egg albumin into peptones, which finally form serum albu- 
 min, whereas with a slower digestion more of the egg albumin is 
 absorbed unaltered. 
 
 According to the experiments of Stokvis, coagulated egg albu- 
 min cannot be made to reappear in the urine of healthy animals, 
 but raw egg albumin can. 
 
 Oertel (Therapeutics of Circulatory Derangements, in von Ziems- 
 sen's Handbook of General Therapeutics), as a result of numerous 
 experiments upon man and animals in opposition to the above view, 
 declares that " egg albumin, given in whatever quantity, is not nor- 
 mally excreted as such by the kidneys, and does not cause albumi- 
 nuria." The albumin absorbed is all destroyed in the blood or tissues 
 and excreted as urea from the kidneys. He further says that " a 
 great increase of albumin supplied to the blood causes no increased 
 excretion of albumin by the kidneys, and, in particular, that egg 
 albumin gives rise to no irritation of the renal vessels and no albu- 
 minuria (nor does it increase an existing albuminuria)." 
 
 This statement, if corroborated by further observation, would 
 considerably alter the prevailing notions in regard to the advisa- 
 bility of giving eggs to patients with chronic Bright's disease. 
 
 Of all the varieties of albuminuria, those which are most amen- 
 able to dietetic treatment are the functional form and that which 
 accompanies chronic Bright's disease. The functional albuminuria 
 which is produced by eating an excess of protein or by muscular 
 fatigue, which results in the accumulation of large quantities of 
 nitrogenous waste matter and interference with normal oxidation 
 processes, is usually curable by ascertaining and removing the cause. 
 
 It seems to be almost impossible to produce functional albumi- 
 nuria in the lower animals, such as dogs, by overfeeding them with 
 a very large excess of albuminous food. Voit caused a dog to absorb 
 within twenty-four hours six times the amount of albumin contained 
 in the blood plasma without exciting albuminuria. 
 
THE URINARY SYSTEM 495 
 
 In the instance given above of albuminuria caused by eating 
 large numbers of eggs, it was emphasised that the proteid in the 
 urine is egg albumin and not serum albumin. It is stated, however, 
 that occasionally serum albuminuria may be produced in man by 
 eating large quantities of meat. If true, this is certainly very un- 
 usual, and this form of albuminuria is by no means as readily induced 
 as the glycosuria caused by an excess of starches in the food. But 
 if albuminuria already exists, certain forms of nitrogenous food will 
 greatly increase the amount eliminated by the kidneys. 
 
 It is probable that some persons inherit a special weakness of the 
 kidney structure or an abnormal irritability of the renal cells which 
 favours the occurrence of albuminuria from slight provocation. 
 Granger Stewart (Lectures on Important Symptoms of Albumi- 
 nuria) states that he has observed in certain persons that cheese, 
 pastry, and eggs are substances capable of producing temporary 
 albuminuria. In one case this symptom was accompanied by oedema 
 of the eyelids. 
 
 In regard to the production of functional albuminuria from die- 
 tetic errors Yeo argues, and I think correctly, as follows : " May not 
 the true explanation be that the ingestion of so large an excess of 
 albuminous material may throw upon the kidneys such an excess 
 of nitrogenous waste (to be secreted) that a temporary functional 
 hyperemia of the kidneys is excited, and that this leads to a slight 
 escape of albumin from the blood? It appears to us that this is a 
 sound physiological explanation of what is observed to occur, and 
 accounts for its occurrence in fever or disordered constitution, and 
 not in the perfectly sound and vigorous." 
 
 Albuminuria also results from passive hyperemia of the ves- 
 sels of the kidney, as well as from active congestion and inflam- 
 mation. 
 
 In functional albuminuria, when traces of serum albumin appear 
 from time to time in the urine, it is found that the amount is pro- 
 portionately increased by any special fatigue or exhaustion. It is 
 possible, although it is by no means proved, that nerve currents 
 supplying the epithelial cells of the renal tubules or the walls of the 
 renal capillaries may cause a functional alteration in the activity of 
 these cells, which compels them to exercise a selective action upon 
 the albumin of the blood serum, and favours its osmosis. The theory 
 is advanced by Mills, of Montreal, that the epithelium of the capil- 
 laries possesses some at least of the functions of glandular epithelium, 
 and that it is capable of controlling and varying the quality as well 
 as the quantity of such substances as may pass through the minute 
 capillary walls. 
 
 Albuminuria is very common as a result of elimination of irritant 
 poisons from the kidneys, and it is believed that the albuminuria 
 usually present in diphtheria and the exanthemata is produced by 
 
496 DIET IN DISEASE 
 
 the irritant effect upon the kidneys of toxins developed in these 
 diseases which are being eliminated in the urine. 
 
 Dietetic Treatment. — The frequent return of functional albumi- 
 nuria should be regarded as an indication of special weakness of 
 the kidneys in the same way that frequent glycosuria invites sus- 
 picion of the strength of the digestive power of the liver, and it 
 demands a careful regulation of the diet. Meat should be reduced 
 in quantity, or temporarily forbidden, as well as all forms of alcoholic 
 drinks or other substances liable to produce renal irritation, and 
 the diet should consist chiefly of fruits, vegetables, and milk. Care- 
 ful attention must be paid to increasing the activity of the bowels. 
 When functional albuminuria is observed in children and adoles- 
 cents, it is not necessary, nor is it advisable in ordinary cases, to 
 wholly exclude nitrogenous food, but it should be restricted, espe- 
 cially in regard to eating butcher's meat and eggs, and the evening 
 meal should be made very simple, consisting of food such as bread, 
 crackers, rice or porridge, and milk. 
 
 Chronic Bright's Disease 
 
 Causation. — Chronic interstitial nephritis may be of primary ori- 
 gin, or it may occur as a result of arterio-fibrosis and other condi- 
 tions. It is usually a very slow process, and is often provoked by 
 chronic alcoholism. 
 
 Urine of a low specific gravity is passed in greater amount than 
 normal, and thirst is increased. The arterial walls are thickened and 
 their tension is high. 
 
 That an exclusive meat diet is not the cause of chronic Bright's 
 disease is proved by the fact that Eskimos and other races, who 
 subsist altogether upon it, are not especially liable to the dis- 
 ease, although in the long sunless winter they live under very bad 
 hygienic conditions. (See the relation of proteid food to albumi- 
 nuria, p. 493.) It is nevertheless a fact that the disease is very 
 prevalent in this country among men past forty years of age who 
 for years have been overworked with business cares, and who have 
 neglected to take sufficient exercise and care in eating. In the early 
 stages of the disease much may be accomplished by dietetic treat- 
 ment. Osier says that " care in food and drink is probably the most 
 important element in the treatment of these early cases." 
 
 Whatever views may be entertained in regard to the causation 
 of albuminuria, it is agreed by all that cooked meats, eggs, and 
 highly seasoned food in general are injurious in all cases of existing 
 albuminuria. One should be cautioned against regarding the amount 
 of albumin present in the urine from time to time in the course of 
 chronic albuminuria as an exact indication of the extent of the renal 
 disease. The fluctuations observed are often due to diet merely, and 
 
THE URINARY SYSTEM 497 
 
 the albumin may occasionally be considerably reduced in quantity, 
 or actually absent temporarily from the urine, although the lesion of 
 the kidneys is making uninterrupted progress. The volume of albu- 
 min in the urine must not, therefore, be estimated alone as an indi- 
 cation for dietetic treatment ; it is merely one of many symptoms 
 incident to the course of chronic Bright's disease whfch are bene- 
 fited by a strict regimen. 
 
 Extensive disease of the excretory surface of the kidneys always 
 interferes with the normal elimination of nitrogenous waste matter 
 which accumulates in the system until it finally produces toxic or 
 ursemic symptoms of a most serious character. If the alimentary 
 canal is overloaded with food above the actual requirements of nu- 
 trition, or beyond the capabilities of the system for oxidising food 
 products, toxic symptoms are sure to follow. For these reasons the 
 diet in chronic Bright's disease must be definitely regulated, and a 
 mean must be maintained between overburdening the digestive 
 apparatus and withholding food which is needed to support the 
 bodily strength. This applies especially to the waste of nitrogenous 
 food, which passes off through the kidneys, whereas the waste of 
 farinaceous food is eliminated largely from the lungs and skin in the 
 form of water and carbonic acid. 
 
 Milk Diet. — In many cases of chronic Bright's disease the effect 
 of feeding the patient for six weeks, or even two or three months, 
 upon an exclusive milk diet is remarkably gratifying. The quantity 
 of urine, urea, and extractives increases, while the albumin dimin- 
 ishes, and cedema and general anasarca disappear. The patient's 
 strength and general condition improve, the pulse is strengthened, 
 and if dyspnoea pre-existed it subsides. 
 
 The quantity of milk to be prescribed for an exclusive milk diet 
 in Bright's disease must depend on the age and size of the patient, 
 as well as upon his ability to take exercise and use up force in 
 muscular energy. If the patient is invalided so as to be confined 
 to his room or the house, from five to seven pints of milk daily are 
 quite sufficient. Seven pints of milk contain 216 grammes of albu- 
 min and casein, 172 grammes of fat, and 161 grammes of lactose; 
 whereas, according to Pettenkofer and Voit, a healthy adult requires 
 137 grammes of dry albumin, 117 grammes of fat, and 352 grammes 
 of carbohydrates (see p. 286). The milk diet is therefore deficient 
 in carbohydrates, but the latter are estimated in Voit's table for a 
 person taking active exercise, and requiring the development of more' 
 muscular energy and heat than the invalid. If the patient loses 
 weight on a milk diet, although it otherwise agrees with him, it 
 may be well to add farinaceous food in the shape of rice or bread. 
 Many patients will live contentedly with no other food than a bowl 
 of bread and milk four or five times a day. In some cases it is in- 
 advisable to commence the milk diet immediately, and a good result 
 
49$ DIET IN DISEASE 
 
 can be best attained by cutting off one article of solid food after 
 another and replacing the loss by an additional tumbler of milk. 
 Where it is expected to employ a milk diet for many months, as 
 in an advanced case of Bright's disease, it is usually found that the 
 milk is better borne if taken fresh at a natural temperature and with- 
 out flavouring of any kind. Although the treatment may seem se- 
 vere at first, if the patient understands the gravity of the situation 
 he is usually willing to accept it, and after a few days seldom com- 
 plains of the monotony of this most restricted form of feeding. In 
 the worst cases it is desirable to give the milk at brief intervals, in 
 quantities of six ounces, once an hour during the daytime, with an 
 extra tumblerful at night, and on awakening in the morning. Or- 
 dinarily, however, it is tiresome to have to drink milk so often, and 
 the quantity may be so regulated as to give the requisite amount 
 once every three hours. The quantity of milk necessary to support 
 life for any length of time and maintain good nutrition, especially 
 if the patient is exercising at all, is considerable, and he must take 
 from fourteen to eighteen, or even twenty-two six-ounce tumbler- 
 fuls of milk in the twenty-four hours. It is usually impossible to 
 commence at this rate without producing gastric disturbance from 
 souring of the milk in the stomach, and possibly diarrhoea. The 
 latter symptom is an almost certain indication that the milk is being 
 imperfectly digested, and a temporary reduction in its quantity is 
 advised. 
 
 It is very important to thoroughly cleanse the mouth after drink- 
 ing the milk, in order to avoid coating of the tongue and the dis- 
 agreeable taste which destroys the appetite and interferes with the 
 efficacy of the treatment. For a full discussion of this subject the 
 reader is referred to the article on milk diet in typhoid fever (p. 
 426). Obstinate constipation, which almost invariably results from 
 a long-continued milk diet, must be met by medicinal treatment, or 
 the use of glycerin suppositories or enemata. As a rule, the milder 
 laxatives are the only remedies necessary ; a glass of citrate-of-mag- 
 nesia solution, a half tumblerful of bitter water taken on rising in 
 the morning, a drachm of the compound-licorice powder, or a two- 
 grain pill of extract of cascara sagrada at night, will prove sufficient. 
 There is, however, no objection in most cases to allowing the use 
 of a few stewed prunes or the soft part of two or three baked apples. 
 
 It will be observed that whereas the normal average quantity of 
 urine for an adult male is fifty-two ounces for the twenty-four 
 hours, the milk diet under discussion requires the ingestion of up- 
 ward of one hundred ounces of fluid. This necessitates greatly in- 
 creased activity of the kidneys, but the polyuria usually results in 
 the removal of the anasarca which frequently exists. The body 
 weight may remain normal, or even be slightly increased on this 
 treatment. It is not infrequently diminished, however, but much 
 
THE URINARY SYSTEM 499 
 
 depends upon the condition of the patient at the time when the 
 milk diet was inaugurated. The abundant urine is of a pale-yellow- 
 ish hue, which is somewhat typical of the milk diet. The specific 
 gravity is low, and the reaction may be neutral or faintly acid on 
 account of the great dilution of the fluid. The albumin, which at 
 first may be present in considerable bulk — sufficient when coagu- 
 lated to almost solidify the contents of the test tube — gradually 
 diminishes, and the urea and salts increase. In mild cases this 
 milk diet should be continued from four to eight weeks, after 
 which a slight variation may be allowed in the shape of farinaceous 
 food, fresh vegetables, and fruit, such as oranges and lemons. In 
 other cases it may be necessary to prolong the treatment for half 
 a year or more, because it will be found that any attempt to mate- 
 rially alter the diet is followed by an increase in the albumin and 
 dropsy, with return of other symptoms. In such patients the lesion 
 of the kidney is far advanced and incurable, and the most that 
 can be hoped for from any treatment is an amelioration of the worst 
 symptoms, and it is found that in many cases this can be best se- 
 cured by milk diet. For the class of cases in which this treatment 
 is found for any reason to be impracticable, either from the persist- 
 ent refusal of the patient to take milk or from any other cause, be- 
 fore giving up its use efforts should be made to modify its prepara- 
 tion in various ways, tempting the patient with different flavours 
 and with light farinaceous foods, of which milk forms an important 
 basis, such as bread and rice puddings. A good deal of milk may 
 be taken in very weak coffee or tea, or in the form of soups and 
 purees made with celery or potatoes, or gruels may be given, or 
 milk thickened with tapioca, vermicelli, sago, or rice, and flavoured 
 with a little lemon or orange peel, cloves, or allspice. It is not 
 desirable to use much high seasoning for fear of irritating the dis- 
 eased kidneys. 
 
 As the patient improves, the milk diet may be given up, but it 
 should never be too suddenly abandoned. A sudden restriction of 
 fluids in chronic nephritis is always injurious. In adopting any 
 other diet it is a good rule never to let the nitrogenous food bear 
 a greater proportion to the non-nitrogenous than one to four. The 
 former increases the proportion of urea in the urine ; the latter 
 reduces it. A purely vegetable diet has often been tried for albu- 
 minuriacs, but it causes too pronounced anaemia if its use is per- 
 sisted in, and a minimum of animal food must therefore be pre- 
 scribed. Granger Stewart says, in speaking of the very chronic 
 albuminuria of Bright's disease, " In the more advanced stages the 
 diet should be as nutritious as possible, and then certainly fresh 
 meat is by no means injurious." Vegetarianism should never be 
 persisted in if the patient continues to lose weight and strength. 
 
 When, after a milk diet, the change is to be made to a more 
 
500 DIET IN DISEASE 
 
 liberal menu, the hours of taking the milk may be reduced in fre- 
 quency, and some of the milk may be replaced by boiled fish, 
 chicken, or game, and fresh green vegetables, potatoes, cream, but- 
 ter, and bacon. Cereal foods may be eaten ad libitum, such as 
 hominy, corn bread, oatmeal, sago, tapioca, rice, vermicelli, bread 
 pudding, and macaroni. Cheese may be eaten occasionally. The 
 urine should still be periodically examined, and if it is found that 
 the eating of meat is followed by an increase in the albuminuria 
 the patient must return to the milk diet. 
 
 It not rarely happens that strict adherence to a milk diet for 
 several months produces more lasting improvement in the action 
 of the kidneys, so that a diet to which steak, roast beef, chops, and 
 eggs are admitted may not only be well borne, but may increase the 
 strength of the patient. This is a matter which obviously cannot be 
 regulated by fixed rules. If the general principles of the treatment 
 are understood, it is within the province of any intelligent physi- 
 cian to apply them to individuals. In cases in which it is found 
 after trying all methods that milk cannot be assimilated in any form, 
 the patient must live upon a carbohydrate diet, consisting of fresh 
 vegetables and fruits, with butter, cream, and olive oil. Dujardin- 
 Beaumetz allows pork and ham to be eaten by those who refuse 
 to relinquish meat entirely. Cheese is to be avoided. 
 
 Senator believes that whenever serious albuminuria is present 
 Qgg albumin and meat should be withheld, although a little fish or 
 flesh poor in albumin, like that of chicken or veal, may be given if 
 necessary, but he prefers to prescribe only vegetables, salads, and 
 fruits, or an exclusive milk diet of two litres per diem. 
 
 Semmola recommends the use of the following drink, which 
 may be mixed with milk, and which possesses a decided diuretic 
 action : 
 
 Sodium iodide 15 grains. 
 
 Sodium phosphate 30 " 
 
 Sodium chloride 90 " 
 
 Drinking water 36 ounces. 
 
 In general, the patient had better leave alcohol alone, especially 
 in the form of malt liquors. If habituated to its use, a feeling of 
 dulness and drowsiness after a glass of wine is a strong reason for 
 giving it up. An occasional " spree " may do the patient less harm 
 than continued drinking in smaller quantity. For a non-alcoholic 
 subject, if weak and anaemic, as he improves, a little light wine or 
 claret diluted with Seltzer water or Apollinaris may be ordered as a 
 beverage. Tea, coffee, and cocoa are permissible. 
 
 The effect of dietetic treatment will be much enhanced by secur- 
 ing systematic outdoor exercise, and freedom from worry and anx- 
 iety, and particular attention must be paid to keeping the bowels 
 
THE URINARY SYSTEM 501 
 
 open, for which laxative fruits may be taken freely. The patient 
 must be cautioned against overeating, and all food must be thor- 
 oughly masticated. 
 
 PYELITIS 
 
 Most cases require abundant fluid, such as alkaline mineral 
 waters, for the purpose of washing out the pelvis of the kidney, and 
 if there is much irritation or painful micturition, it is well for the 
 patient to be put on an exclusive milk diet after the manner de- 
 scribed above for treatment of nephritis in the preceding section. 
 
 OXALURIA 
 
 The condition of oxaluria may be unsuspected by the patient, 
 or it may attract his attention by a sensation of burning in the 
 urethra, desire for frequent micturition, headache, " nervous- 
 ness," etc. 
 
 Causation. — The occasional presence of a trace of calcium oxa- 
 late in the urine need not be considered as abnormal, but the con- 
 tinued presence of this substance in excess is mainly caused by eat- 
 ing certain kinds of food and by dyspepsia and perverted nutrition, 
 involving incomplete oxidation in the system of starchy, saccharine, 
 and fatty foods. 
 
 Ellis says that " oxalic acid is very readily prepared in the 
 chemical laboratory by the action of reagents upon sugar, starch, 
 and cellulose. This fact would seem to render probable the possi- 
 bility of its formation from the imperfect oxidation of these sub- 
 stances in the body," especially from bacterial fermentation in the 
 alimentary canal. 
 
 Fliigge has shown that bacteria can form this acid, and its crys- 
 tals occur in the intestine and are often found in the faeces. Oxa- 
 luria is common in connection with dyspepsia, and it is not 
 altogether improbable that some of it may be derived from imper- 
 fect digestion of food in the intestine, and be absorbed into the blood 
 just as ptomaines are. 
 
 Cantani finds that oxaluria is frequently present among those 
 who indulge too freely in saccharine and amylaceous foods. Beneke 
 holds quite an opposite theory, and attributes the condition to im- 
 perfect metabolism of proteid foods. Even fasting animals may 
 still show traces of calcic oxalate in their urine, and both in- 
 creased and diminished oxidation have been held accountable for 
 oxaluria. 
 
 Vegetables and fruits containing oxalic acid and its salts, and 
 which may cause oxaluria when eaten in excess, are rhubarb, toma- 
 toes, turnips, onions, sorrel, spinach, figs, strawberries, apples, 
 pears. Many other fruits and vegetables contain traces of oxalic 
 
502 DIET IN DISEASE 
 
 acid, but this fact is of little or no dietetic importance. Raw fruits 
 and vegetables which contain citric, malic, and other organic acids 
 seem to bear close relation to the formation of oxalic acid. The 
 latter is not necessarily ingested with the food, but is produced in 
 the body from a variety of substances. 
 
 Dietetic Treatment. — The diet should consist of animal food — 
 fish, poultry, game, and meat — with stale bread or toast with a 
 minimum of butter. Tea, coffee, carbonic-acid water, and alcohol 
 should be temporarily forbidden. Hot water (three quarters of a 
 pint) should be sipped half an hour before each meal, and before 
 breakfast a drachm or more of Carlsbad salts may be taken in con- 
 stipated cases. Dilute mineral acids, hydrochloric or nitro-hydro- 
 chloric, are beneficial if taken immediately after meals in doses of 
 fifteen or twenty minims in water. 
 
 CALCULI, RENAL AND VESICAL 
 
 Beverages. — When the presence of vesical calculus has been 
 demonstrated it becomes important to regulate the diet so as to 
 prevent, if possible, aggravation of the trouble. Not much is to be 
 hoped from the action of any solvents, such as the alkaline waters 
 or lithia salts, upon a large stone already formed, but diuretics may 
 certainly do much to prevent recurrence of the formation by con- 
 trolling vesical catarrh, and the production of mucus which forms 
 the nucleus, and sometimes a considerable part of many stones. 
 As White observes : " Our object should then be to make the urine 
 as bland and abundant as possible, and for this purpose there is 
 nothing better than milk and the free use of water between meals. 
 The particular kind of water to be used is of minor importance, as 
 the most noted waters in the treatment of stone seem to have 
 purity as their chief recommendation." 
 
 The still spring waters, such as Poland, Londonderry, or Bed- 
 ford, may be prescribed, or the waters of Vichy, Saratoga, or Ems, 
 on the principle that many patients will drink more fluid which 
 bears the name of some reputed " Spring " than they will if it be 
 plain water. 
 
 Paget was fond of trying the effect of an exclusive milk diet 
 before advising lithotomy. The milk is soothing, and while it is a 
 good diuretic, it lessens the desire for frequent micturition which is 
 often such an annoying symptom of vesical stone. 
 
 The occurrence of vesical calculus in children is believed by 
 Cadge, White, and others to be directly proportional to the diffi- 
 culty of getting abundant milk. It is therefore much commoner 
 among the children of the poor. White believes that '" diet and 
 regimen, at least in cities, have much more to do with the produc- 
 tion of stone than heredity, climate, water, soil, etc." 
 
THE URINARY SYSTEM 503 
 
 Young infants should not "be given lime water indefinitely with 
 their milk. 
 
 It is best for adults to relinquish the use of alcoholic stimulants, 
 but if this is not feasible light Rhine wine or still Moselle is ad- 
 missible, especially if neutralised by some alkaline table water 
 (Yeo). Lager beer is not harmful, and a little dry champagne or 
 a light hock or white wine may be taken. All the heavier clarets, 
 Burgundy and sweet wines of every sort, port, sherry, strong beer, 
 ale, porter, and stout are forbidden. Weak tea and coffee may be 
 drunk. Only such beverages should be allowed as contain no free 
 acids and no sugar, and those having the greatest diuretic effect 
 are the best. 
 
 Foods. — All highly seasoned and irritating articles, like vinegar, 
 pickles, strong condiments, such as mustard, should be rigidly for- 
 bidden, as well as anything prone to excite acid dyspepsia. 
 
 Among patients who have calculi of various kinds a consider- 
 able number are at the same time afflicted with obesity. Such per- 
 sons must be especially abstemious in regard to the use of fats and 
 sugars. Less corpulent persons may be allowed a little more laxity 
 in this regard. 
 
 Other substances to be avoided are puddings made with eggs 
 and sugar, and containing rice, sago, or other farinaceous foods, 
 suet puddings, pastry of all kinds, meat fat, and fat pork. 
 
 Bread, oatmeal, hominy, cracked wheat, cornmeal bread, cus- 
 tards, blancmange, boiled fish, and eggs are all admissible. 
 
 In many cases total abstinence from animal food for a week or 
 ten days is followed by marked improvement, the patient living 
 meanwhile on green vegetables, salads, and cooked fruits which are 
 not too acid, such as apples, not sweetened, but flavoured with some 
 bland aromatic, like cinnamon, nutmeg, or cloves. In other cases 
 it may not be necessary to withhold meat completely, but it should 
 always be taken in moderation, not more than once a day, and it 
 should be rare, lean, and thoroughly masticated. White meat of 
 chicken may be eaten. 
 
 The Carlsbad dietary, in which butter and sugar in all forms are 
 rigidly proscribed, is found to benefit calculus cases even more than 
 the total withdrawal of meat. 
 
 The above directions apply to the treatment of most varieties of 
 calculi, and not to any one kind alone. 
 
 In elderly people, in whom such disorders are relatively com- 
 mon, the functional elimination of waste from the body is consider- 
 ably impaired. For such persons, as well as for those who live 
 sedentary lives, it is important to abstain from overeating and espe- 
 cially from the use of animal food in excess. 
 
 34 
 
504 DIET IN DISEASE 
 
 LITH^MIA— URIC-ACID DIATHESIS— GRAVEL 
 
 Symptoms. — Lithsemia is a condition in which the blood con- 
 tains an excess of uric acid or its salts, and is usually productive of 
 such symptoms as insomnia, vertigo, tinnitus aurium, disagreeable 
 fulness of the head, and general " nervousness." The urine be- 
 comes loaded with nitrogenous waste. 
 
 When uric acid appears in excess as a sediment in the urine it is 
 very desirable that its formation should be checked, if possible, and 
 that any crystals already deposited in the kidneys and bladder 
 should be dissolved and eliminated. If the accumulation continues, 
 the presence of crystals (" gravel ") gives rise to attacks of renal or 
 vesical colic, causing intense agonising pain, and often haematuria. 
 A majority of the different forms of calculi are composed wholly or 
 in part of uric acid, and they may be formed in any part of the 
 urinary system, which, in addition to the other symptoms, may pos- 
 sibly cause ulceration and inflammation of the mucous membrane 
 or serious obstruction to the outflow of the urine. The exact mode 
 of production of uric acid in the body is still a matter of uncertainty, 
 but it is undoubtedly associated with nitrogenous metabolism, and 
 the acid is an imperfectly oxidised form of nitrogenous material. 
 The final destination of uric acid is its conversion into urea, but 
 from lack of perfect oxidation in the tissues this process is checked. 
 
 Dietetic Treatment. — The indications for dietetic treatment are 
 clearly, therefore, to reduce the animal foods in amount or tem- 
 porarily withhold them altogether, while giving large quantities 
 of plain water and of waters containing potassium or lithium salts 
 to aid in dissolving the uric acid already existing in the kidneys or 
 bladder, and promote its conversion into urea and hippuric acid. 
 The same rules apply to renal inadequacy from any cause, especially 
 to lessen the quantity of nitrogen consumed. 
 
 Although the acidity of the urine is not caused by uric acid, but 
 by acid sodium phosphate (Na 2 P0 4 ), the deposition of uric acid is 
 accomplished in an acid menstruum, and it is well to reduce the 
 urine temporarily to a neutral or even somewhat alkaline reaction. 
 This can be done by adapting both food and drink. 
 
 Animal food, except milk, tends to make the urine acid, whereas 
 milk and vegetable food favour alkalinity. In speaking of the lithic- 
 acid diathesis in children, Fothergill wrote that " lean meat, raw 
 meat minced, and beef tea are so much poison." Lithsemic head- 
 aches will often cease when the patient stops eating butcher's meat, 
 cheese, etc., if excessive indulgence in animal food has been the 
 previous habit. Peptonised food is worse, for the dyspepsia which 
 often accompanies lithsemia is in a way a conservative process, 
 checking the digestion of animal foods, whereas the predigested 
 foods are more promptly and easily carried to the overburdened 
 
THE URINARY SYSTEM 505 
 
 liver. Some lithaemic patients cannot take meat well in hot weather, 
 but can do so at other seasons. But an excessive meat diet cannot 
 be regarded as the sole cause of lithaemia ; other factors are con- 
 cerned, such as overeating and the abuse of saccharine food, which 
 causes malfermentation, deranges the functions of the liver, and 
 alters the composition of both blood and urine. 
 
 Murchison declares that " habitual lithaemia often results from 
 the patient taking more food than can be converted into tissue or 
 disintegrated in the liver," and Sir Henry Thompson expressed his 
 views in regard to sweets thus forcibly : " Sugar, in all its forms, at 
 every meal, and wherever met with, forbid it altogether, ... let 
 fatty matters, butter, cream, and the fat of meat, whether simply 
 cooked or in combination to form pastry, be taken very sparingly." 
 This is the practice at Carlsbad also, and it reduces the work of 
 the liver and kidneys. For some patients — especially the obese — it 
 is more important than wholly eliminating meat from the regimen. 
 
 Murchison, who was among the first to advocate a rational die- 
 tetic treatment of habitual lithaemia, forbade all saccharine and 
 oleaginous food, especially " made dishes," and highly seasoned 
 foods, sauces, rich gravies, etc. In severe cases he advised giving 
 up amylaceous foods as well, and forbade the eating of potatoes, 
 rice, sago, fruits, etc., and bread was allowed only in moderation. 
 In most cases, however, vegetables were given sparingly, and white- 
 fish, poultry, game (if not too rich), and eggs were included. The 
 total quantity of food was reduced. 
 
 Many acids contained in fresh fruits, such as benzoic or quinic 
 acid, have a favourable solvent action. These acids are found in 
 the external cuticle of fresh fruits and vegetables, which may be 
 eaten in cases of gravel. According to Lyman, eating raw, unpeeled 
 apples in considerable quantities supplies potassium salts, which 
 tend to increase the alkalinity of the blood, but sweet fruits, pears, 
 grapes, plums, strawberries, etc., must not be indulged in. 
 
 Patients may eat abundantly of oatmeal, wheaten and Graham 
 bread toasted, macaroni, fresh young peas, string beans, Lima 
 beans, rice, spinach, asparagus, celery, lettuce, and other salads, 
 except tomato (without oil). Meat should not be eaten oftener 
 than once a day. Fresh fish, sweetbread, poultry, and game may 
 be taken sparingly. No diet can be rigidly enforced in every case 
 alike. Alexander Haig (Diet and Food) classifies as " uric-acid- 
 free " foods, milk and its products, breadstuff's, cereals and glutens, 
 nuts, vegetables, and fruits. 
 
 If lithaemia is present in young children after three or five years 
 of age, they require a larger proportion of fat. They may have 
 bread and butter with a little fat bacon, or a baked potato with 
 butter, and puddings of bread, crackers, rice, or sago, but not of 
 raw flour. They must not be offered sweets. They have poor ap- 
 
506 DIET IN DISEASE 
 
 petites, and some variety must be prescribed, or they will lose 
 weight and strength. 
 
 Some writers are disposed to attach less importance to dietetic 
 errors as influencing lithsemia, and the cooking is far more im- 
 portant than the composition of the food. Reasonable variety, in- 
 cluding proteid food, should be allowed, for " lithaemics do best on 
 plenty of well-prepared food in the greatest variety according to 
 the seasons " (L. C. Gray). 
 
 Beverages. — Various alkaline mineral waters are constantly pre- 
 scribed for adults, and patients who can afford to take the course 
 are benefited by the baths of Carlsbad, Vichy, Neuenahr, Ems, etc., 
 but for those to whom travel is an impossibility and whose means 
 do not allow them to purchase artificial mineral waters, very good 
 substitutes are to be made by dissolving sodium carbonate or so- 
 dium phosphate in soda water or sour lemonade, or in plain water, 
 in the proportion of from one to two drachms in three or four pints, 
 to be taken in the course of the twenty-four hours, or two to five 
 grains of the carbonate of lithium may be employed in the same 
 way. Effervescent lithium tablets are now sold which may be added 
 to a tumbler of water at the table and taken with meals. 
 
 Solution of the deposits, or at least the prevention of their in- 
 crease, is aided by the free drinking of Londonderry, Buffalo, or 
 other lithia waters, Vichy, Waukesha, etc., although it must be 
 said of most so-called lithia waters that their use is chiefly that of 
 pure water, for a barrelful would have to be drunk to obtain an 
 ordinary medicinal dose of lithium. 
 
 Most patients do better without alcohol in any form. They may 
 feel the loss of accustomed stimulation for a few months, but they 
 should make a strong effort to give it up completely. Malt liquors 
 and sweet wines, champagne, and spirits had better be absolutely 
 forbidden, but if necessary, a little good sound claret or Scotch 
 whisky in water may be drunk. 
 
 Gravel is much less common among habitual beer drinkers than 
 among those whose daily beverage is wine. This is attributed by 
 Moleschott to the greater acidity and larger proportion of alcohol 
 in the latter. On the contrary, Ebstein holds that beer is not in- 
 jurious in lithiasis, and tea also has some reputation in checking the 
 deposition of uric acid. Coffee does no harm. 
 
 Gonorrhoea 
 
 The dietetic treatment of gonorrhoea consists in avoiding all 
 alcohol and stimulating food and drinking bland diluents. 
 
 In severe cases, and in cases among young children who have 
 in some manner been infected, a skimmed-milk diet should be or- 
 dered at first. Later, light farinaceous articles, stale bread and but- 
 
THE ALIMENTARY CANAL 507 
 
 ter, milk, and rice puddings should be added. Patients, for fear of 
 attracting attention to their ailment, are often unwilling to restrict 
 their meals, but they must avoid acid fruits, all highly seasoned and 
 fried food, condiments, and pastry. Alcoholic drinks in all forms 
 are absolutely prohibited. Malt liquors are especially bad, as they 
 are in all diseases of the urethra, bladder, or prostate. No late 
 meals should be taken. By observing these directions troublesome 
 chordee and ardor urinse, so apt to appear in the first fortnight, may 
 be prevented. Large quantities of such waters as soda, Seltzer, 
 Apollinaris, and two or three quarts of plain water should be drunk. 
 The fluid dilutes the urine, diminishes the danger of cystitis, and 
 has the additional advantage of decreasing the appetite. 
 
 DIET IN DISEASES OF THE ALIMENTARY CANAL 
 
 Diet in Abnormal Dentition 
 
 In abnormal dentition in children the food is imperfectly masti- 
 cated, and gastric dyspepsia or gastric catarrh may follow. If den- 
 tition is delayed and the teeth are imperfect, as in the case of rickets, 
 scrofula, tuberculosis, or any protracted disease involving nutrition, 
 the diet should be made as nourishing as possible, and meat, eggs, 
 milk, cream, and broths should be given in addition to cereals. 
 Cod-liver oil is usually prescribed with benefit. There is no one 
 food of special value for retarded dentition on account of its con- 
 taining the lime salts of the teeth, and the chief reliance for this pur- 
 pose must be placed in building up general nutrition. 
 
 In all cases of dyspepsia, gastric catarrh, rickets, or syphilis the 
 teeth must be carefully examined before prescribing special dietetic 
 treatment. 
 
 If the teeth are broken or irregular all solid food should be 
 carefully prepared by mincing or otherwise reducing it to a form 
 requiring but little mastication. In a young child a sore mouth from 
 swollen gums is often overlooked as a cause of anorexia. 
 
 The perfection with which false teeth are now fitted has done 
 much to improve the digestion of adults and to add to the comfort 
 and, no doubt in some instances, prolong the life of the aged. Their 
 use enables solid food to be eaten, and the act of mastication in- 
 creases the flow of saliva, which not only digests starchy food but 
 tends to neutralise a too acid gastric juice, if the latter be present. 
 
 Catarrhal Stomatitis 
 
 Catarrhal stomatitis is a simple inflammation of the mucous 
 membrane of the mouth which, among other causes, may be ex- 
 cited by taking food or drink at either extreme of temperature. 
 
508 DIET IN DISEASE 
 
 Food which is very acid or too highly seasoned with condiments 
 mar cause it, so also may excessive drinking and smoking. 
 
 No special diet is required beyond giving food which is easily 
 swallowed and which is free from the above objections. 
 
 When the disease occurs in infants their diet must be regulated 
 according to the directions for feeding detailed under the heading 
 Infant Feeding. 
 
 In gangrenous stomatitis the mouth may become too sore to ad- 
 mit of swallowing, in which case food must be given by the rectum. 
 (See Nutrient Enemata, p. 408.) Otherwise small quantities of 
 fluid food must be ordered at frequent intervals. Concentrated 
 meat broths, egg albumin, meat juice, and milk are to be taken at 
 hourly intervals. If the stomach is irritable this food should all be 
 predigested with pancreatin. Alcohol, preferably in the form of 
 brandy, should be frequently given to the limit of toleration. 
 
 The above directions apply also to cases of inflammation of the 
 mouth and pharynx caused by corrosive poisons, such as carbolic 
 acid, ammonia, etc. 
 
 TONSILITIS AXD QUINSY 
 
 These diseases require no special care in the acute stage beyond 
 giving food in such fluid form as can be most easily swallowed. 
 The pain caused by this act is often so extreme that it is advisable 
 to concentrate all food, to lessen the number of necessary acts of 
 deglutition. Meat juice, peptonoids, beaten eggs, and brandy may 
 be added to good milk. Plain vanilla ice cream may be given. Its 
 coldness is sometimes soothing to the pharynx. 
 
 Holding cracked ice in the mouth before swallowing will some- 
 times annul the pain momentarily, or in extreme cases the pharynx 
 and tonsils may be sprayed with cocaine, and the period of tempo- 
 rary anaesthesia may be utilised for swallowing considerable nour- 
 ishment. This is rarely necessary, for unless the patient is ema- 
 ciated by previous serious illness, he is not apt to be in need of 
 much food for a day or two. In bad cases of suppurative tonsilitis 
 the strength suffers more, and stimulants may be given by the rec- 
 tum if deglutition is impossible. 
 
 After all forms of tonsilitis there is apt to be considerable anae- 
 mia, and the patient for a week or two should eat abundantly of 
 animal food. Eggnog and milk punches are often needed for the 
 first few days of convalescence. 
 
 Dysphagia 
 
 When the normal mechanism of swallowing the food is disturbed 
 the condition is called dysphagia. It is commonly due to one of the 
 following causes : Spasm of the muscles of mastication (trismus) ; 
 
THE ALIMENTARY CANAL 509 
 
 inflammations of the mouth, tongue, pharynx, or tonsils ; diphtheria ; 
 tubercular, cancerous, or syphilitic pharyngeal disease ; retropharyn- 
 geal abscess ; stricture or carcinoma of the oesophagus ; paralyses 
 (sometimes of central origin) ; operations upon or near the pharynx ; 
 or the wearing of an O'Dwyer tube in the larynx. 
 
 The devices employed to enable the patient to overcome pain or 
 difficulty in swallowing his food should include reduction of the 
 efforts at swallowing to a minimum. A raw egg or oyster may 
 sometimes be gulped down by a single act when the dread of pain 
 from more repeated effort deters the patient from taking other food. 
 Whatever is given should therefore consist of concentrated nutri- 
 ment in a smooth, semisolid or gelatinous form. Wine jelly may 
 be re-enforced with beef peptonoids or tgg albumin, and custards 
 may be thickened with farinaceous material to a consistence which 
 will enable them to be quickly swallowed. 
 
 When patients are unable to swallow, an oesophageal tube is in- 
 serted for feeding, which, however, should be a catheter of small 
 calibre (English 8 to 18), and which need not be passed very far 
 down into the oesophagus. If necessary, a 2- or 4-per-cent solu- 
 tion of cocaine may be first applied to the pharynx to relieve pain 
 and irritation. The fluid food — eggnog, broths, thick gruels, milk, 
 etc. — is poured into the tube through a funnel. 
 
 When the tube feeding cannot be practised, it becomes necessary 
 to resort to rectal enemata, or both methods may be employed in 
 order to reduce the number of feedings through the painful throat. 
 
 Delavan calls attention to the important fact that the point of 
 greatest irritation is often the palatine arches, and by passing the 
 tube through the nose into the pharynx behind them this difficulty 
 is neatly avoided. 
 
 In hopeless cases of cancer or of tubercular ulceration of the 
 epiglottis, tonsils, etc., which are so intensely painful, it may be 
 justifiable to perform gastrotomy in order to place food directly in 
 the stomach. This is certainly preferable to letting the patient starve 
 to death because he finds the agony of swallowing is even worse 
 than the pangs of hunger. 
 
 Stricture and Carcinoma of the CEsophagus 
 
 In diseases of the oesophagus which render swallowing difficult 
 all food must be given in semisolid or fluid form. Many vegetable 
 substances can be made into purees, which can be strengthened by 
 meat extracts, peptonoids, or beef meal. Milk, in its various forms, 
 is always soothing, and it may be the only food which the patient 
 can take. 
 
 Richardson states that in oesophageal stricture cold food relaxes 
 the circular fibres of the oesophagus and dilates its lumen, whereas 
 
5IO DIET IN DISEASE 
 
 hot food has an opposite effect. In some hysterical patients this 
 may prove true, but in most cases of genuine stricture or occlusion 
 the temperature of the ingested food makes but little difference. 
 When the occlusion or the difficulty or pain in deglutition becomes 
 so great that the patient suffers from inanition — as, for example, after 
 corrosive poisons have been swallowed — he must be fed by nutrient 
 enemata. Should the trouble not be overcome, a gastric fistula must 
 be made, and the patient is to be fed by this means. 
 
 Feeding through a Gastric Fistula. — When a gastric fistula is 
 made the wound may be left open with a drainage tube, or, what 
 is better, a permanent hard-rubber or metallic tube is inserted, having 
 a double flange, like a spool. The tube is nickel-plated to prevent 
 erosion by the acid gastric juice. The lumen may be a third of an 
 inch in diameter, and when not in use it is kept closed by a cork. 
 When the patient is to be fed he must lie upon his back. The cork 
 is removed, the tube cleansed with a syringeful of warm water, and 
 through a glass funnel, to which is attached an inch or two of rubber 
 tubing, fluid food and water is poured directly through the fistulous 
 opening into the stomach. If desirable, lavage may be performed in 
 a similar manner. Any kind of food may be given which the patient 
 is able to digest. Even small pieces of chopped meat can be pushed 
 into the stomach with a glass rod or forceps. Medicines are con- 
 veniently given through the same opening. When the fistula has 
 been made for other cause than, malignant disease the tube may be 
 worn indefinitely with no other inconvenience than that attending 
 the peculiar process of feeding. I have seen several patients who 
 have worn such tubes for several years, and who go about like other 
 men, excepting that they take their meals in private and feed them- 
 selves while lying on the back. One of these patients, who was 
 operated upon in Bellevue Hospital by F. S. Dennis for a benign 
 stricture of the pylorus following typhoid fever, first masticates his 
 food, then expectorates it and pushes it into the tube with a glass rod. 
 He maintains robust health. 
 
 FOREIGN BODIES SWALLOWED 
 
 When foreign bodies have been accidentally swallowed, such as 
 coins, buttons, safety or other pins, large cherry, plum, or other 
 fruit stones, fish bones, chicken bones, or pieces of clam or oyster 
 shells, if the patient is seen within two or three hours, the object 
 having passed beyond the reach of the finger or oesophageal pro- 
 bang, an emetic may be given. If this fails to return the foreign 
 body from the stomach, the patient should eat large quantities of 
 bread, oatmeal, or potatoes. The plan of this treatment is to fur- 
 nish a bulk of faecal matter, which in the intestines may envelop 
 the pin or bone, and prevent its sharp or roughened ends from in- 
 
THE ALIMENTARY CANAL 5 1 1 
 
 juring the mucous membrane. Six or eight hours later a dose of 
 castor oil should be given. By this means many dangerous objects 
 may be safely voided. If the foreign body does not appear after 
 the oil has acted, the treatment should be repeated next day, and 
 the stools must be carefully watched until it is recovered. Experi- 
 ence has shown that the search should not be abandoned for at least 
 eight or ten days. Men who earn a precarious livelihood by publicly 
 exhibiting themselves as possessing " iron stomachs," and who swal- 
 low broken glass, coins, nails, etc., take considerable risk from ex- 
 citing grave injury or peritonitis, but by eating the foreign bodies 
 only when the stomach is nearly full, and by following the treatment 
 outlined above, they manage to escape death. 
 
 Indigestion and Dyspepsia 
 
 Symptoms. — Indigestion and dyspepsia are terms which refer 
 essentially to functional slight and often temporary derangement of 
 the digestive system, although these conditions may result from 
 many varieties of disease, especially from fever due to almost any 
 cause. The terms are used somewhat vaguely to include a number 
 of minor symptoms, such as weight and oppression at the epigas- 
 trium and prsecordium, eructations, " water brash," palpitations, ver- 
 tigo, headache, modified taste and thirst sensations, loss of appetite 
 or morbid craving for certain indigestible articles of food, flatu- 
 lency, hiccough, and sometimes nausea, heartburn, pain referred to 
 the cardiac end of the stomach, lassitude, irritability, drowsiness or 
 restlessness, and despondency. As Sir Henry Thompson said : " The 
 word indigestion denotes not a disease, but an admonition." 
 
 Fothergill wrote : " If it were not for the protection of indiges- 
 tion, of which many so bitterly and ungratefully complain, the lives 
 of a large number of individuals would not attain their furthest po- 
 tential expansion." 
 
 Many of these symptoms, especially those referable to the nerv- 
 ous and vascular systems, are explained by the belief that morbid 
 products which closely resemble poisonous alkaloids in their action 
 (as indeed in their composition), and which are called ptomaines or 
 leucomaines, are easily absorbed, and produce effects varying in 
 intensity from slight headache to the collapse of violent ptomaine 
 poisoning (p. 374). Other symptoms are doubtless due to imperfect 
 elimination of waste matter of food or " ashes " from the system. 
 
 Bauer says : " It is beyond doubt that insufficient secretion is the 
 essential cause of most dyspeptic symptoms as they appear in vari- 
 ous disorders of the stomach." 
 
 In severe fevers and conditions of advanced anaemia or gastric 
 catarrh the stomach secretes chiefly a ropy alkaline mucous fluid, 
 with little or no true gastric juice. 
 
512 DIET IN DISEASE 
 
 As a rule, the acid gives out before the pepsin, and a deficiency 
 of acid is a very common condition, especially in anaemia. Anaemia 
 produced experimentally by repeated bleeding of animals will 
 cause it. 
 
 Chronic hyperemia and inflammation of the stomach excited by 
 coarse irritating food have the same result, and the free acid, if 
 secreted, is neutralised by abundant mucus. 
 
 Deficiency of hydrochloric acid in the gastric juice has a three- 
 fold effect: i, Failure to digest proteids ; 2, failure to arrest mal- 
 fermentation or putrefactive changes in the food ; 3, failure to excite 
 gastric peristalsis, so that the food lingers too long in the stomach. 
 Other causes of delay may be found in too large a bulk of food, 
 lack of peristalsis, and obstruction through stenosis of the pylorus 
 without corresponding increase in contractile power of the stomach. 
 
 Gases. — The normal gases of the stomach are those of atmos- 
 pheric air; but food which is improperly fermenting is capable of 
 evolving others, and those which have been determined by analysis 
 of eructations are C0 2 ,H 2 ,0 2 N 2 ,CH 4 (marsh gas) C 2 H 4 (olefiant 
 gas). Ewald reports a case in which sufficient marsh gas was evolved 
 from the stomach to burn with a pale-yellow flame. 
 
 Some degree of lactic-acid fermentation may be a normal accom- 
 paniment of gastric digestion, but the process is easily carried too 
 far ; butyric acid develops, and gases are evolved. This action re- 
 sembles that produced outside the body when decomposing albumin 
 comes in contact with saccharine substances. 
 
 Distention of the stomach and intestine with gas interferes with 
 the free play of the diaphragm in the respiratory movements, and 
 since the heart lies upon its side, separated from the stomach only 
 by the diaphragm, an inflated stomach compresses and displaces the 
 heart, interfering with its rhythm and force and causing palpitations. 
 The latter, in connection with impeded extent of movement of the 
 diaphragm, produces dyspnoea, especially on exertion. 
 
 Pain is a very frequent accompaniment of dyspepsia. It is usu- 
 ally of a dull aching variety, but is sometimes sharp and acute. It 
 is often erroneously referred to the heart, but it is due rather to 
 hyperesthesia of the stomach wall, excited by products of imperfect 
 digestion. 
 
 In all diseases of the stomach the retention of any particles of 
 undigested food gives rise to irritation and malfermentation, which 
 still further complicates the diseased condition of the organ itself 
 and interferes with its proper action upon fresh quantities of food. 
 This may be occasionally relieved by vomiting or by the ingestion 
 of some simple fluid which will aid in washing the stomach contents 
 onward into the intestine. 
 
 Etiology, Idiosyncrasies. — Personal idiosyncrasy is a very potent 
 factor in dyspepsia. Not only do individuals vary from one another 
 
THE ALIMENTARY CANAL 513 
 
 in this regard, but the same person varies at different periods, in 
 different stages of health, or at different ages. One not uncom- 
 monly observes persons who are most confirmed dyspeptics at home, 
 but who when at sea are able to eat and digest all manner of richly 
 cooked and thoroughly indigestible food without either nausea or 
 discomfort, only to return to their dyspepsia on shore. On the other 
 hand, many persons whose digestion is normal at home are made 
 constipated and dyspeptic by the lack of exercise and by other con- 
 ditions at sea, even though they be never " seasick." How often 
 do dyspeptics who have been long kept upon a rigid regimen break 
 away from all restraint and give astonishing accounts of the for- 
 bidden articles which they have suddenly discovered they can eat 
 for a time with impunity ! One who cannot digest the most tender 
 mouthful of prepared meat or a crust of dry bread will thrive upon 
 enormous quantities of nuts and oranges ; another requires a pre- 
 posterous quantity of pickles or of Cayenne pepper to stimulate the 
 sluggish digestion into any sort of activity, and another lives largely 
 upon raw apples ! 
 
 Many people cannot eat strawberries without attacks of heart- 
 burn, dyspepsia, and angina, while for others they are very whole- 
 some food. Some persons cannot eat cauliflower without exciting 
 dyspepsia, and for others the use of melted butter invariably brings 
 on such an attack, while butter spread upon bread does not. Others 
 exhibit intolerance for twice-cooked meats, new bread, potatoes, 
 sweet jams of any kind, etc. (See Idiosyncrasies in Regard to Food, 
 
 p. 39I-) 
 
 Other Causes. — Fats and greasy foods set up butyric-acid fer- 
 mentation which causes heartburn, regurgitation, and a rancid dis- 
 agreeable taste. 
 
 Sweets and raw or insufficiently cooked starches cause lactic-acid 
 and other fermentations, with flatulence. 
 
 Combinations of certain foods almost always disagree, as, for 
 example, sweets and acids, fruits and beer, ice cream and beer, milk 
 and cherries, milk and crabs. 
 
 Dyspepsia is often caused by the continued abuse of irritants, 
 such as alcohol and highly seasoned food, pickles, mustard, Cayenne. 
 
 Tobacco and strong tea and coffee have a depressing action upon 
 the nervous force of the stomach. 
 
 To enumerate all the various substances which may at some time 
 or other cause indigestion would be to include practically the entire 
 list of foods. Each new case must be separately studied, and gen- 
 eral rules admit of many exceptions. 
 
 Balfour concisely sums up the relations of food to enfeebled 
 stomach digestion by saying : " Three things greatly disturb gastric 
 comfort — too large a meal, too short an interval between the meals, 
 and, lastly, the ingestion of food into a stomach still digesting." 
 
514 DIET IN DISEASE 
 
 Examination of the Patient. — It is important at the outset to 
 understand all the patient's habits of daily life, the amount of sleep 
 and exercise taken, the hours of meals and quantity and quality of 
 food eaten, habits of drinking or smoking, the habit of the bowels, 
 condition of the stools, and the nature of any irregularity — the habit 
 of eating too fast or taking too much or too little fluid with the 
 meals. The condition of the teeth and tongue and breath must also 
 be observed, and in obscure cases the possible existence of sources 
 of reflex irritation, like ovarian disease, must be investigated. The 
 proper cooking of the food should be insisted upon. Thorough 
 cross-examination in regard to all of these conditions may reveal 
 habits not suspected by the patient to be injurious, and which may 
 be easily corrected. 
 
 Slow Eating. — A simple explanation of the normal physiology 
 of digestion will often interest an intelligent patient and secure his 
 hearty co-operation in methods suggested for his cure, which other- 
 wise he would find extremely irksome. He should understand that 
 digestion commences at once in the mouth by the proper preparation 
 there of all food and the digestion of starch in particular, and that 
 the practice of slow eating gives time not only for more thorough 
 mastication, but also for more abundant secretion of the neces- 
 sary digestive fluids, saliva, and gastric juice. Very slow eaters 
 are far less often dyspeptic than those who " eat and run." 
 The sign " Quick Lunch," so commonly displayed in restaurants 
 in business quarters of active American cities, has contributed 
 much toward earning for Americans the title of a " Nation of 
 Dyspeptics," for a meal quickly served is too quickly eaten as 
 well. A dyspeptic child should be taught to count between his 
 mouthfuls. 
 
 Solid food insufficiently masticated passes into the stomach too 
 dry and in too large masses for the gastric juice to act upon it 
 promptly, and stomach digestion is greatly retarded. In persons 
 with feeble digestive power who eat hastily, pieces of meat and 
 tough vegetable fibres often appear in the stools wholly unaltered. 
 The sense of taste may be utilised in order to prolong mastication 
 by savoury cooking. It also stimulates the secretion of saliva and 
 gastric juice. In such cases, as well as in those in which the teeth 
 are absent or defective, it is well to prohibit all food which is not 
 completely subdivided or tender, as, for example, tough meats and 
 stringy or fibrous vegetables. 
 
 Pain. — In nervous dyspepsia pain exists as a prominent symp- 
 tom, and is often independent of the quality of the food — even a 
 mouthful of water may cause it, but, as a rule, fatty and acid foods 
 excite it, and must therefore be avoided. The appetite, too, varies 
 greatly — it may completely fail at one time, and return in an exag- 
 gerated form at another. Decker reported the case of a patient who 
 
THE ALIMENTARY CANAL 5 1 5 
 
 was uniformly awakened from sleep by such excessive hunger that 
 he was obliged to take a hearty luncheon in the middle of the night. 
 
 EXAMINATION OF THE STOMACH CONTENTS 
 
 In all cases of protracted dyspepsia which do not yield readily 
 to dietetic treatment and proper medication it becomes important 
 to ascertain the exact condition of the stomach and gastric juice, 
 and for this purpose several ingenious clinical tests have been de- 
 vised. These tests are applied to ascertain — I. The degree of acid- 
 ity of the gastric juice. 2. The vigour of peristaltic action of the 
 stomach wall. 3. The rate of absorption from the mucous mem- 
 brane. 
 
 To determine the acidity of the gastric juice, a fresh specimen 
 must be obtained for analysis, and by far the best method is by 
 siphonage. The stomach tube is inserted in the manner described for 
 gastric lavage (p. 538), and the contents of the stomach are with- 
 drawn in sufficient quantity to yield a satisfactory analysis. 
 
 Some hysterical dyspeptics vomit so readily that the gastric juice 
 may be obtained from the ejecta at any time. 
 
 TEST MEALS 
 
 The composition of the gastric juice is best determined by fol- 
 lowing lavage by a test meal. After a definite period the stomach 
 tube is again introduced and a sample of the stomach contents is 
 withdrawn, filtered, and examined for hydrochloric acid and pepsin. 
 If desired, other tests may be made for rennet ferment, carbohy- 
 drates, peptones, albuminoses, lactic acid, phosphates, and fatty acids. 
 The test for hydrochloric acid is the only one commonly applied 
 for clinical purposes, and to aid the selection of proper diet, the 
 others belong rather to special research. 
 
 The best test meals are Riegel and Leube's test dinner, and a 
 modification of this, known as Ewald's test breakfast, which is easier 
 to eat and does not obstruct the stomach tube, although it stimu- 
 lates the digestive activity of the stomach somewhat less. The stom- 
 ach contents should be withdrawn for examination one hour after 
 the breakfast, but between four and five hours after the dinner. 
 
 Riegel and Leube's test dinner consists of — 
 
 Beef soup . 400 cubic centimetres. 
 
 Beefsteak 200 " 
 
 White bread 5° " 
 
 Water 200 " 
 
 Ewald's test breakfast is 35 to 70 cubic centimetres of wheaten 
 bread (one or two white coffee rolls) with 300 cubic centimetres of 
 water or weak tea without sugar or milk. When the contents of 
 
516 DIET IN DISEASE 
 
 the stomach are withdrawn one hour after ingestion of this meal 
 its total quantity should be found reduced to 20 to 40 cubic centi- 
 metres. 
 
 In withdrawing the contents of a stomach after a test meal the 
 same tube is used, and in the same manner as that employed for 
 lavage, described on p. 538. It is important that its introduction 
 should not be accompanied by violent retching, for when this takes 
 place bile is very apt to be regurgitated into the stomach and neu- 
 tralise its acid contents, rendering subsequent tests useless. The 
 retching may be overcome by painting or spraying the pharynx with 
 a 2- or 4-per-cent solution of cocaine, or, as Stewart recommends, 
 by allowing the patient to swallow a few drops of the solution, to 
 anaesthetise the oesophagus. The use of a rather stiff tube, quickly 
 inserted, diminishes the liability to retching. The tube should not 
 be lubricated when used for the test meals, but it may be wetted. 
 The gastric contents may be forced out through the tube by direct- 
 ing the patient to forcibly expire, thereby compressing the stomach 
 by the abdominal muscles, and simultaneously the epigastrium should 
 be firmly compressed by the hands. It is also obtained by attaching 
 to the stomach tube the bulb of a Davidson syringe or a suction 
 bottle such as that in common use for aspirating the thorax or abdo- 
 men. If no fluid flows, a little air or warm water may be forced 
 through the tube to cleanse the obstructed fenestra. 
 
 Dujardin-Beaumetz gives a test breakfast of coffee or tea with 
 milk and a little sugar, and one or two plain rolls ; no butter. The 
 fluid must not exceed a pint. The normal stomach digests such a 
 meal without sensation. If within two hours there is a sensation of 
 heat in the stomach or burning and acidity, hyperacidity is present. 
 If there is eructation of gas, fulness and weight at the stomach, 
 then there is diminished or hypoacidity. 
 
 If pain occurs within fifteen minutes with increasing intensity 
 there is probably some organic lesion. In hyperacidity, moreover, 
 Beaumetz says that the burning is worse three to four hours after 
 eating, and is commonest in the middle of the night. It is often 
 relieved by ingestion of food, which temporarily dilutes the acid. 
 He urges dyspeptics to sleep on the right side, to aid the passage 
 of food through the then dependent pylorus. 
 
 TEST FOR TOTAL ACIDITY OF THE GASTRIC JUICE 
 
 Before testing for the presence of free hydrochloric acid, the 
 total acidity of the stomach may be obtained, which is the combined 
 acidity produced by HC1 and lactic or other organic acids commonly 
 developed by malfermentation. This total acidity should equal nor- 
 mally 40 to 65 (Ewald), which represents "the number of cubic 
 centimetres of test solution required to exactly neutralise 100 cubic 
 
THE ALIMENTARY CANAL 517 
 
 centimetres of gastric filtrate " (D. D. Stewart). The test solution 
 is prepared as follows : 
 
 " Four grammes of NaOH dissolved in one litre of distilled water 
 is used for neutralisation ; each cubic centimetre of this solution will 
 exactly neutralise 0.00365 gramme of absolute hydrochloric acid. 
 The number of cubic centimetres so used multiplied by 0.00365 
 equals the percentage of HC1 contained in 100 cubic centimetres 
 of the gastric filtrate " (Stewart). 
 
 CHEMICAL TEST FOR FREE HYDROCHLORIC ACID 
 
 A number of chemical tests have been devised for the detection 
 of hydrochloric acid. 
 
 Giinzberg's Test for Free Hydrochloric Acid. — 
 
 Phloroglucin 2 
 
 Vanillin I 
 
 Absolute alcohol 30. Mix. 
 
 Two or three drops of this solution are placed on a white por- 
 celain dish and allowed to slowly flow in contact with a similar 
 quantity of filtered gastric juice. The dish is very slowly and gently 
 heated over a spirit flame or Bunsen burner, and if hydrochloric 
 acid is present, a faint rose-red hue appears at the line of contact, 
 which deepens as evaporation continues into a brilliant cherry 
 red. If the acid is abundant, minute cherry-coloured crystals will 
 form. If the acid is feeble, it is best to concentrate the stomach 
 filtrate upon a water or sand bath to about one tenth of its origi- 
 nal bulk. 
 
 When merely a faint trace of the free acid is present the appear- 
 ance of the colour should be carefully watched, for it is very eva- 
 nescent. 
 
 Gunzberg showed that one drop of the normal gastric juice — i. e., 
 juice containing 0.2 per cent of free hydrochloric acid — when diluted 
 ten times, should still give the colour. If it appears when the dilu- 
 tion is carried beyond this limit, hyperacidity is present. 
 
 This is, on the whole, the most reliable clinical test which has yet 
 been devised, and the ease and quickness of its application for diag- 
 nostic purposes has much to recommend it. It requires no special 
 skill, and should always be made, to test the progress of the treat- 
 ment, while lavage is being performed. 
 
 The Boas Test for Hydrochloric Acid. — The Boas test is performed 
 in a similar manner to the Gunzberg test, but the colour produced 
 varies from rose to vermilion, and the solution is made as follows : 
 
 Sublimed resorcin 5 
 
 Sugar 3 
 
 Dilute alcohof. 100. Mix. 
 
518 DIET IN DISEASE 
 
 Both tests are only of value from a positive standpoint — i. e., if 
 the colour reaction occurs, free hydrochloric acid is surely present, 
 They are, however, of little or no value as negative tests, for the 
 reason that if peptones or certain other substances are present in the 
 stomach contents the reaction may be entirely obscured. The latter 
 difficulty is met by application of the calcium-carbonate test, which 
 is uninfluenced by other substances likely to be associated with the 
 gastric juice, with the single exception of an excess of acid phos- 
 phates. 
 
 The Calcium-carbonate Test. — This is conducted as follows : A 
 sample of gastric contents is heated to remove fatty acids, and shaken 
 with ether to remove any lactic acid present, and blue litmus paper 
 is dipped in the fluid. Another blue litmus paper is dipped in a 
 fresh sample of the gastric contents which has been neutralised by 
 the addition of dry pure CaCo 3 . The redness of the first paper when 
 compared with the second will declare the presence of free hydro- 
 chloric acid. 
 
 A strong Giinzberg reaction usually indicates normal reaction or 
 hyperacidity. Its absence when hydrochloric acid is revealed by 
 the CaCo 3 test indicates subacidity. If the latter test fails, then no 
 free acid is present. 
 
 Acid Salts. — If the litmus dipped into the gastric juice neutral- 
 ised by CaCo 3 is reddened, the presence of acid salts (phosphates) 
 is indicated. 
 
 The normal gastric free hydrochloric acid maintains a remarkable 
 uniformity in strength, very rarely exceeding 0.2 per cent. 
 
 It has been shown by Ewald and Leo that it is not secreted dur- 
 ing fasting, but enters the stomach as soon as the stimulus of food 
 is felt. At first it replaces the acids from lactates and phosphates, 
 setting these acids free and forming chlorides with their bases. The 
 hydrochloric acid also unites with albuminoids. For these reasons 
 free HC1 is not apparent in the gastric juice until the combina- 
 tions mentioned have been all saturated, after which it increases 
 in strength to the normal standard of 0.15 to 0.2 per cent. If 
 alkalies are ingested, more HC1 is secreted ; but if acid be taken, the 
 further secretion of HC1 is checked, so that the average strength is 
 preserved. 
 
 These conditions explain why it is that within fifteen minutes 
 after ingestion of an Ewald test breakfast lactic acid may be found 
 in the stomach contents, while free HC1 may not appear for half or 
 three fourths of an hour. 
 
 Lactic acid is obtainable for an hour, or until the full strength of 
 free HC1 secretion is reached. If a heavy meal of bread and meat 
 and vegetables has been eaten, the lactic-acid reaction will continue 
 for a couple of hours, but free HC1 may not be demonstrated for 
 from three to four hours. 
 
THE ALIMENTARY CANAL 5 19 
 
 This is an observation of considerable practical importance ; for 
 in the early stage of digestion, the acidity being low and due only 
 to organic acid, the ptyalin digestion of starches still continues, 
 but it must cease as soon as any appreciable quantity of HC1 is 
 present. 
 
 Free hydrochloric acid checks further development of organic 
 acids, such as butyric, acetic, or lactic. The Bacilli acidi lactici fail 
 to act in its presence, and other bacilli, like those of typhoid fever and 
 cholera, are destroyed by the antiseptic action of the HC1. 
 
 HYPERSECRETION 
 
 Hypersecretion of gastric juice is determined by withdrawing the 
 contents of the stomach in the morning after lavage the previous 
 evening. If more than fifty cubic centimetres are obtained, hyper- 
 secretion may be said to exist, the exact nature of which is to be 
 determined by the Gunzberg test (p. 517). Suggestions for the diet 
 of such cases are given on p. 525. Gastric atony is determined by 
 finding in the morning washing of the stomach undigested particles 
 of food eaten the night before. 
 
 The microscopic examination of the washing will exhibit bac- 
 teria, sarcinse, and saccharomyces. The treatment of this condition 
 is given under Chronic Gastric Catarrh (p. 531) and Dilatation of 
 the Stomach (p. 537). ! 
 
 TEST FOR PEPSIN 
 
 The presence of pepsin may be determined by digesting either 
 egg albumin or blood fibrin, the latter being preferred. The fibrin 
 is whipped from fresh beef blood and washed in water until it be- 
 comes white. A small piece is placed in a test tube with fifteen or 
 twenty cubic centimetres of filtered gastric juice, and kept at a uni- 
 form temperature of 40 C. for two or three hours. If there is 
 but little normal HC1 present, a few drops more should be added. 
 If no digestion occurs after some hours, pepsin is absent and the 
 fibrin will decompose. Quantitative or comparative tests may be 
 made by using definite amounts of fibrin and gastric juice, and 
 noting the time required for complete digestion. 
 
 TEST FOR RENNET FERMENT 
 
 The presence of the rennet ferment is easily demonstrated by 
 adding a few cubic centimetres of the filtered gastric juice to a half- 
 teacupful of fresh milk, and keeping the mixture for a short time 
 at 40 C. A loose coagulum forms with a limpid yellowish whey 
 if rennet be present. 
 
 35 
 
520 DIET IN DISEASE 
 
 TEST FOR MOTOR POWER OF THE STOMACH 
 
 The motor power of the stomach is demonstrated in various 
 ways. 
 
 Leube's Method. — Leube's method is to empty the stomach after 
 the ingestion of a Leube's test dinner (p. 515), or Ewald's test 
 breakfast (p. 515). If the stomach is empty three hours after 
 the former and one and a half after the latter, hypermotility is pres- 
 ent — i. e., the food is being too rapidly hurried into the duodenum. 
 If undigested food remains six or seven hours after eating the Leube 
 test dinner, the motility is impaired, and the diet must be regulated 
 accordingly. (See Chronic Gastric Catarrh, p. 531, and Dilata- 
 tion, p. 537.) 
 
 Ewald and Siever's Method. — Another method, that of Ewald and 
 Siever's. is very simple, but not very reliable. Fifteen grains of 
 salol are given in a wafer immediately after a meal, and the urine 
 is tested for salicyluric acid, which is derived from salicylic acid 
 formed in the alkaline intestine as one of the products of dissocia- 
 tion of salol. Salol escapes being acted upon by the gastric juice, 
 and the salicyluric acid appears in the urine half an hour or an hour 
 after it is sw T allowed if hypermotility be present — otherwise, not for 
 several hours. The salicyluric acid is readily detected by the violet 
 colour which appears in the urine on adding a drop or two of ferric- 
 chloride solution. The chief difficulty in the performance of the test 
 is in getting urine when wanted without catheterisation. Frequent 
 catheterisation merely for the purposes of such a test is to be con- 
 demned, and patients cannot usually micturate every fifteen minutes. 
 Brunner and Huber prefer to make the test dependent upon the 
 disappearance of all trace of salicyluric acid after ingestion of one 
 gramme of salol. Normally it can be detected for only twenty-four 
 hours, but if the motor power of the stomach is impaired it may 
 be obtained as late as forty-eight hours after. 
 
 Bourget found that the reaction time is delayed an hour or more 
 by giving a dose of HC1 with a meat meal, whereas it is accelerated 
 by a less acid meal of which fruits and vegetables form a part. 
 
 Stewart, in referring to this experiment, points out that hyper- 
 acidity of the gastric juice, by neutralising the duodenal juices, 
 might retard the salol reaction without the existence of motor in- 
 sufficiency. 
 
 Klemperer's Method. — Klemperer has the patient swallow one 
 hundred grammes of olive oil into an empty stomach, or the oil may 
 be poured in through a stomach tube. It is left for two hours, and 
 then the stomach contents are washed out. The oil is abstracted 
 from the washing with ether, and the ether is separated. The oil is 
 then measured. Between seventy and eighty grammes of oil should 
 
THE ALIMENTARY CANAL 521 
 
 pass on into the intestine inside of two hours but if it has not done 
 so there is lack of motility. 
 
 TEST FOR ABSORPTIVE POWER OF THE STOMACH 
 
 This test, as devised by Penzoldt and Faber, is very simple. Into 
 an empty stomach are taken three grains of potassium iodide in a 
 clean gelatin capsule, with a wineglassful of w^ater. 
 
 The saliva is collected at two- or three-minute intervals in sepa- 
 rate saucers, and with normal absorption from a healthy stomach 
 iodine may be detected in the secretion in from six and a half to 
 fifteen minutes, but in gastric catarrh it may not appear for several 
 hours. The test is made by dipping a filter paper, previously soaked 
 in starch paste, into the saliva, and adding fuming nitric acid. A 
 blue colour appears if iodine is present. This test is not very reli- 
 able, for if the stomach is full of food the reaction is always much 
 retarded, as it also is by fever and in most diseases of the stomach, 
 notably ulcer, carcinoma, and dilatation. 
 
 DIETETIC TREATMENT OF DYSPEPSIA 
 
 The foregoing details of the clinical examination of the digestive 
 power of the stomach have been given in this connection as a con- 
 venient place to summarise them. It is not intended to imply that 
 every case of simple dyspepsia should be subjected to so complex 
 an examination, but, on the other hand, there are many persons 
 afflicted with chronic dyspepsia who waste much time, energy, and 
 expense in taking medicines and diet " cures " which are entirely 
 unadapted to their particular trouble because it has never been 
 thoroughly investigated by the only means which in really serious 
 cases permit of an accurate diagnosis. The passage of a stomach 
 tube two or three times is all that is necessary for the patient to 
 submit to to enable such a diagnosis to be made, and although it 
 is never an agreeable process, it is far better than to prolong in- 
 definitely a condition of great discomfort, and one which in time may 
 develop into much more serious ills. 
 
 The dietetic treatment of dyspepsia is so complex that it is easier 
 for some persons to be put upon a very rigidly restricted diet for 
 two or three weeks than to have to select for themselves appropriate 
 articles at each meal. 
 
 It includes the study of all classes of foods, and for convenience 
 they may be grouped into — 
 
 A. Foods forbidden in all cases. 
 
 B. Foods occasionally allowable. 
 
 C. Foods which are desirable. 
 
 A. Foods forbidden in all Cases. — 
 I. Rich soups, gravies, and sauces. 
 
522 DIET IN DISEASE 
 
 2. Strong condiments, pickles. 
 
 3. Fresh soft bread of any kind (which makes a tenacious bolus), 
 hot breads, all kinds of pastry, cakes, griddle cakes, doughnuts, 
 muffins. 
 
 4. Sweets, tarts, jam, confectionery and candies of every kind. 
 Sugar in all forms, especially in coffee and tea with milk. 
 
 5. Raw vegetables, such as celery, radishes, cole. 
 
 6. Heavy vegetables — potatoes, sweet potatoes, corn, peas, 
 beans, eggplant, cabbage, cauliflower, Brussels sprouts, turnips, 
 carrots, parsnips (nearly all the roots and tubers). 
 
 7. Fat in quantity, all fried or greasy food. 
 
 8. Lobsters, crabs, shrimps, salmon, herring. 
 
 9. Dried, smoked, cured, potted, or " devilled " meats, fish, and 
 pork in every form. 
 
 10. Corned beef, duck, goose, wild fowl, rabbit. Veal, except as 
 broth. 
 
 11. Twice-cooked meats, hash (unless freshly made, without po- 
 tatoes), stews, ragouts. 
 
 12. Cheese of all kinds. 
 
 13. Very acid or very sweet fruits, nuts, dried fruits in general. 
 All skins and seeds of fruits. 
 
 14. Tea, beer, and sour wines. 
 
 The excessive use of tobacco in any form should be forbidden. 
 
 B. Foods Occasionally Allowable. — There are foods which may 
 be allowed to some patients but not to others, and many of them 
 constitute exceptions to the foregoing general rules. Such are : 
 
 Vegetables. — Mealy, well-baked potatoes, not too young or new, 
 raw tomatoes, spinach, thoroughly boiled onions, very young tender 
 fresh peas, very young Lima beans, string beans, asparagus, stewed 
 celery, celery plant (sea-kale). 
 
 Starchy Foods. — Where it is desirable to give starchy food in 
 some form, macaroni, spaghetti, or rice may be allowed, or one of 
 the prepared foods, such as Carnrick's or Mellin's. All starchy foods 
 should be most thoroughly cooked, for salivary digestion is often 
 feeble in connection with gastric disorders. 
 
 Fats. — Bacon, very fat, sliced thin and well broiled ; cream, good 
 fresh butter, olive oil. 
 
 Eggs. — Many patients find that eggs disagree with them con- 
 stantly. There are a few who can take them with impunity if rightly 
 cooked — that is, cooked very slowly and soft. They sometimes 
 agree better when not given with other food, but as eggnog. 
 
 As a rule, sweet fruits disagree, though they can be eaten by 
 some patients. 
 
 C. Desirable Foods to be recommended in Ordinary Cases are : 
 Cereals. — Wheaten bread, porous or aerated, stale or toasted ; dry, 
 
 unsweetened rusk or zwieback ; soda crackers. (The bread from 
 
THE ALIMENTARY CANAL 523 
 
 some bakers is easier of digestion than that from others.) Macaroni, 
 sometimes oatmeal, but without sugar. 
 
 Fats. — In moderation only ; butter to be very thinly spread and 
 well rubbed in. Sometimes a thin rasher of bacon. 
 
 Vegetables. — Chiefly as purees, thoroughly cooked, made of toma- 
 toes, asparagus, or sometimes potatoes or fresh peas. (Fresh green 
 vegetables as in preceding list.) Lettuce. 
 
 Fish. — Oysters, fresh-boiled or broiled fish without rich sauces. 
 They may be eaten with a little fresh butter and salt. (Some per- 
 sons cannot eat fish at all.) 
 
 Eggs. — In any form if they are found to agree (except hard- 
 boiled or fried). 
 
 Sweetbreads, Meats. — Broiled steak or chop, tender roast beef or 
 mutton, chicken (roasted or boiled), boiled capon, roast partridge, 
 grouse, woodcock, plover, prairie chicken, squab. All meats should 
 be short-fibred and tender. They need not be very rare. Grilling 
 is the best method of cooking them. 
 
 Fruit. — Baked or stewed apples or prunes. Occasionally a little 
 fresh fruit in season, better eaten between meals to prevent consti- 
 pation. Oranges, peaches, grape fruit. 
 
 Naturally, in bad cases the diet must be still further restricted, 
 and a bread-and-milk regimen may have to be enforced until im- 
 provement occurs. 
 
 Beverages. — Tea is generally injurious, especially if drunk with 
 meals, but weak tea taken clear in very hot water is sometimes 
 beneficial by enabling patients to imbibe the , fluid which they need. 
 Strong tea is astringent ; it precipitates pepsin and provokes con- 
 stipation. Coffee, on the contrary, favours peristalsis, and is mildly 
 stimulating to the nervous system. Drunk with milk and sugar it 
 often excites dyspepsia and increases flatulency. Taken black after 
 dinner it is an adjunct to digestion. If it produces insomnia or 
 " nervousness " it should, of course, be discontinued. Yeo says that 
 both tea and coffee may cause dyspepsia in those who are under 
 mental strain, but not otherwise in the same individual. Light China 
 teas are less injurious than the stronger Indian varieties. Coffee 
 contains more tannin than tea, which has only a trace. It does not 
 itself ferment, but the milk and sugar drunk with it does. 
 
 Cocoa (not chocolate, which is too sweet) may be allowed. An 
 infusion of cocoa nibs often agrees. 
 
 Milk and Vichy or milk and Seltzer may be drunk as a beverage 
 in non-flatulent cases. 
 
 As a general rule, malt liquors and beers of all kinds must be 
 forbidden, although Fagge recommends the use of light, still, bitter 
 ale or of porter in some cases ; but he says, " Whatever causes flush- 
 ing of the face after meals is bad." Alcoholic dyspepsia is only 
 cured by entire cessation of drinking. This the patients are un- 
 
524 DIET IN DISEASE 
 
 willing or unable to accede to unless very strongly influenced or 
 frightened as to the probable outcome of continued indiscretion. In 
 simple atonic dyspepsia the use of pure wine, or weak brandy, or 
 whisky and water and drunk at meals may prove serviceable. Some- 
 times a little dry wine, claret, or hock may be allowed twice a day 
 with meals. 
 
 Tobacco, smoked in moderation, in the form of mild cigars or in 
 pipes (not cigarettes), promotes digestion by slightly stimulating the 
 nervous system and increasing peristalsis. 
 
 Special Systems of Treatment. — The following systems of treat- 
 ing dyspepsia are condensed from the writings of several of the 
 best-known dietists : 
 
 Dujardin-Beaumetz divides dyspepsia into three classes, and 
 regulates their diet accordingly, as follows : 
 
 I. Dyspepsia with abundant gastric juice. Diet, fresh vegetables 
 and fruits, farinaceous food, milk, no meat or wine. 
 
 II. Dyspepsia with deficient gastric juice. Diet, meat, broths, 
 milk, peptonised food, weak brandy and water. No vegetables or 
 saccharine food. 
 
 III. Dyspepsia with sympathetic affections, especially vertigo. 
 Diet, purely vegetable food. 
 
 His diet of vegetable food is very liberal, and includes cereals 
 as well as fruits. It contains such articles as dry bread crust, toast ; 
 farinaceous purees made of one of the following materials : Maize, 
 flour, chestnut meal, oatmeal, pearl barley, potatoes, lentils, reva- 
 lenta, macaroni (plain or buttered), vermicelli ; purees of fresh vege- 
 tables, such as green peas, carrots, turnips ; the vegetables of julienne 
 soup ; salads, spinach, sorrel, French beans, fruits, except grapes 
 cooked as compote, lightly cooked eggs. 
 
 Germain See's treatment of dyspepsia is exactly the reverse of 
 that of Dujardin-Beaumetz. He divides dyspeptics into two classes : 
 
 I. Those who have hyperacidity of the gastric juice, for whom 
 he prescribes a nitrogenous diet with sodium bicarbonate after meals. 
 
 II. Those having diminished acidity, for whom he prescribes a 
 purely vegetable regimen, with dilute hydrochloric acid after meals. 
 
 He directs in all cases to wash out the stomach and stimulate 
 the gastric mucous membrane, for which he orders the alkaline 
 sodium bicarbonate in a tumblerful of Vichy an hour and a half 
 before eating. 
 
 Leube graduates dyspeptics into four groups according to the 
 severity of their symptoms. The diet which he recommends is as 
 follows, commencing with the severest cases : 
 
 I. Broth or clear soup, Leube's meat extract, milk, eggs (raw 
 or lightly cooked), carbonic-acid water, Apollinaris, or Seltzer. 
 
 II. Boiled calves' brains, sweetbread, breast of chicken or squab, 
 bread and milk, custard, unsweetened tapioca pudding. 
 
THE ALIMENTARY CANAL 525 
 
 III. The same as the two preceding, with the addition of raw 
 ham [sic] and rump steak. The latter is strongly beaten, scraped, 
 and roasted quickly before a hot fire with a little fresh butter. 
 
 IV. This diet, intended for the mildest cases or for convales- 
 cence, includes milk, rice, spinach, roast chicken, partridge, venison, 
 rare beef, veal, macaroni, fresh green vegetables, salads, fruit com- 
 potes, stewed apples, and light wines. He sometimes allows fish, 
 such as bass. 
 
 General Rules for Dyspeptics. — The following general rules are 
 applicable to all cases of dyspepsia and indigestion : 
 
 1. Eat slowly, masticate thoroughly. 
 
 2. Drink fluid an hour before or two or three hours after meals, 
 rather than with food. 
 
 3. Eat at regular hours. 
 
 4. If greatly fatigued, lie down and rest quietly before and after 
 luncheon and dinner or supper. 
 
 5. Avoid as far as possible taking business worries or profes- 
 sional cares to the table. 
 
 6. Take systematic exercise in the open air. Bicycle and horse- 
 back riding are the best forms. 
 
 7. On rising, cold sponging and vigorous friction of the body is 
 advisable. 
 
 8. The bowels should be kept open by laxative foods and fluids 
 rather than by medicines. 
 
 9. Avoid too much variety at any one meal. Take meats and 
 vegetables at separate meals. 
 
 RULES FOR SPECIAL VARIETIES OF DYSPEPSIA 
 
 Dyspepsia with Excessive Flatulency. — This often occurs in nerv- 
 ous women, and is especially annoying at night. 
 
 Avoid particularly all sweets and amylaceous food. Take no 
 fluid with meals. Drink hot water, half a pint before meals, and 
 again two hours after. Do not eat vegetables and meat at the same 
 meal. Try cream instead of milk in coffee, and saccharin instead of 
 sugar. Avoid tea and alcohol, especially malt liquors and effer- 
 vescing water, with meals. 
 
 Dyspepsia with Hyperacidity. — The diet should consist largely 
 of rare finely minced or scraped beef (one hundred grammes, or 
 three and a quarter ounces, is ample), with two slices of stale bread 
 or toast, or a few crackers with a little butter (thirty grammes). 
 Later the patient may partake of the lighter fresh vegetables and 
 subacid fruits. Milk may be useful, with 10 grains of sodium bicar- 
 bonate to the tumblerful. Vegetables should be thoroughly cooked 
 and mashed or made into purees. Fruit must be stewed or, in the 
 case of apples, baked. Alkaline Vichy may be drunk. 
 
526 DIET IN DISEASE 
 
 A few weeks' course of such a diet faithfully adhered to often 
 results in cure. 
 
 Dyspepsia with Excessive Nervousness, Irritative Dyspepsia. — 
 Avoid tea, coffee, much alcohol, tobacco, stimulating food of all 
 sorts, condiments and pickles, and do not overeat. Eat slowly. 
 Avoid eating when fatigued or worried. Take one or two extra 
 meals a day, if necessary, especially a light one before retiring, to 
 promote sleep. (See Insomnia.) 
 
 In the main, vegetable food will be better borne than proteids, 
 unless flatulency is annoying. 
 
 Atonic Dyspepsia, Dyspepsia with Deficient Gastric Juice. — Take 
 three meals per diem, and freshly cooked meat should be included 
 in two of them. Beef, mutton, and poultry are recommended. Meat 
 broths and soups, stale bread, toast, or crackers. All meats should 
 be tender and simply cooked. 
 
 In purely atonic dyspepsia, with loss of tone in the muscular 
 wall of the stomach and sluggish secretion, a diet which is too bland 
 and tasteless fails to stimulate the stomach sufficiently, and it is 
 better to offer a reasonable variety and a moderate use of condi- 
 ments. 
 
 Dyspepsia in the Gouty. — Avoid particularly sugar in every form, 
 malt liquors, sweet wines, and champagne. (See Gout.) 
 
 Dyspepsia with Bulimia. — A certain class of dyspeptics are al- 
 ways abnormally hungry, for hunger is a general sense, due to the 
 needs of the tissues rather than to the purely local condition of the 
 stomach. Suffering from indigestion, they fail to assimilate food 
 properly, become hungry again soon after meals, and do not obtain 
 the full nutritive value of what they do eat. They therefore over- 
 eat or eat between meals, and do not give the stomach sufficient 
 time for rest. They must be taught to restrain the appetite and to 
 stop eating short of satiety to prevent overloading the stomach, and 
 a sufficiently long period should intervene between meals for the 
 thorough digestion of the food. These patients sometimes have 
 hyperacidity. 
 
 Dyspepsia with Anaemia. — Anaemic patients require abundant 
 nitrogenous food, and well-seasoned, stimulating meat broths are 
 recommended. Such patients may take an extra luncheon or two 
 between the regular meals and before retiring. (See Anaemia, 
 p. 486.) 
 
 DYSPEPSIA IN CHILDREN 
 
 Children vomit much more easily than adults when they have 
 taken improper food, and often suffer less in consequence, although, 
 if such food is retained, they may have a gastric fever with a greater 
 rise of temperature and, perhaps, more alarming symptoms than 
 occur later in life. 
 
THE ALIMENTARY CANAL 527 
 
 When vomiting occurs in infants the stomach should be rested 
 by omitting the next feeding, and for the second feeding the milk 
 should be diluted and reduced in amount. If vomiting persists, a 
 little bicarbonate of soda or one or two tablespoOnfuls of lime water 
 should be added. Other substances, such as gelatin or one of the 
 prepared infant foods, may be used to dilute the milk and prevent 
 the formation of large curds in the stomach. In obstinate cases it 
 may be well to change the diet completely and give up milk for a 
 few days. In place of it a mixture may be used consisting of one 
 part of cream and two parts each of whey and boiled (not boiling) 
 water. 
 
 An overfed infant vomits soon after nursing or taking the bottle, 
 and the stools contain milk curds. When an infant receives too little 
 food, " the bottle is emptied quickly and ravenously ; the child cries 
 when it is taken away, sucks violently at its fingers, and cries before 
 the next feeding is due " (Holt). 
 
 Older children should not be allowed to eat between meals, and 
 must be forbidden the premature use of coffee, tea, spices, coarse 
 vegetables (cabbage, turnips, etc.), and unlimited ice water, fruits, 
 and sweets. (See Diet for Infants and Diet for Children.) 
 
 Acute Gastric Catarrh 
 
 Causation. — Acute gastric catarrh is commonly due to dietetic 
 errors, although it is also excited in other ways. The dietetic 
 causes are : 
 
 1. Food taken in too large quantity. 
 
 2. Food too hastily swallowed or " bolted." 
 
 3. Food in itself irritant or too highly seasoned with sauces, con- 
 diments, fats, etc. 
 
 4. Food which has undergone decomposition, such as " high " 
 game or fish, overripe cheese, sour milk, or improperly canned 
 vegetables. 
 
 5. Alcohol habitually consumed in excess and in concentrated 
 form, or a combination of drinking beer and wine or liquor, or 
 drinking beer in excess with improper food. 
 
 It may be caused by corrosive poisons. Many individuals appear 
 to have special weakness or irritability of the stomach, so that at- 
 tacks of gastric catarrh are excited in them by conditions which 
 would prove insufficient in others. 
 
 Excessive consumption of food beyond the wants of the system 
 and out of proportion to the gastric juice is often an exciting cause 
 of gastric catarrh, especially in children. This food need not in 
 itself be indigestible. Such cases may result, for example, from 
 eating large quantities of meat hash or of ice cream. Favourable 
 circumstances are also present in anaemia, nervous exhaustion, con- 
 
528 DIET IN DISEASE 
 
 valescence from protracted illness, and in fevers, in all of which 
 conditions the gastric juice, and especially its hydrochloric acid, 
 is apt to be diminished in amount or temporarily absent. In these 
 cases digestion is retarded far beyond the ordinary limits, and the 
 retained food decomposes by abnormal fermentation, thus becom- 
 ing both a mechanical and a chemical irritant to the mucous mem- 
 brane. 
 
 Symptoms. — The chief symptoms dependent upon the local in- 
 flammation of the stomach are severe vomiting, nausea, pain, weak- 
 ness, and fever. 
 
 Dietetic Treatment. — Acute inflammation of any structure is best 
 treated by rest, and the stomach forms no exception. Hence total 
 abstinence from food and great reduction in the quantity of fluid 
 imbibed is often curative after an interval of twenty-four or thirty- 
 six hours. The irritation is maintained by ill-advised attempts to 
 give food at frequent intervals with the object of supporting the 
 strength. The attacks, from the very nature of their causation, often 
 occur in robust people who can well afford to forego nourishment 
 for a few hours or until the nausea and pain cease. To others who 
 have been enfeebled by continued illness or in whom the acute 
 attack produces alarming prostration, enemata and stimulants and 
 predigested albuminous food must be given. 
 
 The vomiting and nausea are allayed by cracked ice, small quan- 
 tities of iced champagne, carbonic-acid w r ater, plain soda water, cold 
 lime water sipped in doses of a tablespoonful at a time and at inter- 
 vals of fifteen minutes. Strong black coffee is also serviceable. 
 These symptoms may also be relieved by hot poultices and turpen- 
 tine stupes, or spongiopiline soaked in hot water and sprinkled with 
 a few drops of laudanum placed over the epigastrium (Fagge). 
 
 The thirst should not be met by large draughts of water, which 
 only distend the stomach and excite vomiting. It may be relieved 
 by sucking a piece of sliced lemon or by placing a few drops of 
 mineral acid, such as dilute phosphoric or dilute hydrochloric acid, 
 in a small tumbler of cold water and sipping it from time to time. 
 Thirst may be lessened in some cases by holding water in the mouth 
 for a few moments without swallowing it, for a certain amount of 
 fluid is absorbed directly through the buccal mucous membrane. If 
 large quantities of fluid have been vomited, a simple enema of salt 
 and water (fifteen grains to the pint) may be injected into the rec- 
 tum, where it is soon absorbed. 
 
 When nourishment is first taken by the mouth, it must be fluid 
 and carefully prepared, so that it will either undergo prompt absorp- 
 tion or pass into the duodenum for digestion. It must be admin- 
 istered only in small doses — half an ounce or an ounce at a time. 
 Pancreatinised milk, or cold milk diluted with an equal volume of 
 lime water or soda water or alkaline Vichy, milk whey flavoured 
 
THE ALIMENTARY CANAL 529 
 
 or added to beaten white of egg, beef extracts, peptone solutions, 
 black coffee, expressed meat juice, and beef tea properly made, are 
 all recommended. Most broths contain too much fat or oil. Milk 
 given alone or undiluted soon curdles in the stomach, and is prompt- 
 ly ejected in large tough coagulse. Many persons either actually 
 cannot digest milk, or more commonly think they cannot, and avow 
 a violent distaste for it, declaring that it leaves a perpetual bad taste 
 in the mouth and causes headache and nausea. Their experience 
 is usually based upon the use of undiluted and unprepared milk, and 
 with tact and perseverance they can be got to retain and digest 
 prepared milk very well. (See Milk Predigestion, p. 78.) Some 
 patients prefer warm milk diluted with water and flavoured with a 
 little cinnamon, a taste of coffee or caramel, or they may take barley 
 water and rice water. 
 
 If patients cannot drink milk they may be allowed mutton, veal, 
 or chicken broths from which the fat has been removed. 
 
 It is best to forbid all alcoholic fluids, even champagne, unless 
 the patient is so exhausted that some stimulation becomes necessary, 
 in which case brandy diluted with soda water may be given in small 
 quantities, or it may be added to beef tea or arrowroot gruel. It is 
 important always to aid the recovery of the digestive organs by 
 absolute bodily and mental quiet. 
 
 Convalescence. — In convalescence the diet must be very slowly 
 increased ; otherwise relapses may follow very easily. After some 
 degree of improvement has been reached, the gastric mucus accu- 
 mulates with more butyric-acid fermentation, and the vomiting and 
 other symptoms return. 
 
 At first but one article at a time should be added to the fluid 
 food, gradually replacing it. Broths may be thickened by beaten 
 or dropped eggs, crumbled toast, or scraped beef or chicken. Later 
 plainly cooked meat, such as broiled tenderloin steak, chicken, a 
 tender chop, squab, or a bit of broiled fresh fish with lemon juice 
 may be allowed with dry toast and rice pudding. 
 
 It is well to give dilute hydrochloric acid (ten to fifteen drops) 
 with two grains of pepsin after each meal. When the illness has 
 been very severe the patient must be cautioned to be careful in 
 eating for several weeks after the acute symptoms have subsided lest 
 a relapse or gastric dilatation occur. Alcoholic subjects will prob- 
 ably not heed this warning, but it should be given none the less. 
 
 ACUTE GASTRIC CATARRH— GASTRIC FEVER IN CHILDREN 
 
 Acute gastric catarrh in infants is oftenest due to improper feed- 
 ing. It is also excited, or rather promoted, by teething and other 
 reflex irritations which interfere with the normal stomach functions. 
 There is an acute inflammation of the gastric mucous membrane, 
 
530 DIET IN DISEASE 
 
 accompanied by more or less fever, vomiting, local pain, and ano- 
 rexia. This affection is comparatively rare among nurslings. When 
 it does occur in them, the mother's milk should be analysed, and 
 any errors in her own mode of life, diet, etc., must be corrected. 
 If the breast milk continues to disagree, a wet nurse must be 
 procured, and, failing this, the child must be weaned if the disorder 
 continues. 
 
 Children just weaned acquire the disease from overfeeding and 
 from improperly prepared food, and the number of meals must be 
 carefully regulated according to the rules for infant feeding. 
 
 Older children who are allowed to come to table develop the 
 disease from eating too rich or stimulating articles, such as pickles, 
 sauces, spiced dishes, sweets, pastry, fried food, from drinking large 
 quantities of hot or very cold fluid, from eating hurriedly without 
 proper mastication, or from gorging themselves with enormous 
 quantities of articles of which they are particularly fond, such as 
 hash, cakes, etc. 
 
 If seen early, if vomiting has not already occurred and the stom- 
 ach is full, it should be emptied by an emetic dose of ipecac. Other- 
 wise, if the stomach contents have passed into the intestine, the 
 irritating food should be expelled by a laxative, such as calomel or 
 grey powder. No food should be allowed for some hours, for it 
 will keep up the hypersemia. Nothing should be swallowed but a 
 few sips of water or a teaspoonful of cool lime water or a little 
 cracked ice. After ten or twelve hours of complete rest the stom- 
 ach may tolerate one or two teaspoonfuls of pancreatinised milk or 
 milk diluted one half with lime water or Vichy. If this is not re- 
 tained, it is better to give a little meat juice or beef broth. The 
 next day mild farinaceous food may be allowed, such as arrowroot 
 gruel, cornstarch, or farina. Junket also, or milk toast, may be 
 retained. It is best to return to a solid diet very slowly and care- 
 fully, and such articles as rice pudding, scraped beef, the breast of 
 chicken, or the soft part of oysters may be given for a day or two 
 longer before the regular diet is resumed. 
 
 For some time after an attack it may be best to reduce the num- 
 ber of meals per diem — a child who has been taking five should take 
 but four, or one who has had four should take but three. 
 
 Chronic Gastric Catarrh — Chronic Gastritis 
 
 Causation. — Chronic gastric catarrh may be the outcome of such 
 errors in diet as have been described as causative of the acute form. 
 It commonly results, however, from alcoholic excess. It also accom- 
 panies diseases in which the hepatic, and consequently the portal cir- 
 culation is obstructed, producing engorgement of the vessels of the 
 gastric mucous membrane. It may complicate pulmonary and car- 
 
THE ALIMENTARY CANAL 53 1 
 
 diac diseases which cause obstruction to the venous circulation. It 
 is caused by the severer forms of stomach diseases. 
 
 Pathological Physiology. — Besides congestion of the blood ves- 
 sels, which interferes with the maintenance of proper secretion and 
 with absorption, the glands of the stomach furnish a hypersecretion 
 of tenacious, ropy, alkaline mucus, which clings to the mucous coat 
 and prevents the food from exciting the secretion of the gastric 
 juice, and it neutralises and prevents the latter from reaching the 
 food. The food therefore is retained for hours in an alkaline medi- 
 um, where it undergoes maceration and fermentation, which is par- 
 ticularly liable to develop large volumes of carbonic-acid and marsh 
 gas, which are periodically belched up with such force as to carry 
 out the acrid fluid, and even particles of disintegrated food, pro- 
 ducing a bitter and nauseous taste in the mouth. The symptom of 
 heartburn is due to the eructation of organic acids. The appetite 
 is not always lost. It may even be excessive, and it is usually ca- 
 pricious. Thirst is often a prominent symptom. Vomiting occurs 
 at intervals, especially on rising in the morning, after the gastric 
 mucus, mingled with the saliva swallowed, has accumulated during 
 the night. 
 
 Dietetic Treatment. — If any improvement is to be hoped for in 
 the condition of a patient with chronic gastritis it is absolutely 
 necessary to secure the intelligent co-operation of the patient him- 
 self by strict obedience to rules which must be made very specific 
 and distinct. Many patients will be found to have so little will 
 power that, with the best intentions, when they sit at the table with 
 others whose good health enables them to partake of all the lux- 
 uries of the season they are utterly unable to resist temptation. 
 
 The patient with gastric catarrh should, as far as possible, be 
 kept from mental strain and worry or business responsibilities, and 
 especially from brooding over his symptoms. A person suffering 
 from chronic gastritis often seems to have but a small amount of 
 nervous energy to expend, and if too much is diverted in other 
 channels, but little is left for the processes of digestion, and gland 
 secretion is altered or withheld. It is a matter of every-day experi- 
 ence with such persons that when free from all concern and anxiety 
 their digestion promptly improves and they can often eat quite in- 
 digestible food, whereas much plainer food wholly disagrees with 
 them while under mental strain. It is highly important for them 
 that meals should be taken with regularity and that abundant time 
 should be allowed for mastication. Regular habits, outdoor exer- 
 cise, and daily sponge bathing in cold water, followed by active fric- 
 tion of the skin, are to be recommended. In forbidding certain 
 classes of food, it is often observed that the patient has discovered 
 that some one apparently indigestible material can be eaten with im- 
 punity, and there may be no harm in allowing this to be continued 
 
532 DIET IN DISEASE 
 
 in mild cases. Sometimes merely eliminating from the diet such 
 obviously indigestible foods as pies, griddle cakes, pickles, fried 
 foods, or rich cheese, will produce marked improvement, but it is 
 often necessary to enforce a very strict regimen. 
 
 Milk Diet. — Severe cases, especially those complicating Bright's 
 or cardiac disease, demand rigorous restriction of the diet, and it 
 may become necessary to give milk exclusively for two or three 
 weeks. From two to two and a half or three quarts of fresh milk 
 are required for this diet in the twenty-four hours, the amount de- 
 pending upon the size and weight of the patient and his ability to 
 take exercise. The latter, however, must be reduced to a great ex- 
 tent while the milk diet is in force. The milk may be given either 
 hot or cold, but hot milk is best. It should be diluted with soda 
 water or an alkali, such as sodium bicarbonate or magnesia, and 
 salt should be added. Very bad cases with extensive atrophy and 
 abundant mucous secretion may require pancreatinised milk and beef 
 preparations. 
 
 In some cases, especially those due to chronic alcoholism, there 
 is annoying thirst, which is relieved by diluting the milk with equal 
 parts of Vichy or Apollinaris water. The fluid has the additional 
 advantage of increasing the elimination of waste from the system 
 through the kidneys. 
 
 To most patients who are ill enough to require a fluid or an 
 exclusive milk diet, it is preferable to give food frequently, at the 
 rate of four ounces of the above mixture once in two hours, until 
 the condition of the stomach improves, when the dilution of the 
 milk is to be reduced, given in larger quantity (six to eight ounces), 
 and the intervals may be prolonged to three hours. When much 
 gastric irritation or nausea exists, the milk, if at all rich in cream, 
 should be skimmed, as fat is not well tolerated. Buttermilk is used 
 quite extensively in Germany and somewhat in this country for the 
 treatment of gastric catarrh. It may be taken undiluted. To some 
 persons the taste is more agreeable than that of ordinary milk. 
 The casein of the buttermilk is already coagulated and exists in a 
 condition of fine subdivision, so that it does not form large clots 
 in the stomach. Patients usually tire sooner of buttermilk than of 
 plain milk. Milk, no matter how given, is apt to produce consti- 
 pation. 
 
 When patients insist that milk always disagrees with them this 
 is often on account of their not having the methods by which it may 
 be prevented from forming tough coagulse in the stomach, and it is 
 worth while to explain this fact to them, and secure their consent to 
 give a fair trial to some of the numerous means which may be em- 
 ployed for improving the digestibility of this invaluable food (see p. 
 75). If there is much dilatation of the stomach, milk is usually con- 
 traindicated. 
 
THE ALIMENTARY CANAL 533 
 
 Other Diet. — Should it prove impossible for the patient to digest 
 enough milk to support strength, his diet must be supplemented 
 with other articles of food, such as scraped meat or peptonised meat. 
 As a rule, the food should be either fluid or almost entirely solid ; 
 drinking considerable fluid with solid food dilutes the feeble gastric 
 juice too much for proper digestion. No broth or soup should be 
 allowed with meals. Alcohol should in general be forbidden, and 
 tea, coffee, or cocoa are to be taken only in moderation, much di- 
 luted, and without milk and sugar. Occasionally light wine, such 
 as hock and Moselle, may be given, but effervescing wines are 
 forbidden. Fluids should not be taken too cold. 
 
 Oysters may be allowed either raw, broiled, or panned. Butter 
 may be allowed very sparingly, and cream sometimes, but in gen- 
 eral fats and oils should be avoided as well as all fat meats, pork, 
 sausages, and solid food cooked in grease. Rich gravies and sauces 
 of every kind must be forbidden, and all solid food must be thor- 
 oughly masticated. Many persons, especially those who have an 
 excessive secretion of hydrochloric acid, live best on a diet of lean 
 roast beef, rare steak, or white meat of chicken, eaten with stale 
 white bread or dry toast and very little butter. This diet can be 
 taken for some time before serious objection is made to its mo- 
 notony. 
 
 One occasionally meets with persons in whom the digestion of 
 salt and smoked meats seems to be more easily accomplished than 
 that of fresh meat. The explanation offered by Niemeyer is that 
 these preparations are less likely to decompose and form abnormal 
 fermentation products in the stomach. Dried smoked beef, cut in 
 thin slices and eaten almost or quite raw, is palatable and easily 
 digested. Some dyspeptics can also digest lean boiled ham, lean 
 smoked bacon, and salt fish, such as shredded codfish, thoroughly 
 cooked, better than they can fresh meat. Leube allows caviare, 
 smoked ham, and boiled lean veal. Sweetbreads and calves' brains 
 are digestible. Tough meat and flesh of young animals recently 
 killed, such as " bob " veal, must not be eaten. 
 
 Fish and soft-cooked eggs disagree w T ith some persons, but others 
 can digest them without difficulty. 
 
 Saccharine and farinaceous foods are to be avoided. Sooner or 
 later they are almost certain to undergo lactic and butyric-acid fer- 
 mentation in the stomach with the production of much eructated 
 flatus and " sourness." When improvement is established, the pa- 
 tient may gradually be allowed a little carefully prepared starchy 
 food, but still no sweets of any kind. A single lump of sugar in a 
 cup of cafe an lait drunk at breakfast can produce an acute dyspep- 
 sia, lasting all day. The varieties of starchy foods which may be 
 first eaten are those which have been thoroughly subjected to the 
 heat of baking or long boiling. Such are : Dry bread thoroughly 
 
534 DIET IN DISEASE 
 
 toasted, bread crust, plain crackers, zwieback, gruels or meat soups 
 thickened with arrowroot, thoroughly cooked sago, or ground rice, 
 vermicelli, and macaroni well boiled. The purest carefully baked 
 wheat bread from hard white wheat flour agrees better than the 
 coarser varieties of brown bread, whole-meal breads, etc. 
 
 Many persons who take an intelligent but not hypochondriacal 
 interest in their digestion find by repeated trial that the bread of a 
 certain baker agrees with them, while that of another does not, 
 although its nutritive value for normal stomachs may be the same 
 in both cases. 
 
 Potatoes are apt to produce flatulency with sour eructations, and 
 when this is the case they must be forbidden. If roasted and very 
 mealy they may be sometimes allowed. Among vegetables those 
 which are especially forbidden are cabbage and cauliflower, the leg- 
 umes, and corn. A little fruit may be allowed between meals, such 
 as cooked apples, either baked or stewed, or stewed prunes, if not 
 too sweet. 
 
 Especially forbidden are pastry, sweets of all sorts, sweet pud- 
 dings and cakes, griddle cakes, hot breads, pickles, fried foods, and 
 strong condiments. 
 
 In all cases of chronic gastric catarrh it is important to reduce 
 the bulk of food taken so as to diminish the liability of its remain- 
 ing in the stomach undigested. Food which is so selected and pre- 
 pared as to diminish the work of the stomach should be given only 
 at long intervals in order that the digestion of one meal may be 
 thoroughly accomplished before the next is eaten. It is well to 
 order at least six-hour intervals between the meals, and they should 
 not be eaten too soon after exercise. 
 
 Convalescence. — As the patient improves, the dietary may be 
 somewhat enlarged, and thoroughly cooked fresh vegetables, such 
 as spinach, celery, asparagus, onions, and fresh young peas, may 
 be added. 
 
 Fresh ripe fruit will be found serviceable in curing constipation, 
 which almost invariably follows as a result of concentrated diet. In 
 many cases this trouble must be counteracted by the daily morning 
 use of some aperient, and a half tumblerful of hot Hunyadi water, 
 or of Friedrichshall bitter water, or a drachm of Carlsbad salts in a 
 tumbler of hot water, should be taken each morning before any food 
 is swallowed. The salts are further serviceable by diminishing hy- 
 persemia of the stomach and hepatic engorgement. Much benefit is 
 derived from drinking a glass of hot water or a glass of hot Vichy 
 from half to three quarters of an hour before each meal, the object 
 being to separate the layer of thick ropy mucus which overlies the 
 orifices of the gastric tubules. Much of the advantage to patients 
 with chronic gastric catarrh received from a course of treatment at 
 Carlsbad and similar spas is due to the action of sulphate of soda 
 
THE ALIMENTARY CANAL 535 
 
 and other alkalies in removing mucus from the stomach and cleans- 
 ing the membrane beneath, rather than to any specific virtue in the 
 salts themselves. 
 
 Hydrochloric Acid. — The value of hydrochloric acid given to aid 
 digestion consists quite as much in its power to promote the con- 
 version of pepsinogen into active pepsin as to act directly upon the 
 food. The latter can be accomplished very well by artificial digestion 
 outside of the body. If therefore there is complete atrophy of the 
 gastric tubules in chronic gastric catarrh of long standing, the giving 
 of the acid fails to excite secretion from tubules permanently de- 
 stroyed, and Boas declares that the acid combines so readily with 
 the salts and albuminoids of the food that it is not practicable to 
 give enough of it to have any free acid remaining, and he only 
 recommends it for those cases where the function of the gastric 
 tubules, as shown by testing the digestive power of a sample of the 
 stomach juice, is not wholly abolished. He admits its usefulness as 
 an antifermentative. This view is not generally held, however, and, 
 as a matter of practical experience, the majority of these cases are 
 improved by taking dilute hydrochloric acid with any solid animal 
 food which is allowed them which is otherwise found to cause dis- 
 comfort. It is best to give the acid not immediately with the food, 
 but half an hour later, and twenty minims may be prescribed in one 
 dose, or two or three doses of ten or fifteen minims may be given 
 at intervals of half an hour. It may be prescribed alone in half an 
 ounce of water, or mixed with a little glycerin in a claret glassful of 
 water, and it should be swallowed through a glass tube to save the 
 teeth from injury. 
 
 Exercise, Massage, Lavage, etc. — Exercise should be recom- 
 mended, but so regulated as not to interfere with digestion. It 
 should be postponed until digestion has been in progress for at 
 least an hour or two, and, when the patient's strength admits of it, 
 gentle horseback or bicycle riding and moderate rowing is bene- 
 ficial for the young and middle-aged. 
 
 Massage of the stomach, performed two hours after meals, is of 
 service, and lavage is of great value when pyrosis and gastric dis- 
 tress occur so soon after eating as to indicate active malfer- 
 mentation. 
 
 Daily morning douching of the stomach to remove mucus and 
 muco-pus in those in whom a dyspeptic tendency exists will serve 
 to prevent the advent of chronic catarrhal gastritis (D. D. Stewart). 
 This process, which is fully described in connection with the treat- 
 ment of Dilatation of the Stomach (p. 537), is now much less in 
 vogue than formerly for simple gastric catarrh. 
 
 Saline laxatives and appropriate tonics, such as strychnine and 
 arsenic, are indicated in addition to the dietetic measures above de- 
 scribed. 
 
 36 
 
536 DIET IN DISEASE 
 
 Electricity is of service only when one pole of the battery is in- 
 troduced into the stomach by Einhorn's method (p. 542). 
 
 In obstinate cases change of scene and occupation may do much 
 good, and a sea voyage is sometimes to be suggested. 
 
 CHRONIC GASTRIC CATARRH IN CHILDREN 
 
 Children with chronic gastric catarrh should always eat their prin- 
 cipal meal in the middle of the day, and take only a light supper. 
 
 When of nervous temperament, they are apt to bolt their food 
 without proper mastication. At the age, too, when their deciduous 
 teeth are being replaced they may from time to time have difficulty 
 in eating solid food. This matter should be inquired into, and if 
 necessary all such food must be minced before it is given to the child. 
 Children accustomed to luxury usually overeat, and suffer in con- 
 sequence. Their supervision at table is often left to ignorant or 
 careless servants, who should be cautioned, and better heed will be 
 taken if the instruction is given by the physician rather than by an 
 indulgent mother. 
 
 In young children gastric lavage is easily performed, and it may 
 be beneficial, but older children are apt to struggle and resist it. 
 The tube may be passed as in gavage (see Gavage), and directions 
 for lavage are also given on p. 538. For this purpose it is well to 
 use only water which has been previously sterilised by boiling. 
 
 Dilatation of the Stomach — Gastrectasia 
 
 Causation. — Dilatation of the stomach may result from stricture 
 of its pyloric end, or from chronic gastric catarrh, in which case it 
 is accompanied by the secretion of much tenacious mucus. The 
 stricture may be due to a carcinomatous growth, to hypertrophied 
 mucous membrane caused by chronic gastritis, or to contracture 
 following gastric ulcer. 
 
 Gastric dilatation is also produced by loss of tone or paresis of 
 the muscular coat, by destruction of the muscular coat due to ulcer- 
 ation, and by lack of proper nervous or nutritive supply, such as 
 results from debilitating illness, like typhoid fever, tuberculosis, or 
 general nervous prostration. Less often it is caused by abuses of 
 diet, especially those which give rise to much gas by excessive use 
 of effervescing beverages, etc. The varieties due to gastritis, de- 
 bility, and dietetic errors are most amenable to treatment. 
 
 Pathological Physiology, — The food is improperly digested, 
 owing to want of gastric juice and of peristalsis or to admixture 
 with quantities of mucus. It therefore lingers in the stomach be- 
 yond the usual time, ferments, interferes with thorough digestion 
 of the next meal, and renders the chyme unfit for the intestine. 
 Food will often lie undigested in a dilated stomach all night, and 
 
THE ALIMENTARY CANAL 537 
 
 be vomited with accumulated mucus in the morning. The undi- 
 gested food accumulates, and by its weight drags down the stomach 
 and favours further dilatation by stagnation and development of 
 gases. The motor function of the stomach is almost completely 
 suspended, and the organ must therefore be taxed as little as possible. 
 
 Dietetic Treatment. — For these reasons it is necessary to limit 
 the quantity of solid, and especially of fluid nourishment. Nothing 
 but the simplest articles of diet should be allowed. All food should 
 be given in a concentrated and readily assimilable form, so that 
 it will either be absorbed directly from the stomach wall or pass 
 promptly into the duodenum. 
 
 In bad cases food should be predigested as much as possible, 
 although many of the predigested foods are open to the objection 
 that they are much diluted in the process, and are therefore less 
 serviceable. The more concentrated varieties should be chosen. 
 Ewald recommends the employment of peptonised condensed milk, 
 which is very nutritious and of an agreeable flavour. It should be 
 condensed without addition of the usual excess of cane sugar, which 
 will surely ferment in the stomach. 
 
 The patients are often thirsty, and, in fact, the original dilatation 
 may have been caused by excessive imbibition, but the amount of 
 fluid drunk with meals must be restricted to four or six ounces, or 
 in bad cases no fluid at all should be allowed at mealtimes. If the 
 thirst is considerable, a tumblerful of hot water may be taken a half 
 hour before meals, to be absorbed or pass into the intestines before 
 the food enters the stomach. Water is more quickly absorbed hot 
 than cold. In bad cases thirst may be relieved by water enemata, 
 but they are rarely necessary. 
 
 The proper diet for gastric dilatation is the same as that recom- 
 mended for chronic gastritis, except that it is even more concen- 
 trated and smaller in bulk, and farinaceous food is almost wholly 
 forbidden. 
 
 At first only animal food should be given, such as scraped beef 
 or a piece of broiled chicken, with perhaps a very little dry toast or 
 toasted cracker. If vomiting is a persistent symptom, Petrequin 
 advises the patient to drink milk very slowly, taking crushed ice 
 with each mouthful. Later, after from two or three to six weeks, 
 if improvement has resulted, more latitude is permissible, and the 
 food advised is lean meat free from coarse fibres ; fresh vegetables, 
 young peas, asparagus, tomatoes, tender and well-cooked purees, dry 
 bread, haricots, lentils, lettuce or cress with vinegar, simple starches, 
 such as sago, macaroni, rice, tapioca, and vermicelli, boiled or 
 broiled oysters or fish, soft-cooked eggs, orange juice, stewed or 
 baked apples without sugar, stewed pears. Some patients may drink 
 a tumblerful of boiled milk between meals, but, as a rule, it is best 
 to take nothing. Some dietists recommend a perfectly dry diet, 
 
538 DIET IN DISEASE 
 
 omitting all fluids, and order three meals a day at long intervals. 
 In mild cases, coffee and tea without sugar are allowed. 
 
 To be avoided are most forms of starchy food, and sugar, pota- 
 toes, old peas, beans, corn. Fruit consists largely of water in pro- 
 portion to its nutritive value, and its vegetable acids are apt to 
 disagree. It must therefore be eaten sparingly. Fats, butter, and 
 oils are not digested in the stomach. Thirst-exciting foods, as salt 
 fish, must not be taken, nor beer, effervescing mineral waters, red 
 wine, thin soups, milk, water, tea, coffee, diluted or light alcoholic 
 beverages. 
 
 In all cases too long continuance of a very rigid diet is liable to 
 cause the patient or the stomach itself to rebel. The patient should 
 be weighed once a week. The stools must be examined and the 
 general nutrition carefully considered. If weight is rapidly lost, the 
 food, whatever it may be, is not being assimilated, and it should be 
 changed. It may become necessary to disregard the rules for fluid 
 and put the patient for a time upon a diet of prepared milk. 
 
 Aids to Dietetic Treatment. — Other means of treatment which 
 are really adjuncts to dietetic measures should be recommended. 
 Such are lavage, massage, and electricity, which will be considered 
 below. Mucus, especially that which is accumulated overnight, may 
 be washed out of the stomach by sipping a cup of very hot water 
 or taking alkaline mineral water, or a pint of water with ten grains 
 of bicarbonate of soda, on rising. 
 
 It is often desirable for the patient to lie down for an hour and 
 a half after eating, and he should especially avoid mental and bodily 
 fatigue, which tend to divert both nerve energy and the blood from 
 the functions of digestion. 
 
 Hydrochloric acid and pepsin mixtures with the nitrogenous diet 
 are serviceable. 
 
 Lavage. — In cases of either dilatation or catarrh of the stomach 
 which fail to improve on restricted diet and other methods of treat- 
 ment lavage or stomach washing becomes necessary. This is an 
 entirely safe procedure, and one to which patients become readily 
 accustomed, provided sufficient tact and care is employed when the 
 method is first applied. It was first practised by Kussmaul in 1867. 
 The operation met with so much success that it has since that time 
 been generally adopted, and it is perfectly easy to perform with a 
 little experience and care. It should be attempted in all serious cases 
 in which other methods to relieve the patient have been already 
 tried and have failed. It is almost indispensable in those cases in 
 which the atony of a greatly distended stomach wall prevents the 
 food from being expelled into the intestine, causing constant accu- 
 mulation and fermentation, or in cases in which decomposing food 
 passes into the duodenum, exciting intestinal dyspepsia, meteorism, 
 and diarrhoea. 
 
THE ALIMENTARY CANAL 539 
 
 As many as sixteen varieties of bacteria have been obtained from 
 the washings of a dilated stomach in which food had been stag- 
 nating. 
 
 The advantages of lavage are twofold ; it not only removes irri- 
 tating and fermenting material from the stomach, and the ropy, 
 tenacious mucus which it contains, and allays vomiting, but the 
 water itself applied to the mucous membrane cleanses it and stimu- 
 lates the gastric glands to normal secretion and the stomach wall to 
 contraction. It also promotes more regular action of the bowels. 
 
 The relief from the sensations of weight, oppression, discomfort, 
 and nausea which is promptly experienced after lavage is usually 
 immediate and lasts for several hours. It is so great that patients 
 not infrequently learn to pass the oesophageal catheter themselves, 
 and, holding a pitcher of warm water in one hand and a funnel in 
 the other, they wash and siphon out their own stomachs with ease. 
 Usually it is sufficient to wash the stomach once a day. In extreme 
 cases it may be necessary to perform the operation twice a day, but 
 when improvement is once established, washing may be limited to 
 every other day or may be employed occasionally, according to 
 need, but it should be continued for several weeks after the sub- 
 sidence of all symptoms. As a result of this treatment, the stomach 
 may diminish in size, and the food is always better digested and 
 more completely absorbed, while nutrition and assimilation are cor- 
 respondingly improved. 
 
 The best time for digestion of the principal meal of the day is 
 within an hour after each lavage, when the stomach is empty and 
 thoroughly cleansed, and the meal can often be assimilated com- 
 pletely. If decided repugnance to food exists, the tube may be 
 used for forced feeding, and peptones and predigested milk may be 
 poured in before it is withdrawn from the stomach, although, as a 
 rule, it is best that too much fluid food should not be given. 
 
 In performing the operation of lavage a medium-sized oesopha- 
 geal tube should be selected, about one third of an inch in diameter, 
 having two or three large smooth eyes or " velvet " fenestra and 
 made of good, smooth red rubber which is sufficiently flexible with- 
 out being so easily bent as to allow the tube to double upon itself 
 in its passage. This tube should be fully eighteen inches long, and 
 it is attached to a length of three feet of common rubber tubing by 
 means of a small glass tube ; the other extremity of the rubber tubing 
 is fastened to a funnel through which warm water is poured into 
 the stomach. A glass funnel is preferred, which makes it easier to 
 examine the washings as they return. The patient is cautioned to 
 keep the head straight forward and thrown back and not to bite the 
 operator's finger, and the tube is gently pushed over the dorsum 
 of the tongue down over the posterior pharyngeal wall into the 
 oesophagus. The insertion of the tube will be facilitated by oiling 
 
540 DIET IN DISEASE 
 
 it slightly with a little olive oil, butter, white vaseline, or glycerin, 
 but white of tgg or milk are less likely to nauseate. 
 
 If there is any difficulty in introducing the tube, its downward 
 passage may be aided by passing the forefinger to the back of the 
 pharynx. If the patient, who either sits or stands, is instructed to 
 make an effort at swallowing while the tube is being inserted it 
 will descend much easier, and pains should be taken to explain the 
 process and reassure him, for nervousness and struggling may excite 
 spasms of the laryngeal muscles and make it difficult or impossible 
 to pass the tube. On reaching the cardiac end of the stomach, the 
 tube is occasionally stopped for a moment, but the patient should 
 be instructed to try and swallow, and with gentle pressure the ori- 
 fice soon relaxes and the tube enters the stomach. Or a little water 
 poured into the tube may cause the cardia to relax. The funnel is 
 raised above the patient's head, but before pouring in much fluid it 
 should be ascertained that he is able to breathe comfortably and 
 quietly when the tube is momentarily compressed. He should be 
 reassured that he will not choke. Accidents have occasionally hap- 
 pened from passing small tubes down into the larynx, and I have 
 known of one fatal case in which a nasal tube was thus passed and 
 milk was poured into the lungs. A case has been reported in which 
 beef tea was poured into the lungs in this manner, but the patient 
 recovered and the beef tea was coughed up or absorbed. There is 
 very little danger of introducing an oesophageal tube of the or- 
 dinary size in the wrong direction, for any attempt to push it into 
 the pharynx will be met by obstruction and spasmodic coughing. 
 If the stomach is full when the tube is first passed, some of the 
 contents may be immediately siphoned out by lowering the funnel 
 below the stomach level and holding it over a foot tub or pail. If 
 necessary, water can be poured in gently to the extent of a quart, 
 or until the patient complains of uncomfortable fulness in the stom- 
 ach. Care should be exercised not to admit air bubbles. The tube 
 and funnel are then inverted over a foot tub or wash basin and the 
 contents of the stomach are quickly siphoned out. This operation 
 may be repeated a number of times until all the food and mucus 
 have been removed and the washings return quite clear and neutral 
 in reaction. 
 
 The quantity of water used in the washing should be measured 
 so that it all may be siphoned out again, as it is undesirable to leave 
 any fluid behind. 
 
 When the tube is introduced for the first few times it may excite 
 efforts at vomiting, but it is not necessary to remove it, for the 
 patient can usually regurgitate the long, stringy mucus alongside 
 of it. Salivation is often produced in the first few trials. After one 
 or two attempts patients will learn to swallow the tube themselves 
 with very little assistance and cease to gag upon its introduction. 
 
THE ALIMENTARY CANAL 541 
 
 If there is hyperesthesia of the pharynx the pharyngeal wall may 
 be touched with a 2- or 4-per-cent cocaine solution just before the 
 introduction of the tube, or several large doses of bromide of potas- 
 sium may be administered during the previous twenty-four hours. 
 If nausea occurs when the tube first reaches the cardia it is usually 
 overcome by pouring in a little fluid. The success of the opera- 
 tion at the first trial depends largely upon the skill of the physician 
 and the degree to which he has obtained the confidence of his 
 patient, and has been able to overcome any nervous feeling in re- 
 gard to a process which is at best highly disagreeable. After the 
 sufferer from gastric dilatation has experienced the relief which 
 lavage of the stomach can give, he usually requires no urging to 
 allow the process to be repeated. In withdrawing the tube it should 
 be compressed in order to avoid having any of its contents trickle 
 into the larynx. 
 
 The fluid used for washing the stomach may be either cool, 
 warm, or quite hot water. Warm water is best, but it is well to 
 sterilise it by previous boiling. If much mucus is present or much 
 acidity, sodium bicarbonate may be added in the proportion of two 
 or three per cent (15 grains to the pint), or a similar quantity of 
 sodium borate or boric acid, a one-half-per-cent solution of salicylic 
 acid, or a i-per-cent solution of sodium salicylate. Vichy is occa- 
 sionally used. 
 
 The best time for conducting lavage is shortly before the midday 
 meal, the patient having had a very light breakfast, and it should 
 only be performed when the stomach is believed to be compara- 
 tively empty. If the tube is introduced before breakfast, having 
 had nothing to eat for a number of hours, patients are more apt to be 
 disagreeably affected, especially if the washing be long continued, 
 and I have occasionally seen them become faint under these circum- 
 stances. It is better, therefore, that a light breakfast of bread and 
 milk, pancreatinised milk, or of a scraped-beef sandwich and a cup 
 of black coffee should be taken ; three hours later the stomach is 
 to be washed. There are exceptional cases in which the patient is 
 so distressed by the effort to pass the tube or by the operation of 
 rinsing the stomach itself that it has to be abandoned. Lavage 
 must be avoided in cases complicated by much prostration, feeble 
 heart action, aneurism, hsematemesis, or haemoptysis. 
 
 Accessory measures which are to be used in connection with 
 lavage and careful regulation of diet are massage and medicinal 
 treatment which consists largely of the administration of tonics, 
 especially strychnine, with the object of increasing the muscular 
 action of the stomach. This remedy may be given hypodermically 
 if necessary. 
 
 Massage. — Gastric massage should be performed about two and 
 a half or three hours after each meal for ten minutes. The patient 
 
542 DIET IN DISEASE 
 
 must lie upon his back, with knees drawn up and muscles relaxed. 
 The movements, stroking and kneading, must be always made over 
 the stomach in the direction of the pylorus, the object being to 
 facilitate emptying the stomach through that opening, and to stimu- 
 late peristalsis. If not too weak, the patient may be taught to per- 
 form these movements himself. This treatment is often of consid- 
 erable aid in mixing the food and gastric juice and in propelling the 
 food into the intestine. It increases peristalsis. 
 
 Electricity. — Faradisation of the stomach is believed by many 
 to increase its muscular tone, and various forms of electrodes have 
 been devised for this purpose. It is probable that very little, if any, 
 electric stimulation reaches the stomach when currents of ordinary 
 strength are applied over the epigastrium, although Ewald and 
 Sievers claim that it does in some cases. This is especially true of 
 faradism. Canstatt first proposed to apply the current directly 
 within the stomach wall, and methods have been devised by Bardet, 
 Einhorn, and others to serve this purpose. 
 
 The ingenious electrode invented by Einhorn, of New York, is 
 easily passed into the stomach. It consists of a hard-rubber cap- 
 sule about the size of a small French olive. The hollow capsule 
 has numerous perforations and within it is a small metallic elec- 
 trode. The capsule is fastened to a fine flexible conducting wire, 
 which is attached to the battery, and the wire is protected by a 
 minute soft-rubber tube one inch in diameter. This electrode is 
 readily swallowed by placing it upon the dorsum of the tongue and 
 then drinking water. About forty centimetres of the wire should be 
 swallowed. In withdrawing the electrode after use it sometimes 
 catches at the cardiac end of the stomach, but if the patient swal- 
 lows a little water it slips past. When this electrode is in the 
 stomach, which has been previously partially filled with a pint or 
 more of warm water or saline solution, the second electrode, broad 
 and flat, is placed over the epigastrium or over the back to the 
 left of the seventh dorsal vertebra, and the electric current is care- 
 fully turned on. 
 
 This treatment is designed especially to increase the muscular 
 tone of the stomach in atonic dilatation and stimulate peristalsis, 
 but it also serves to promote secretion, and hence it doubly aids 
 digestion. The electric current may be applied daily, immediately 
 after lavage, for ten or fifteen minutes, and it should be strong 
 enough to induce good peristalsis. Even patients who are not 
 accustomed to lavage seldom object to swallowing the electrode. 
 
 A variety of medicinal remedies are also used with the object of 
 preventing fermentation of food in the stomach and intestine and 
 for artificially aiding digestion by these organs. Among the former 
 are to be mentioned creosote and other substances allied to carbolic 
 acid, naphthaline, salicylic acid, etc. The use of hydrochloric acid 
 
THE ALIMENTARY CANAL 543 
 
 and pepsin have been described in connection with chronic gastric 
 catarrh (p. 531). 
 
 Vomiting— Seasickness— Vomiting of Pregnancy 
 
 Vomiting occurs as a symptom of so many diseases and func- 
 tional derangements that it will be advantageous to consider col- 
 lectively the general dietetic means for its relief. The details of 
 treatment will be explained under the headings of the various dis- 
 eases in which vomiting may become a serious or prominent 
 symptom. 
 
 Pathological Physiology. — Vomiting as far as it is related to 
 dietetics may be caused by: 1. Excess of food. 2. Foods and 
 drinks improperly combined (as crabs and milk, beer and cham- 
 pagne, etc.). 3. Fermenting or poisonous food. 4. Irritating and 
 indigestible food, including that which is improperly cooked. 5. 
 Hastily eaten food. 
 
 In hysterical patients and in very neurotic conditions of the 
 system, either the sight, taste, smell, or mental suggestion of food 
 may excite nausea and vomiting. 
 
 Instances of the influence of the mind over stomach digestion 
 and the mechanism of vomiting are too familiar to need elaboration 
 here. Food which is in itself nourishing may promptly nauseate 
 through disgusting association or environment. For example, a 
 party of early California settlers while crossing the continent were 
 lost during a severe winter in the Sierras. When nearly dead of 
 starvation some friendly Indians took compassion and fed them 
 upon a delicious finely ground meal, which for some days was their 
 staple article of diet, and on which they rapidly gained strength. 
 Being at first unable to understand the Indians, the emigrants could 
 not learn of what the meal was composed. When at length they 
 found out that it was made from pounded dried grasshoppers it pro- 
 duced such nausea that none could touch the food again. 
 
 Dietetic Treatment. — The first principle in the dietetic treat- 
 ment of vomiting from any cause is to give the stomach rest. If it 
 has been overloaded with a large bulk of food, or with indigestible 
 material, it is well to encourage emesis, and distressing retching may 
 be overcome by taking large draughts of lukewarm water. A 
 quart or two will rinse out the stomach and allay irritation to a 
 marked degree. 
 
 Well-nourished patients when serious vomiting first occurs 
 should usually refrain from taking food of any kind for from ten 
 or twelve to even twenty-four hours. Exceptions to this rule are 
 sometimes found in that type of seasickness, and sometimes in the 
 vomiting of pregnancy, in which, as soon almost as the stomach 
 is emptied, there is a desire to replenish the loss. 
 
544 DIET IN DISEASE 
 
 In any case in which the gastric irritation is persistent it is 
 necessary to give fluid food, and only in small oft-repeated doses, 
 preferably in predigested form. The food is best given cold, as a 
 rule, although some persons can relieve nausea by sipping very 
 hot water. 
 
 A teaspoonful of prepared milk, or in extreme cases but a few 
 drops, given with a medicine dropper once in ten or fifteen minutes, 
 may be all that the stomach will at first tolerate. 
 
 The following is a list of dietetic substances which are commonly 
 prescribed for the relief of nausea and vomiting, or for nourishment 
 while those conditions exist : Cracked ice ; pancreatinised milk ; milk 
 with sodium bicarbonate (ten grains), and cerium oxalate (five 
 grains) ; milk and lime water ; milk and Vichy, soda, Seltzer, or 
 carbonic-acid water ; whey ; koumiss and zoolak ; beef extracts 
 and peptonoids, such as Johnson's Fluid Beef and Carnrick's Beef 
 Peptonoids, somatose, Valentine's or Liebig's meat juice ; raw meat 
 pulp, scraped ; strong black coffee ; sour lemonade or lemonade and 
 Vichy; clam broth. Dry crackers, dry toast, and ginger-snaps will 
 sometimes be retained in seasickness, or a cracker buttered and 
 sprinkled with a little Cayenne pepper ; brandy and soda ; iced dry 
 champagne ; iced brandy diluted with water, soda water, or Apol- 
 linaris. 
 
 Very severe and protracted cases may require lavage or nutrient 
 enemata. Vomiting after abdominal surgical operations is often 
 controlled by lavage. 
 
 SEASICKNESS 
 
 There is no known dietetic treatment of seasickness which is ap- 
 plicable to many cases. There are those who overeat because of the 
 tonic of the bracing sea air. The idleness and lack of accustomed 
 exercise, and perhaps something in the quality of the air itself, all 
 contribute to make them bilious, and unloading stomach and bowels 
 thoroughly once for all suffices to cure them for the rest of the 
 voyage. The habit of indulging in late " farewell suppers " is nat- 
 urally the worst preparation possible for a sea voyage. 
 
 Some persons at sea can leave the table, vomit the first two or 
 three courses of a dinner, return, and finish the meal with astonish- 
 ing equanimity. With them nausea is not a persistent or annoying 
 symptom, and they need no treatment. Others are always nauseated, 
 but fail to vomit, and consequently grow weak from lack of food. 
 They do well to take a mild emetic at first, and usually a tumblerful 
 of lukewarm water will serve to empty the stomach of food lying 
 there undigested and fermenting. They are then temporarily re- 
 lieved, and can assimilate some form of predigested food. 
 
 Still others, after severe experience with emesis, strongly crave 
 and can actually retain and digest, in defiance of all dietetic laws, 
 
THE ALIMENTARY CANAL 545 
 
 substances which they could scarcely eat at home. Old cheese, nuts 
 and raisins, sour pickles, canned lobster, and similar incongruities of 
 diet are indulged in without a qualm. 
 
 There is a class of persons of both sexes, though the greater 
 number are women, who become so ill at sea as to reach a serious 
 condition of prostration. These patients are constantly nauseated, 
 not alone by the taste, but by even the sight and odour of food. 
 The mere idea of it, as the suggestion from reading an elaborate 
 menu, will nauseate. It is often difficult for such patients on a 
 crowded steamer to obtain the proper food and service, and it is well 
 for them to go provided with certain articles which are most useful. 
 Chief among these is sterilised milk. This is now easily obtainable 
 before sailing, and there is no difficulty in keeping it fresh during 
 the length of an ordinary transatlantic voyage. It may be peptonised 
 at the time it is needed, or diluted with equal parts of Vichy or lime 
 water, or taken with ten grains of bicarbonate of soda and three 
 grains of cerium oxalate to the tumblerful. The Swiss milk, con- 
 densed without sugar, may also be used. Fresh lemons and sour 
 oranges are very acceptable to many patients, the former particu- 
 larly so on account of their greater acidity and special power to quiet 
 the nausea of seasickness. The juice of one or two lemons, squeezed 
 into a tumbler of iced Vichy or Apollinaris, with a little sugar or sac- 
 charin, and a pinch of bicarbonate of sodium, makes a most refresh- 
 ing and soothing beverage. 
 
 Prepared clam broth, like milk, can also be taken in bottles, and 
 it often allays nausea. It is mildly stimulating and nourishing. 
 
 Other drinks which are recommended besides those above men- 
 tioned are weak brandy and soda or Seltzer, cold champagne, or 
 sparkling Moselle. Too much ice water should not be drunk, but 
 cracked ice may be sucked. Strong black coffee is excellent. If 
 there is uncertainty about this being obtained good at sea, the ex- 
 tract of coffee may be carried, which can be drunk diluted in hot 
 water. Coffee distinctly allays nausea, besides being a good cardiac 
 stimulant and diuretic. Some persons can take porter or stout in 
 small doses with benefit. 
 
 It is not well to take too much soup or broth at once, for if there 
 is much motion the weight of the fluid, tipping about in the stomach 
 as the vessel rolls and pitches, may easily accentuate the nausea. 
 In some cases patients may retain dry, solid food better than liquids, 
 and they should try soda crackers, zwieback, lemon ginger-snaps, 
 and chipped smoked beef, which can be obtained in boxes at the 
 grocer's before sailing. In extreme cases it may be necessary to 
 use beef peptonoids or other meat preparations, such as beef meal, 
 given either by mouth or in enemata. The white of egg may be 
 given in brandy. Preserved dry ginger helps some persons. Lime- 
 water tablets may be used. 
 
54 6 DIET IN DISEASE 
 
 Epigastric applications of hot-water bags or mustard pastes afford 
 relief. It is desirable to lie down at once after taking food, and lie 
 perfectly horizontal, without a pillow. It is very important to keep 
 the bowels freely open with bitter water of some sort. Rubinat is 
 less objectionable in taste than others. Seidlitz powders are usually 
 well retained, and so is citrate of magnesia. 
 
 VOMITING OF PREGNANCY 
 
 The vomiting of pregnancy usually takes the form of simple 
 " morning sickness." This may not appear until the patient arises 
 in the morning, when she feels faint, dizzy, and nauseated. Such 
 cases are benefited by remaining in bed until a glass of milk, or a 
 cup of warm broth with a biscuit, or a cup of cocoa or coffee and a 
 sandwich has been taken and digested. There may then be no re- 
 turn of nausea during the day, but the diet should at all times be 
 simple, especially the last meal of the day, and all richly cooked 
 food, pastry, sweets, sauces, and elaborate " made dishes " should be 
 avoided. Beyond this such patients may need no further treatment. 
 
 In other women the nausea is more persistent, and in the worst 
 instances the symptom is very difficult to control by any therapeutic 
 or dietetic measures. 
 
 Such cases are to be treated on the lines suggested above for the 
 cure of vomiting in general and for severe seasickness. Nutrient 
 enemata should be early resorted to if there is any sign of failing 
 strength, and before a patient is allowed to die of inanition artificial 
 delivery may be necessitated. Such extreme cases are fortunately 
 very rare. 
 
 The treatment of other forms of vomiting will be considered 
 under the headings of Alcoholism (p. 393), Acute Gastritis (p. 
 528), Chronic Gastritis (p. 531), and Dilatation of the Stomach 
 (P- 537). 
 
 Ulcer of the Stomach 
 
 In ulceration of the mucous membrane of the stomach there is 
 danger of irritation of the abraded surface through either the 
 chemical or mechanical action of the food. Excessive secretion of 
 gastric juice itself is believed to be similarly irritating. In serious 
 cases where the ulcer is extensive or where it is deep and the stom- 
 ach wall is thinned, there is liability of a rupture being caused by 
 overdistention or an undue amount of peristaltic action. In the 
 normal relaxed condition of the stomach wall the mucous membrane 
 is folded into rugae, but when it is slightly distended the surface is 
 smoothed out, and a greater degree of stretching may rupture an 
 ulcer which is on the point of perforation, but which might still 
 heal over if the tension were not too great. Further danger from 
 the presence of ulcer of the stomach lies in the fact that small blood 
 
THE ALIMENTARY CANAL 547 
 
 vessels may be occasionally eroded, giving rise to profuse haemor- 
 rhage, and any food which irritates the surface of the ulcer increases 
 this risk. 
 
 Dietetic Treatment. — For these reasons, if the patient is seen 
 soon after the occurrence of gastric haemorrhage, it is necessary to 
 withhold all alimentation from the mouth and nourish the patient 
 exclusively upon nutrient enemata. This treatment permits the 
 stomach to remain relaxed, and it is not stimulated to peristalsis or 
 secretion of irritating gastric juice. 
 
 In addition to the ordinary nutrient enemata it may be advis- 
 able twice a day to give rectal injections of a pint of salt water, 
 which by its absorption prevents thirst and relieves the patient of 
 the craving for swallowing liquid, which might result in exciting 
 further vomiting. In severe cases, if the irritability of the stomach 
 continues or the haemorrhage is repeated, it becomes necessary to 
 continue the rectal alimentation for many days, and patients may 
 live upon it comfortably for a week or, in some cases, much longer. 
 
 Lavage has been employed successfully when vomiting and pain 
 in the stomach were uncontrollable. One usually hesitates in 
 adopting this practice on account of a fancied danger of pushing 
 the oesophageal tube through the weakened wall of the stomach, 
 and I have known of one case which resulted fatally from this 
 procedure, where the stomach wall, however, was already eroded 
 through both the mucous and muscular layers, and perforation in 
 any event was imminent. When the. stomach wall is weakened the 
 mere act of vomiting itself is a menace of rupture, and the opera- 
 tion of lavage is justifiable if carefully performed. There is no 
 special danger to be apprehended from the use of a very flexible 
 tube which is not pushed too far into the stomach, as the ulcer is 
 usually some distance from the cardiac end, and food can sometimes 
 be poured into the stomach through the tube after lavage with 
 alkaline water, when it may be retained and digested. This treat- 
 ment should only be resorted to in cases where haemorrhage has not 
 occurred within a week, and in which other efforts to control pain 
 and irritation of the stomach have been faithfully tried, but have 
 failed. 
 
 Debove recommends the use of the oesophageal tube for gav- 
 age when vomiting is persistent and nutrient enemata are not satis- 
 factorily retained. The tube should be passed as far as, but not 
 necessarily into, the stomach, and fluid food is poured through it. 
 The act of swallowing is thus avoided, and emesis, as in the case of 
 infantile dyspepsia, is less likely to follow. If the tube proves irritat- 
 ing its use must not be insisted upon. 
 
 Generally speaking, however, after a day or two of complete 
 rest the condition of the stomach will admit of the gradual resump- 
 tion of mouth feeding, but nourishment must be given exclusively 
 
548 DIET IN DISEASE 
 
 in liquid and predigested form. The object is to give only food 
 which will tax the stomach as little as possible, and either be 
 promptly absorbed or pass quickly into the duodenum. 
 
 At first but very small quantities, not exceeding one or two tea- 
 spoonfuls, should be offered at one time, and the effect in regard to 
 nausea or vomiting must be carefully observed. Later, from four 
 to six ounces should be given every two hours. For those cases of 
 ulcer of the stomach in which patients are allowed to take food per 
 os, a milk diet will usually agree the best, provided precautions are 
 observed against the formation of large curds in the stomach, which 
 are exceedingly irritating. The milk should be given in any form 
 in which it is best borne, and the reader is referred to the article 
 upon the modes of preparing milk and rendering it digestible (p. 
 75). If it is tolerated, the dosage may be increased to three to 
 four ounces every two hours. Peptonised milk gruel is strongly 
 recommended by Roberts. Da Costa has found that ice cream gave 
 unexpected relief in some cases. Some patients do well upon 
 koumiss, buttermilk, or zoolak. Ewald advocates the use of milk 
 thickened with flour of various kinds to prevent the formation of 
 large coagulae. The predigested starchy infant foods, such as Nes- 
 tle's, Mellin's, Imperial Granum, or malted milk, may be added, but 
 gruels made with coarse cereals are not permissible. 
 
 When milk preparations fail, it is unwise to persist in giving 
 them, and teaspoonful doses of beef juice should be substituted, or 
 peptonised solutions or pancreatinised meat juice may be tried. 
 Other patients may be fed upon tgg albumin beaten and sweetened 
 or prepared with sherry wine, or the yolk of an egg may be beaten 
 in an ounce of boiling water and added to a tumbler of milk. Less 
 serious cases may be allowed such articles as zwieback or stale 
 bread crumbs or cracker crumbs soaked in milk until quite soft. 
 They will prevent the formation of large coagulse of milk. One of 
 the various malt preparations may be well tolerated and prove 
 nutritious. Leube's Soluble Meat is a German preparation, which 
 relieves the stomach of all necessary work, and consequently re- 
 duces the period of acid secretion in the stomach. It proves very 
 serviceable in the dietetic treatment of gastric ulcer, and may be 
 given alone or combined with milk or salted meat broths and bread 
 crumbs. Leube himself prescribes in this form an equivalent of 
 half a pound of beef in twenty-four hours, and claims good success 
 for it. Mosquera's meat jelly may be employed. 
 
 As a rule, if a patient thrives upon a diet of milk and broths, 
 it is best to let well enough alone for three or four weeks, and any 
 increase in either the quantity or variety of the diet should be made 
 with extreme caution. If improvement follows, as indicated by the 
 diminution in pain and the absence of gastric distress after eating, 
 and the patient gains in strength, other articles may be carefully 
 
- THE ALIMENTARY CANAL 549 
 
 added in moderation to the diet, such as milk toast, sweetbread, 
 eggs (not hard-boiled), scraped meat, custard, a small piece of 
 boiled or broiled white meat of chicken or mutton or fish, chicken 
 broths thickened with arrowroot, rice, vermicelli, clear meat broths 
 or thickened soups to which the yolk of an egg has been added, 
 or crumbled dry toast and a carefully prepared puree of potatoes may 
 be prescribed. Stewart recommends the addition of malt to the 
 puree. 
 
 A few easily digestible solid foods may next be added to the 
 menu, such as tender rare roast beef, beefsteak, tender game, like 
 the breast of partridge, quail, or squab in season. The soft part of 
 large oysters (raw or broiled), boiled fresh fish, such as bass, sole, or 
 whiting, rice pudding, bread and milk pudding, tapioca, sago, farina, 
 and cornstarch — are all articles which may be permitted in modera- 
 tion. 
 
 The patient should be informed of the existing condition in the 
 stomach, and of the dangers attending any serious departure from 
 the rules of diet carefully laid down, and it should be explained 
 that for several months after the acute symptoms of gastric ulcer 
 have subsided the greatest care must be observed not to overload 
 or overwork the stomach, and to refrain from eating food such as 
 coarse bread or groats, or vegetables having tough outside cover- 
 ing, like peas, corn, and beans, all of which are liable to produce 
 mechanical irritation. No fruit except orange, lemon, or peach juice 
 should be allowed. 
 
 Osier recommends the following menu for gastric ulcer : 
 
 8 a. m. — Two hundred cubic centimetres of Leube's beef solution. 
 
 12 m. — Three hundred cubic centimetres of milk gruel or pepto- 
 nised milk gruel made with ordinary flour or arrowroot, to which 
 gruel an equal quantity of peptonised milk is added. 
 
 4 p. m. — Buttermilk. 
 
 8 p. m. — Gruel. 
 
 In addition, rectal alimentation is to be given. The whites of 
 eight eggs may be used in alternation with the beef solution. 
 
 After a month of this treatment the following articles are cau- 
 tiously given : Scraped beef, chicken, fresh sweetbread, a farina- 
 ceous pudding made with milk and eggs. This treatment should 
 last three months, most of which time is to be spent in bed. 
 
 The rules for stimulants are that they should be absolutely for- 
 bidden unless they become necessary through exhausting haemor- 
 rhage or great weakness, in which event they had better be supplied 
 through the rectum. 
 
 Von Ziemssen prescribes Carlsbad water in order to neutralise 
 the acidity of the stomach and hurry its contents into the duodenum. 
 He recommends drinking half a pint to a pint of this water hot early 
 in the mornings during convalescence. 
 
550 DIET IN DISEASE 
 
 Aerated waters should not be recommended. The gas is apt to 
 distend the stomach, and the carbonic acid is believed to be irritating 
 to the raw surface of the ulcer. 
 
 Cancer of the Stomach 
 
 In cancer of the stomach, prolongation of the patient's life and 
 personal comfort depends more upon the dietetic than any other 
 form of treatment. Nourishment should be given in a concentrated 
 and predigested form, and where pyloric obstruction exists, in a 
 condition which admits of direct absorption from the stomach wall. 
 It is necessary to avoid food that is liable to remain long in the 
 stomach and excite nausea and vomiting, which may in turn develop 
 severe pain or fatal haemorrhage, and to prohibit anything which 
 by undue fermentation might cause distention and stretch an already 
 thinned gastric wall to the point of perforation. 
 
 Osier mentions that in organic disease of the stomach pain usu- 
 ally begins soon after eating and continues until its digestion is over 
 or vomiting occurs, but sometimes the pain of carcinoma may be re- 
 lieved by ingestion of food. 
 
 Aside from the local difficulties of digestion in gastric carcinoma 
 in the immediate vicinity of the stomach wall, the gastric juice is 
 either deficient in amount or altered in composition, and the hydro- 
 chloric acid may be totally absent. Hence stomach digestion can- 
 not be counted upon at all, and it is important to digest all food by 
 artificial processes. 
 
 In nearly all cases nutrient enemata will sooner or later be re- 
 quired either as an adjunct to stomach feeding or to replace it en- 
 tirely. Owing to the importance of this subject, it will be separately 
 discussed. (See p. 408.) 
 
 If much pain follows the ingestion of any food, or if there is a 
 tendency to haemorrhage, stomach feeding should be entirely re- 
 placed in this manner. In no other disease can life be supported for 
 so long a time and so comfortably upon exclusive rectal alimentation. 
 After a few days of rest secured by substitution of enemata the 
 stomach may become less intolerant and food can again be swal- 
 lowed. 
 
 The exact nature and site of a carcinomatous lesion cannot 
 always be determined, especially in its early stages, and each case 
 requires special study. Patients soon find by experience what gives 
 them most distress and learn to avoid it. In general, saccharine and 
 farinaceous foods should be proscribed because they are normally 
 not digested in the stomach, and in carcinoma they linger and, aided 
 by the catarrh which is usually also present, undergo abnormal fer- 
 mentation with production of gas, nausea, and vomiting. It is usu- 
 ally the case that predigested albuminous food is better assimilated. 
 
THE ALIMENTARY CANAL 551 
 
 Digestion in such cases should be watched from day to day, and when 
 patients can tolerate a little simple farinaceous food without its pro- 
 ducing eructations or increasing the gastric pain and discomfort, it 
 may be added. 
 
 If the new growth causes stricture of the cardiac end of the stom- 
 ach, only fluid food can be taken, and the act of swallowing should 
 be studied to make sure that dilatation of the oesophagus is not devel- 
 oping. If, on the other hand, it constricts the pyloric end, food can- 
 not pass on into the intestine and gastric dilatation may result. It 
 then becomes highly important to put into the stomach only that 
 which can be absorbed from its wall. Such substances, besides 
 water, include peptones, albumoses, and alcoholic stimulants (cham- 
 pagne, whisky, and brandy), all which may be taken up by the cir- 
 culation of the gastric wall in considerable quantity. Albumoses 
 would theoretically constitute a most useful food, being entirely pre- 
 digested and ready for immediate absorption ; but practically patients 
 soon weary of such a diet, and food of that nature will not long sup- 
 port life when given alone. In complete pyloric obstruction albu- 
 moses may be prescribed, and in advanced gastric dilatation they are 
 needed. They may be sometimes alternated with other foods with 
 advantage. 
 
 If much dilatation exists without nausea or vomiting, fluid foods 
 will sometimes lie unabsorbed in the stomach for one or two days, 
 and then several quarts of fluid will be unexpectedly ejected. It is 
 consequently advisable to examine and percuss the stomach from 
 time to time, to make sure that nourishment swallowed is not accu- 
 mulating there. 
 
 Exceptionally, if the disease has not progressed too far, patients 
 do best on a dry diet, and finally chopped steak, tender rare beef, 
 chicken, scraped beef, soft-cooked or raw eggs may be given, and 
 digestion is facilitated by the use of pepsin and hydrochloric acid or 
 papoid. If there is no pyloric obstruction, and if it does not produce 
 nausea or pain, simple forms of starchy food may be added, such as 
 dry bread, toast, or crackers. 
 
 In advanced cases the diet must be fluid and concentrated ; food 
 should be given only in very small quantities — not over one or two 
 teaspoonfuls at one time, frequently repeated. Meat extracts, albu- 
 moses, buttermilk, pancreatinised milk, koumiss, and prepared 
 egg albumin may be retained. The yolks of eggs are not ab- 
 sorbed from the stomach on account of the fat which they contain. 
 When possible, the diet should consist almost wholly of predi- 
 gested milk. 
 
 Oppolzer advises the use of sour milk in cases of carcinoma of 
 the stomach in which there is more or less constant tendency to vom- 
 iting, and in which ordinary milk coagulates in the stomach in large 
 curds. Sour milk is much less apt to form large tough coagulae. It 
 37 
 
552 DIET IN DISEASE 
 
 is usually better, however, in such cases to pancreatinise the milk or 
 give it in the form of koumiss. 
 
 For the control of vomiting there may be also tried iced carbon- 
 ated water, champagne, bismuth, and counter-irritation. For indi- 
 gestion, eructations, or gaseous distention, antacids and antifer- 
 mentatives are indicated, or pepsin with dilute hydrochloric acid. 
 
 Ewald says : " A diet of starches and vegetables is more easily 
 borne than that of meat, since the diminution in the secretion of 
 hydrochloric acid causes the digestion of albumin and meat to be 
 incomplete. In most cases milk is also poorly borne, on account of 
 the absence of rennet." When milk is tolerated, however, he advises 
 the addition of a few drops of Cognac to each tablespoonful, or the 
 use of kefir or peptonised milk. 
 
 Many special systems of diet have been exploited for the treat- 
 ment of cancer of the stomach, some of which have proved of 
 occasional value, and have at least the merit of being based upon 
 scientific reasoning, whereas others are pure quackery. It is almost 
 needless to say that no such thing as a dietetic " cure " for cancer ex- 
 ists. The most that can be expected of any dietetic system for this 
 fatal disease is that it may make the patient somewhat more com- 
 fortable, and prolong his life perhaps for a few weeks or months by 
 maintaining better general nutrition. 
 
 Lavage is sometimes employed as an adjunct to dietetic treat- 
 ment where much catarrh of the stomach or dilatation is present. It 
 may relieve some of the symptoms in the early stages of the disease, 
 but it should be performed with great care, for it is uncertain to what 
 extent the stomach wall may be eroded. I have known of at least 
 one case in which a fatal result followed the false passage of an 
 oesophageal tube. 
 
 DlARRHCEA 
 
 Pathological Physiology. — Diarrhoea is commonly the result of 
 excessive peristalsis. It may also be occasioned by the presence of 
 a large volume of fluid in the intestine, caused either by lack of 
 absorption of an excess of liquid ingested, or oftener by hypersecre- 
 tion or failure to absorb the fluid of the chyme. 
 
 The exaggerated peristalsis is occasioned — 
 
 1. By increased irritation of the nerves or muscles of the intes- 
 tine, due to mechanical stimulation of irritant or undigested particles 
 of food (e. g., the seeds of berries or husk of corn grains). 
 
 2. By chemical products which are contained in the food. 
 
 3. By abnormal fermentation, the products of which excite mus- 
 cular contractions. There are many dietetic causes of diarrhoea. It 
 may be produced by fermented or putrefactive food, by improper 
 food mixtures, by food which is too coarse, bulky, and irritating, or 
 by monotony of diet. The excessive use of meat extracts or " pep- 
 
THE ALIMENTARY CANAL 553 
 
 tones " is liable to cause it. In the tropics, as shown among the 
 troops employed in Cuba and Porto Rico in the Spanish-American 
 war, it may originate from a salt-pork ration, the consumption of too 
 much meat, canned dried beans (" baked beans "). In the tropics 
 and in hot weather, generally, catarrhal enteritis is easily excited, and 
 animal food soon spoils if exposed to the heat and air. 
 
 Diarrhoea may be (a) acute, due to temporary errors in diet, " tak- 
 ing cold/' causing acute intestinal catarrh, the ingestion of poisons, 
 overdoses of aperients, etc., or (b) chronic, complicating some intes- 
 tinal or other malady. 
 
 Acute diarrhoea often subsides of itself if food be withheld until 
 the irritant matter has passed off from the intestine. 
 
 Chronic diarrhoea of long standing requires great care and pa- 
 tience in treatment. 
 
 Abundant greenish fluid stools showing much bile pigment indi- 
 cate that the stools have been hurried out of the small intestine 
 before digestion was complete. 
 
 Of the many forms of diarrhoeal diseases, the treatment of those 
 only which are most influenced by diet will be discussed in the suc- 
 ceeding pages. There are a few propositions which have general 
 application to the different varieties, which will be mentioned here. 
 
 Dietetic Treatment. — It is a general rule to moderate the quantity 
 of food and avoid all food likely to undergo abnormal fermentation 
 (such as sugars), or having a considerable residue. Unirritating or 
 bland substances only should be taken. Fruits and vegetables must 
 be wholly interdicted. 
 
 At the commencement of an acute attack food may be withheld 
 for ten or twelve hours, and a little barley water or arrowroot gruel 
 flavoured with a mere taste of lemon or spice should then be or- 
 dered with one or two tablespoonfuls of brandy in soda water. Mut- 
 ton or chicken broth may next be given, and, if desirable, it may be 
 thickened with boiled rice, tapioca, sago, or cracker crumbs. Pa- 
 tients who are not at the same time " bilious " or vomiting may 
 take milk diluted with one third lime water. 
 
 The return to ordinary diet should be in all cases gradual, and 
 such articles as milk toast, oysters, well-cooked macaroni, boiled 
 rice with beefsteak gravy, the breast of boiled chicken, or a little, 
 partridge in season, with baked and mashed potatoes, may be first 
 allowed. 
 
 Loose stools sometimes occur immediately after meals, the im- 
 pulse for the bowels to move coming so suddenly that the patient 
 scarcely has time to leave the table for the closet. In such cases 
 " some one article of diet is at fault " (Osier). The patient should 
 be put upon a diet restricted mainly to meat and stale bread or toast 
 for a few days, and made to lie down and rest immediately after 
 meals. Taking food into the stomach excites a reflex intestinal 
 
554 DIET IN disease 
 
 peristalsis, and the intestinal contents are hurried onward before they 
 can be digested. 
 
 For the form of diarrhoea which occurs in hysterical women, if a 
 milk diet is not well borne, Osier recommends feeding the patient 
 upon egg albumin exclusively while medicinal antispasmodics are 
 given to diminish peristalsis. 
 
 In diarrhoeas demulcent and mucilaginous drinks are useful, and 
 they are believed to coat the alimentary canal and protect it from 
 local irritation. It is doubtful, however, whether any such action 
 occurs beyond the stomach. 
 
 DlARRHCEA IN INFANTS AND YOUNG CHILDREN 
 
 Dietetic Causes. — The dietetic causes of diarrhoea in infants and 
 young children may be classed as due to — 
 i. Too frequent or irregular feeding. 
 
 2. Overfeeding. 
 
 3. Feeding with improper or " spoiled " food. 
 
 The first and second causes are commonest in early infancy, and 
 the third is commonest in childhood, although any or all of them 
 may operate at any age. 
 
 Children brought up in the country are much less subject to diar- 
 rhoeal disorders than those raised in cities, owing to the relative 
 purity of their milk and other foods, and the greater resisting 
 power with which their better general health and vigour supplies 
 them. 
 
 In a series of nearly two thousand cases among infants of fatal 
 diarrhoea, collected by various observers (Hope, Meinert, Ballard), 
 only 3 per cent received the breast exclusively. These are very sig- 
 nificant data, and point to the conclusion that the vast majority of 
 cases are due solely to the use of improper or contaminated food. 
 
 Differences in the mere chemical composition of the cow's milk 
 used for feeding are not sufficient to account for the frequency of 
 diarrhoeal diseases, and the further conclusion is reached, and has 
 been sustained by bacteriological research, that the harm is caused 
 by noxious germs. 
 
 Diarrhoea occurring in nursing infants must be accounted for in 
 other ways, although germs may readily have access to the child's 
 mouth from an unclean nipple or from sucking its own soiled fingers. 
 
 Aside from this, anything which disturbs the mother's digestion 
 may excite diarrhoea in her baby, as, for example, improper food, 
 menstruation or pregnancy (rarely), strong nervous influences, such 
 as grief or worry, great exhaustion, extreme anaemia, the use of cer- 
 tain powerful drugs. 
 
 Evidently the intestine becomes stronger or less susceptible to 
 bacterial poisons after the first two years or thirty months of life, 
 
THE ALIMENTARY CANAL 555 
 
 for the frequency of serious diarrhoea lessens, although the child 
 often gets worse milk to drink than it had when fed upon the bottle. 
 
 It has been suggested that water may excite diarrhoea by hur- 
 riedly washing germs into the intestine which are ordinarily killed 
 in transit by the acid of the stomach. The bile is reputed to be 
 antiseptic, but Booker has found that all bacteria will grow in a 
 io-per-cent solution of it, and it easily undergoes fermentation from 
 decomposition of its mucus. Its antiseptic reputation rests upon 
 the fact that it stimulates peristalsis, keeps the bowels moving, and 
 thereby prevents food from accumulating and fermenting abnor- 
 mally. 
 
 In large cities, where women among the poor are obliged to go 
 out to work by the day, they, as a rule, suckle their infants for only 
 the first six months, or if for a longer period, they add other food or 
 have their babies bottle-fed by a neighbour or in a " day nursery " 
 during the hours in which they themselves are away from home. 
 Such hand-fed children are often given more than they can assim- 
 ilate. 
 
 As the infant grows older it is brought to the family table, and 
 when a year and a half old it is not seldom stuffed with any articles 
 from it. Beer, sausages, bananas, potatoes, tea, and coffee — all are 
 given. 
 
 Overfeeding and the use of such harmful food maintains almost 
 constant dyspepsia, and if it does not itself cause diarrhoea it predis- 
 poses to it by keeping the alimentary canal in a constant state of 
 irritation or hypersemia, so that slight additional factors excite the 
 condition, and bacteria find a fertile soil in which to develop. 
 
 In older children foods which are among the commoner causes 
 of diarrhoea are unripe or overripe fruits of all kinds, berries with 
 seeds, vegetables having a tough outer envelope, such as old 
 peas, beans, and green corn, imperfectly cooked cereals, like coarse 
 hominy, rice, or oatmeal, nuts, raisins, and dried currants. Gener- 
 ally speaking, diarrhoea is more apt to be caused by fruits and tough 
 meats imperfectly masticated than by vegetables. 
 
 Examination of the Stools. — In all serious cases the stools should 
 be examined, if possible, microscopically, to determine the degree 
 of digestion and absorption of the food. The chief abnormal in- 
 gredients are fat, bacteria, mucus, casein, starch, and, if meat has 
 been eaten, muscle fibres. The green diarrhoea of infancy is usually 
 of microbic origin. Diarrhoea of putrid character is due to albu- 
 minous fermentation, and produces more severe symptoms (see pto- 
 maine poisoning) than those produced by the simple fetid stools of 
 starch fermentation. 
 
 Fat. — The normal percentage of fat which the stools contain is, 
 according to Uffelmann's analysis, fourteen on the average, but in 
 diarrhoea with intestinal dyspepsia it rises often to forty or fifty, and 
 
556 DIET IN DISEASE 
 
 it has reached sixty-four. The fat appears in minute white flocculi, 
 varying in size from that of a pin's head to a split pea. These small 
 masses are often mistaken for casein, but the careful researches of 
 Wegscheider, Baginsky, and others have demonstrated them to be 
 composed of inspissated fat and colonies of bacteria. It is an easy 
 matter to distinguish them from casein, as they alone are dissolved 
 by the addition of a few drops of alcohol and ether. 
 
 Bacteria. — The commonest bacteria of infant stools are the 
 Bacterium lactis aerogenes and the Bacterium coli commune. In fact, 
 these two normal varieties are the only constant kinds in milk- 
 fed babies (Escherich), although Booker has found in different 
 cases of infantile diarrhoea, and especially cholera infantum, forty 
 varieties in all which bear no special relation to particular foods. 
 The first-named germ occurs only when milk has been ingested, for 
 it thrives, as its name indicates, upon lactose. Its chief site is the 
 small intestine, where it causes milk to ferment. The Bacterium 
 coli commune, on the contrary, elects the large intestine and thrives 
 upon the residue of digested food. Booker is of the opinion that 
 the influence of the various pathogenic germs in the production of 
 diarrhoea is attributable more to alteration of the food and intestinal 
 contents than to direct irritation of the intestinal wall. 
 
 Casein. — Undigested casein is a less common ingredient of the 
 stools than was supposed before the above-described observations 
 were made. When present it is in the form of smooth, somewhat 
 hard masses, often of a yellow or yellowish-white colour without, 
 but white when broken open. They are usually friable, and have a 
 cheesy odour. They may present a semi-transparent or horny ap- 
 pearance. 
 
 Starch. — Starch granules appear in the stools very often when 
 imperfectly cooked amylaceous food has been eaten, such as oat- 
 meal, barley, potatoes, bread, etc. 
 
 They are recognised by the microscope, and by the addition of a 
 solution of iodine, which colours the stools dark blue. 
 
 Meat Fibre. — Muscle fibres are easily recognisable by micro- 
 scopic examination, but not otherwise. 
 
 Dietetic Treatment. — The principles of dietetic treatment of 
 simple bacterial or mycotic diarrhoea occurring in infants under two 
 years of age are, first, to give the alimentary canal rest, and, sec- 
 ondly, to give food which is very thoroughly absorbed, leaving the 
 least possible residue of waste. All food is to be withheld for a few 
 hours, and cool sterilised water or barley water, and cracked ice 
 (if pure) is given to allay thirst. The child will not suffer from lack 
 of food. It will suffer much more with it. If stimulants are needed, 
 ten to thirty drops of brandy, well diluted, may be prescribed. 
 
 After the interval of rest food is to be cautiously administered, 
 but in less than the usual quantity. Unless the infant can have 
 

 THE ALIMENTARY CANAL 557 
 
 breast milk, which is usually most desirable for it, it is best to give 
 no milk at all, but instead such articles as whey, thin mutton or 
 chicken broth, barley gruel, or tgg albumin beaten in half a pint of 
 cold water to which a teaspoonful of brandy and a pinch of salt are 
 added. After two or three days of this diet, if the child continues 
 to improve, the milk diet given before the illness is to be gradually 
 resumed, but the feeding should be watched with care for at least 
 a week. 
 
 To older children, when diarrhoea has been excited by eating im- 
 proper food, unless the bowels have been already very thoroughly 
 evacuated, or if signs of intestinal irritation continue, it is best, as 
 with adults, to give castor oil and opium in the form of paregoric or 
 Dover's powder, and then to feed the child upon the principles laid 
 down above for infants. As a rule, it is best to avoid " prepared 
 foods " or patented infant foods, and good nutritious home-made 
 fresh broth from well-selected lean mutton, or chicken or beef broth, 
 is decidedly to be preferred. 
 
 Enterocolitis in Infants and Children — Summer 
 
 Diarrhoea 
 
 Summer diarrhoea is exceedingly fatal among infants in hot 
 weather in densely populated localities, and they require very care- 
 ful feeding for this disease. Intractable cases are prolonged for 
 several weeks, with more or less vomiting, diarrhoeal mucous stools, 
 fever, and meteorism, and a variety of complications supervene ; 
 hence there is ample opportunity for the exercise of dietetic skill. 
 
 Prevention. — Entero-colitis is a subacute milk infection resem- 
 bling the acute form, cholera infantum, but it is less violent, although 
 much more prevalent. It is produced by toxins developed by the 
 activity of bacteria in the food, and it is therefore to a large extent 
 preventable, and most easily so by continued and exclusive breast 
 nursing. 
 
 The preventive treatment for weanlings in nurseries where there 
 are several children consists in absolute cleanliness and antisepsis, 
 and the nurse must be made to realise the necessity of disinfecting 
 diapers and her own hands at once, and she must never handle either 
 food or food utensils with soiled hands, for by neglect of these sim- 
 ple precautions the germs are passed on from one child to another. 
 When cow's milk is used in hot weather it must always be sterilised 
 or Pasteurised. 
 
 Dietetic Treatment. — If the child is still nursing, and the moth- 
 er's milk is found to disagree, a wet nurse should be secured when- 
 ever possible ; or if it is bottle fed, great care should be taken 
 to introduce only sterile food into the stomach. If the child is 
 fairly strong and well nourished at the commencement, it is best 
 
558 DIET IN DISEASE 
 
 to withhold all food for several hours, and merely give a little barley 
 water or some equally bland beverage. In any event it is best to 
 abandon milk and its preparations entirely for two or three days. 
 In this manner the intestinal germs which are causing the mischief 
 are starved out or replaced by others which are comparatively in- 
 nocuous. 
 
 There are many cases of enteritis in children in which milk 
 wholly disagrees, even when Pasteurised or pancreatinised, appar- 
 ently because the casein is not properly digested in the stomach, and 
 in such cases the casein should be prevented from passing through 
 the alimentary canal in tough and irritating coagulse. 
 
 Fresh meat broths (beef, mutton, or veal), pressed-meat juice, and 
 egg-albumin solution with ten to thirty drops of diluted whisky or 
 good brandy, are to be given in lieu of all milk. Children a year or 
 more old may have gruels of arrowroot, barley, or rice, but commer- 
 cial baby foods and patented meat extracts must be omitted. A 
 mixture of cream and water is sometimes well borne. 
 
 It is important to give nourishment in very moderate quantity, 
 one or two teaspoonfuls at a time, to prevent overfilling of the 
 stomach. For older children a little scraped beef may be prescribed 
 three times a day ; and they may be allowed to drink whey. 
 
 After several days, but not until the symptoms have well-nigh dis- 
 appeared, a very gradual return to Pasteurised milk is permissible. 
 
 In those cases in which children lose all appetite or infants per- 
 sistently refuse to take the bottle, the prognosis is extremely un- 
 favourable, and recourse must be had to rectal feeding and stimu- 
 lation. 
 
 In every protracted case an exact record must be kept of the 
 quantity of food taken, and no general report should be accepted 
 from the nurse that the child is simply " feeding well." Frequent 
 weighing and comparison with the amount of food ingested, com- 
 bined with personal observation of the stools, are the best guides for 
 the physician to follow in regulating the diet, and they should never 
 be neglected. 
 
 During convalescence older children must be carefully watched 
 to see that they do not surreptitiously, or through ignorance of their 
 nurses, obtain unwholesome food. Such articles as potatoes, toma- 
 toes, and other fresh vegetables, coarse cereals, like oatmeal, wheaten 
 grits, and corn meal, must be forbidden, as well as fruits. Holt has 
 seen a fatal issue from eating a few raisins. 
 
 Cholera Infantum, or Acute Milk Infection 
 
 Cholera infantum is a gastro-intestinal disease of violent acute- 
 ness, characterised by severe vomiting, purging by serous stools, 
 collapse, very rapid emaciation, thirst, fever, and other symptoms. 
 
THE ALIMENTARY CANAL 559 
 
 According to Holt, between 2 and 3 per cent of the cases of diarrhoeal 
 disease in infants are cholera infantum. 
 
 It does not occur in nursing infants, but only in those fed by 
 artificial means. No specific micro-organism has been detected, 
 although various germs abound in the watery evacuations. 
 Vaughan believes it to be due to tyrotoxicon, which he has demon- 
 strated in cow's milk, and which exists only in milk or some modi- 
 fied form of it, such as condensed milk, or baby food made in part 
 of milk. 
 
 The disease prevails especially in hot weather, and is so rapidly 
 fatal, usually within one or two days, that very prompt and vigorous 
 treatment is imperative. 
 
 Dietetic Treatment. — The giving of milk in any form must be im- 
 mediately and peremptorily stopped, and, as Vaughan says : " Pre- 
 pared baby foods should be thrown out of the window. Acute milk 
 infection is a form of poisoning by a substance more powerful and 
 deadly than white arsenic." The poison must therefore be washed 
 out ; and no matter how much vomiting and diarrhoea have already 
 occurred, the stomach must be cleansed by lavage, and the colon 
 must be irrigated by at least a gallon of warm Castile soapsuds and 
 water, after which cool water with fifteen to thirty grains of tannic 
 acid to the pint should be injected (Vaughan), with the object of 
 precipitating poisonous proteids. The irrigation has a further ad- 
 vantage in that it replenishes by absorption a portion of the water 
 which has been rapidly drained from the system by the violent purg- 
 ing, as in the case of Asiatic cholera, and the loss of which causes 
 insatiable thirst. The lavage allays gastric irritability, and alcoholic 
 stimulation must then be ordered in the form either of half a tea- 
 spoonful of iced champagne or from ten to fifteen drops to a tea- 
 spoonful or more of whisky or good brandy, diluted in water or 
 Vichy. 
 
 From four to six or eight ounces may be given in twenty- 
 four hours to avert collapse. If necessary, the brandy is to be 
 given by rectum, or the whisky, in extreme cases, by hypodermic 
 injection. 
 
 Accessory means are bathing in warm mustard water and friction. 
 No nourishment except the alcohol is allowable for at least twenty- 
 four hours, when warm meat juice, koumiss, zoolak, pancreatinised 
 meat broths, or egg albumin with whisky is to be prescribed in tea- 
 spoonful doses every half hour or hour. For a day or two this diet 
 will suffice, and milk should not be again given until the expiration 
 of that time, when the ordinary previous diet may be cautiously re- 
 sumed. 
 
 Older children may be allowed to have junket and scraped beef 
 which has been squeezed through a sieve. 
 
560 DIET IN DISEASE 
 
 Cholera Morbus— Acute Catarrhal Enteritis in 
 
 Adults 
 
 Cholera morbus may be caused by the ingestion of indigestible 
 foods or improper drink, such as polluted water, or water or beer 
 drunk in large quantity after long-continued thirst, or chilling after 
 excessive exercise and perspiration. An attack may be excited by 
 unripe fruit and vegetables, such as green apples, watermelons, cu- 
 cumbers, or nuts. 
 
 Dietetic Treatment. — The patient must be kept quiet in bed, 
 well covered, and in severe cases it may be advisable to give no food 
 for the first twenty-four hours, after which the diet should be very 
 light, consisting of meat broth or of pancreatinised milk with lime 
 water in the proportion of one third of the latter, given alone or with 
 a little boiled rice or milk toast. Brandy and soda or champagne 
 may be prescribed. The desire to drink water constantly should be 
 restrained, as it tends to keep the contents of the intestine too fluid 
 and increases the diarrhoea. Thirst may be relieved by cracked ice, 
 very weak cold tea without sugar, or oatmeal water. When the pa- 
 tient is first seen, if there is evidence of accumulation of irritating 
 food in the intestine which has not been wholly eliminated by the 
 diarrhoea, it is advisable to evacuate the bowel with a dose of castor 
 oil or salts. 
 
 The following day, if diarrhoea and vomiting have ceased, the 
 diet may be increased slowly ; otherwise it must be still restricted to 
 broths and milk. Among the foods which may be first allowed are 
 a soft-cooked ^gg, raw oysters, scraped beef with soda crackers or 
 toast, and well-boiled rice. If the attack has lasted but a day or 
 two, the patient may soon return to his normal diet; but if it has 
 been protracted, or if he has been much weakened by it, he must 
 observe caution in eating for several days. The diet for convales- 
 cence given on p. 435 may then be followed. 
 
 Intestinal Putrefaction 
 
 This condition is very common and has a great variety of causes. 
 It may be due to the eating of putrefactive food, to indigestion, 
 either gastric or intestinal, to nervous exhaustion, as in neuras- 
 thenia, etc. It is especially common in epilepsy, chronic Bright's dis- 
 ease, acute melancholia, and hepatic disorders. In children it may 
 be caused by oatmeal and other carbohydrates. It gives rise to 
 flatulence, colic, offensive dark-coloured stools, often diarrhoeal, and 
 to a foul breath. Indicanuria is common. In bad cases it causes 
 auto-intoxication with a variety of nervous and other symptoms. 
 The bowel should be cleansed by a calomel purge or castor oil, and 
 
THE ALIMENTARY CANAL 56 1 
 
 intestinal antifermentatives, such as creosote or guaiacol carbonate, 
 bismuth subgallate, salol, or beta-naphthol, should be given. The 
 diet should temporarily consist of broths and gruels. After two or 
 three days such foods may be given to adults as rare beef, chicken, 
 boiled rice, dry toast, shredded wheat, and crackers. For some time 
 such foods should especially be avoided as butter and other fats, the 
 nitrogenous vegetables, and sweets of all sorts. 
 
 Chronic Enteritis in Adults — Chronic Intestinal 
 Catarrh — Chronic Colitis 
 
 In severe cases it is often advisable to put the patient upon a 
 milk diet for several weeks. Except in tuberculous subjects this is 
 often successful in effecting a cure. The milk may be skimmed or 
 boiled and diluted with lime water. As a rule, fatty and saccharine 
 food is forbidden, and farinaceous food should be restricted in 
 quantity. At first fats fail of digestion in the intestine, and later 
 other foods. Patients must be especially instructed to take their 
 meals very slowly and masticate sufficiently. The diet should con- 
 sist chiefly of bread and lean meats — foods which leave the least 
 residue. Scraped beef, beef meal, and beef peptonoids are useful. 
 The intestinal indigestion may be improved by the use of pancreatic 
 extracts with bicarbonate of sodium. The food may be pancrea- 
 tinised before it is eaten, or pancreatin may be given in keratin- 
 coated pills designed to remain undissolved until they have reached 
 the small intestine. The stools should be watched for undigested 
 particles of food, muscle fibres, etc. 
 
 If emaciation continues with an exclusive diet of animal food, it 
 may be best to give oatmeal porridge or mush which is predigested 
 with diastase or malt extract. Baked potatoes may be similarly 
 treated. 
 
 Foods to be avoided are very rich milk, green vegetables, raw 
 acid fruits, dried fruits and nuts, richly cooked acid or fat dishes, 
 crustaceans, pork, veal, coarse bread, pastry, sweets, and desserts of 
 all kinds. 
 
 In milder cases in which there is more or less constipation with 
 intestinal catarrh, it is important to regulate the bowels, and this 
 may be done in part by the character of the food, also by system- 
 atic exercise, both active and passive. Mild calisthenics, massage 
 of the limbs and the abdominal wall, combined with abundant fresh 
 air, daily bathing in cold water, and friction of the skin, are all use- 
 ful aids to treatment. 
 
 There are cases of chronic colitis in adults which do not improve 
 upon any diet, and after trying a great variety of foods the patients 
 seem to get on even better for a time on a mixed diet of consider- 
 able diversity. 
 
562 DIET IN DISEASE 
 
 Alcoholic stimulants should be given, and the best forms are 
 claret, sherry, or brandy, all diluted to two or three times their 
 bulk with Apollinaris or plain water. See recommends the Tannin 
 Wine of St. Raphael. 
 
 Some patients are considerably benefited by residence for a few 
 weeks at one of the alkaline mineral springs. 
 
 Chronic Intestinal Indigestion in Children 
 
 Chronic intestinal indigestion in children should be treated by 
 dieting rather than by medicines. Diligent inquiry must be made 
 into the cause of the trouble, and the diet must be regulated ac- 
 cordingly. The stools and the urine must always be carefully ex- 
 amined. If the former are hard, white, and lumpy, if they are too 
 loose and contain undigested coagulse of casein and drops of fat, or 
 if they are sour from lactic-acid fermentation, the milk is certainly 
 disagreeing. If the child is nursing, the mother's milk may be at 
 fault. If the woman is worried, exhausted, or possibly pregnant, or 
 suffering from insomnia, menstrual disorder, phthisis, or other 
 chronic ailment, or if lactation is too long continued, her milk must 
 be replaced by that of a good wet nurse, or, failing this, by the bot- 
 tle. This change will often cure the indigestion at once. It may 
 be that the infant is simply overfed, or fed too often. The excess 
 of milk fails to be absorbed, undergoes lactic-acid fermentation, 
 produces gas with abdominal distention and diarrhoea or irregular 
 passages, together with loss of weight, fretfulness, and other symp- 
 toms. If the child is being fed upon a mixed diet with milk and 
 one of the prepared infant foods, such as Mellin's, Ridge's, Horlick's, 
 etc., the difficulty may be with either the proteid or the carbohy- 
 drate elements, but the prepared foods had better be abandoned. 
 It is easy to ascertain which is at fault by confining the diet ex- 
 clusively for a few days to one or the other of these classes of 
 foods, and noting the effect on the bowels. Moreover, proteid in- 
 testinal indigestion usually produces offensive alkaline feculent 
 stools, while carbohydrate indigestion causes acid stools with more 
 flatus. Of course both classes of indigestion may coexist in the 
 intestine, but the difficulty is primarily with one sort or the other, 
 and hence the advantage of substituting for the mixed diet a more 
 elementary one. In place of milk, egg albumin, pressed-beef juice, 
 or meat broths are to be given. Or if these proteids are not di- 
 gested, the diet should consist for a few days of barley or rice 
 gruel, or gruels of " torrefied starch " — i. e., wheat flour which has 
 been boiled or roasted in order to burst the starch granules and 
 partially convert the granulose into dextrin. The digestion is carried 
 still further by the use of diastase or malt extract, or malted milk 
 may be given. 
 
THE ALIMENTARY CANAL 563 
 
 A mixture of cream and water (p. 486) is well tolerated in 
 some cases, or peptonised milk and various other preparations of 
 milk may be given; but at present peptonised milk is less in vogue 
 than formerly, as its power of restoring emaciated tissues has been 
 seriously called in question. " Modified " or " humanised " milk is 
 to be preferred (p. 88). 
 
 Older children may have beef or chicken jelly, scraped beef, 
 etc. It is well to avoid monotony of diet, lest the appetite fail 
 entirely. 
 
 Chronic Gastro-intestinal Catarrh — Chronic Entero- 
 colitis — Chronic Diarrhcea in Children 
 
 These conditions in children should be treated by very careful 
 regulation of the diet. Parents are apt to be ignorant in regard to 
 this matter, and strict written rules should be furnished to them. 
 Children should be fed at regular intervals at least four times a 
 day, in order that the quantity of food given each time may not be 
 too much. They must not be given acid food, such as pickles, or 
 indigestible substances of any kind, or fruit. Many cases do best 
 when put upon a plain milk diet for several weeks, or, if this is not 
 expedient, peptonised solutions or pancreatinised food may be sub- 
 stituted in part. Other good temporary substitutes for plain milk 
 are buttermilk, whey, and koumiss. Beef broth should not be given 
 exclusively, on account of its occasional tendency to increase diar- 
 rhcea. If the stools contain much fat it is an indication that the 
 pancreatic and biliary secretions are deficient, and the use of pan- 
 creatin is then of special service. 
 
 These children cannot digest sugars, starches, or fats very thor- 
 oughly, although cod-liver oil may be assimilated, and when it is 
 it constitutes a valuable food. It does not necessarily increase 
 diarrhcea, and it may even check it indirectly by improving nu- 
 trition. 
 
 Among foods which may be allowed to older children as im- 
 provement begins are raw oysters, boiled or broiled fresh fish, 
 minced beef and chicken, soft-cooked eggs, soda crackers, bread 
 and milk, toast, thin bread and butter, blancmange, custard, junket, 
 and wine jelly. Sometimes the child continues to emaciate upon a 
 diet of animal broths and meats, and fails to digest either eggs or 
 milk. In such cases pancreatinised mush or some simple cereal, 
 such as barley or rice, may be given with malt extract, and among 
 vegetables which may sometimes be allowed, if diarrhoea has ceased, 
 are asparagus, spinach, stewed celery, cauliflower, and thoroughly 
 baked potatoes with a little salt and butter well mixed. 
 
 Hot water should be recommended before meals if the child will 
 take it. It may be given a faint flavour of some spice, such as 
 
564 DIET IN DISEASE 
 
 cinnamon or clove, and whey is an excellent beverag-e. Some chil- 
 dren become very fond of koumiss, but it is expensive unless home- 
 made (p. 81). 
 
 Many of these children become strikingly emaciated, and, in 
 spite of all dietetic regimen, the skin is dry and wrinkled, and care. 
 should be taken to improve its nutrition. This may be done by 
 tepid baths before bedtime and gentle friction, and by inunctions of 
 three or four drachms of warm melted cacao butter or warm olive 
 oil or cod-liver oil, to be rubbed in over the extremities and parts of 
 the trunk other than the abdomen. In this way little if any nour- 
 ishment can be rubbed into the circulation, and the main benefit of 
 the inunction consists in improving the condition of the skin by local 
 action, and in preventing excessive heat loss, to which poorly nour- 
 ished children are prone. 
 
 Massage should be given for a quarter of an hour every morning. 
 It may be applied over the entire body, unless there is much diar- 
 rhoea, when the abdominal wall should be omitted. 
 
 Simple Atrophy — Marasmus 
 
 Marasmus is a form of starvation occurring chiefly in artificially 
 fed infants, but also in those at the breast, in whom there is great 
 wasting of the muscular and other soft tissues, and sometimes 
 catarrh of the alimentary canal. The food is either too limited in 
 quantity, is indigestible, or else is supplied in a form in which the 
 ingredients are not properly balanced. Breast-fed children are more 
 apt to suffer from insufficient quantity, and hand-fed infants from 
 improper quality of food and overfeeding. " Food upon which a 
 child has thrived for three or four months, perhaps, can become 
 unsuitable, and consequently lead to wasting if the digestive powers 
 be suddenly reduced by an intercurrent disease " (Louis Starr). 
 The treatment of marasmus is therefore essentially dietetic, and 
 the reader is referred to the general directions for infant feeding. 
 No detail should be considered too trivial for the physician's per- 
 sonal attention. If nursed, the mother or wet nurse's milk should 
 be examined for richness in cream and curd. If hand-fed, the most 
 scrupulous care must be taken to secure antiseptic cleanliness, and 
 milk or milk and meat juice should be the staple foods, to the exclu- 
 sion of all farinaceous articles and patent " baby foods." The dis- 
 ease is commonest in the first year of life, but may occur in the sec- 
 ond, and its effects in enfeebling the constitution may last much 
 longer. It is just at this period that mothers — for reasons of sup- 
 posed economy or expediency — are tempted to supplant the only 
 natural infant food (milk) with all sorts of prepared foods. It is 
 because they do not know how to prepare cow's milk properly and 
 adapt it to the baby's needs that they substitute or add artificial foods. 
 
THE ALIMENTARY CANAL 565 
 
 All milk should be peptonised or Pasteurised (p. 78), and 
 lime water or barley water are the best diluents, the former being 
 preferred if there is vomiting or acid eructation. (For the correct 
 degree of dilution according to age, see Infant Feeding.) If good 
 top milk cannot be obtained, one or two tablespoonfuls of cream 
 with a teaspoonful of milk sugar is to be added to each bottle. Some 
 infants do better for a shctrt time upon a cream-and-water mixture. 
 
 In other cases all milk should be withheld, and expressed-beef 
 juice, diluted meat broths, and egg-albumin solution must be used. 
 Louis Starr says : " At eight or ten months from two to four fluid 
 ounces of thin mutton or chicken broth free from grease may be 
 allowed each day in addition to the milk ; at twelve months the yolk 
 of a soft-boiled egg, rice and milk, and carefully mashed potatoes 
 with gravy; and at the end of the second year a small quantity of 
 finely minced meat." 
 
 Cod-liver oil should be given, but never until the digestive func- 
 tions are well restored, as shown by the character of the stools, the 
 absence of eructation and flatulence, and a clean tongue. It is to 
 be prescribed pure, or in one of the emulsions with calcium lacto- 
 phosphate. 
 
 Daily warm baths and inunctions of two or three drachms of 
 cod-liver oil, or, better, olive oil, are to be ordered, with fresh air in 
 abundance. 
 
 Mucous Disease— Chronic Pseudo-membranous 
 Gastro-enteritis — Membranous Enteritis 
 
 Pathological Physiology. — Mucous disease is an obstinate chronic 
 affection in which large quantities of thick, ropy mucus are formed 
 in the alimentary canal, but chiefly in the large intestine. The dis- 
 ease is accompanied usually by neurasthenia and disorders of gastric 
 and intestinal digestion and absorption, of greater or less severity. 
 
 In the disease called membranous enteritis a similar condition is 
 present, and the hypersecretion results in the formation of long tube 
 casts of fibrinous mucus. The passage of the casts is sometimes 
 accompanied by severe paroxysmal pains, and blood may appear in 
 the stools. Although they may be separated clinically, the dietetic 
 treatment of these two affections is the same. Young children nor- 
 mally secrete more mucus from the intestines than do adults, and 
 the long continuance of an irritating diet of improper food may 
 give rise to hypersecretion. Chronic mucous disease is sometimes 
 a sequel of the infectious diseases which particularly affect children, 
 notably whooping cough. There are a larger number and variety of 
 bacteria found in the stools than are usually present, but this disease 
 is not definitely attributable to the action of any one species. The 
 disease is also sometimes associated with intestinal worms. 
 
566 DIET IN DISEASE 
 
 Symptoms. — The appetite is very irregular. It may be exag- 
 gerated early in the disease, and fail completely later on. The food 
 does not nourish the child, absorption being prevented by the mu- 
 cus, and it causes flatulency and discomfort. Emaciation is pro- 
 gressive and extreme. Some of the stools consist wholly of mucus, 
 fatty epithelial cells, and granular detritus, while others contain 
 particles of undigested food, milk curds, meat fibre, etc., mixed with 
 mucus. 
 
 Dietetic Treatment. — The only hope of cure of this condition 
 lies in the most rigid dietetic treatment, combined with regular 
 habits, bathing, etc. In the worst cases only predigested fluid food 
 should be given, such as pancreatinised milk, meat juice, and egg 
 albumin. Beef tea, light broths of veal, mutton, or chicken, con- 
 somme, or milk punch may be allowed. 
 
 Sometimes it is necessary to give no food by the stomach for six 
 or eight hours, and then commence to feed very slowly, giving tea- 
 spoonful doses at fifteen-minute intervals. If the child has been 
 living for long upon milk alone, and the stools show fat and undi- 
 gested curds, it is best to make a radical change and proscribe it en- 
 tirely. Jacobi gives instead a mixture containing five ounces of bar- 
 ley water, one to two drachms of brandy or whisky, the white of an 
 egg, and a little salt and cane sugar. Dose, a teaspoonful every five 
 or fifteen minutes. This is a fairly palatable mixture. It is con- 
 sidered best to withhold all farinaceous and saccharine articles until 
 some sign of improvement appears. 
 
 Edwards prescribes the dietary of the London Northeastern Hos- 
 pital for Children. (See Hospital Dietaries.) 
 
 Dysentery 
 
 During an attack of acute dysentery the patient should be kept 
 absolutely quiet in bed, and should not be allowed to rise for the 
 movement of the bowels, making use of a bedpan instead. Through- 
 out the active stage the diet must be strictly confined to easily di- 
 gestible food, and in most cases it is wisest to give only predigested 
 fluid articles. Peptonised or pancreatinised milk, or boiled milk, 
 pressed-meat juice, whey, or raw egg albumin beaten with sherry 
 and flavoured with nutmeg are recommended. Many patients do 
 best upon a diet of raw scraped beef or meat balls (p. in). 
 
 In cases of acute dysentery, and especially in the amoebic form, 
 the loss of strength, anaemia, and emaciation progress very rapidly, 
 and the strength must be supported by stimulation, for which brandy 
 is preferable to whisky. 
 
 During convalescence the diet must be very cautiously increased, 
 and confined to food which is promptly and completely digested, 
 leaving but little residue. For this purpose animal food should be 
 
THE ALIMENTARY CANAL 567 
 
 chiefly eaten, while fish, tender beefsteak, roast beef, boiled or 
 broiled chicken, eggs, custard, blancmange, dry toast, junket, well- 
 boiled rice, or wine jelly, may be given. All fruits and vege- 
 tables must be forbidden, and butter and cream should be taken 
 sparingly. 
 
 If the disease occurs in infancy, the child, if possible, should be 
 fed at the breast. Otherwise all milk given should be Pasteurised. 
 Beef tea and mutton broth may be allowed in moderation, and 
 special care should be observed not to overfeed. 
 
 CHRONIC DYSENTERY 
 
 Chronic dysentery is often best treated by an exclusive milk 
 diet of from two and a half to three quarts a day, with rest in bed 
 or on the lounge. In other cases rare steak or roast beef or chicken 
 and egg albumin may be allowed, with dry toast, zwieback, or crack- 
 ers. The milk and meat diet may be advantageously combined. 
 
 In Osier's opinion, if there is much ulceration of the colon meat 
 is not well borne, and it is better to keep the patient upon a diet 
 which will give but little residue, such as boiled or peptonised milk. 
 
 The stools must be examined every day or two to ascertain the 
 presence of undigested fragments of milk curds or meat, oil globules, 
 mucus, blood, etc. If improvement does not occur, the patient may 
 be put upon a diet of egg albumin with beef juice, or some of the 
 preparations of beef meal (p. in) or peptonoids, with pancreatin- 
 ised milk. Return to solid diet must be very gradual, and may be 
 conducted on the lines directed for convalescence from typhoid fever 
 (P. 435)- 
 
 Acute Intestinal Obstruction 
 
 Many of these cases demand immediate operation, but if for any 
 reason this is not performed nothing should be given by the mouth. 
 If any food be taken it decomposes, and even drink may excite 
 severe vomiting. The patient may be nourished by the rectum, 
 and thirst can be relieved by injection of a pint of lukewarm 
 water with a teaspoonful of salt into the rectum. If the latter is 
 irritable a smaller quantity should be employed, and more fre- 
 quently given. Another method of relieving thirst is to inject a 
 pint or two of warm, sterilised salt solution of the above strength 
 into the cellular tissue beneath the skin, after the manner of the 
 hypodermoclysis recommended in cholera (p. 448). If necessary, 
 half an ounce or more of whisky is to be given from time to time 
 hypodermically, weakened by two or three times the quantity of 
 salt solution. If all these injections are sterilised and inserted 
 deeply they are much less painful than if inserted immediately be- 
 neath the skin. 
 
 If the obstruction is overcome without operation, the diet should 
 33 
 
568 DIET IN DISEASE 
 
 be very slowly increased, giving only fluid nourishment by the 
 mouth for two or three days, or until all symptoms have subsided. 
 
 The fluid food should consist of beef juice, broths, egg albumin, 
 and simple farinaceous gruels. Milk, if not wholly absorbed, forms 
 too bulky feces. 
 
 The symptoms of profound collapse, thready pulse, etc., depend 
 not upon the local condition of obstruction, but upon sapraemic 
 intoxication from toxins produced by decomposition of retained 
 food. This statement is corroborated by the prompt relief which 
 sometimes succeeds emptying the bowel after removal of the ob- 
 struction and the use of lavage and irrigation with warm water 
 (io6° F.). 
 
 Chronic Constipation 
 
 Physiology. — The periodic daily evacuations of the bowels are 
 determined by peristaltic contractions of the muscular wall of the 
 intestines excited by their contents. The thick fluid condition of 
 the food (chyme) which enters the small intestine from the stomach 
 is gradually altered by absorption of water and soluble ingredients 
 in the small intestine. This process is accomplished by rhythmical 
 vermicular contractions of the intestinal wall which are reflex in 
 character and stimulated in different degrees by the bulk and chem- 
 ical combination of the food and by the various digestive secretions, 
 namely, the intestinal and pancreatic juices and, especially, the bile. 
 The peristalsis is more active in the small than in the large intestine, 
 for it has the triple function of (i) mixing the food and digestive 
 fluids ; (2) bringing the whole mass into contact with a large surface 
 for absorption ; and (3) propelling the residue towards the large 
 intestine. 
 
 Simultaneously the local blood current is increased. The vessels 
 and lymphatics in the intestinal wall and mesentery become greatly 
 distended by absorption of food products. The increase in volume 
 and flow of the blood also stimulates peristaltic contractions. 
 
 Towards the lower end of the small intestine the food is found 
 diminished in volume by absorption, and the mass is consequently 
 somewhat drier. The ileo-csecal valve is periodically relaxed by 
 reflex mechanism, and the peristalsis of the small intestine propels 
 the food onward into the large intestine, where further absorption 
 takes place, and the residue is more slowly moved towards the sig- 
 moid flexure. Here it remains and accumulates until a certain bulk 
 is gathered, which by pressure or distention excites the reflex mech- 
 anism of defecation. This mechanism employs a large number of 
 muscles, and hence the need of a controlling nerve centre, which 
 is found in the lumbar region of the spinal cord. 
 
 Constipation, when not due to intestinal obstruction, is dependent 
 upon lack of peristalsis, as diarrhoea is due to excessive peristalsis. 
 
THE ALIMENTARY CANAL J 569 
 
 Many persons are wholly ignorant of what constitutes a normal 
 stool. The custom of using patent water closets often prevents 
 them from seeing the stool, and they are unable to correctly esti- 
 mate its amount or character. A little accumulation of residue left 
 over each day will presently cause very uncomfortable constipa- 
 tion. The normal stool should weigh about five or five and a half 
 ounces, of which only one and a half ounce is solid matter. It 
 should constitute a sausage-shaped mass, in all about six inches 
 in length. 
 
 Pathological Physiology. — Constipation may result from one or 
 more of the following causes, which are related to diet: 1. Insuf- 
 ficient quantity of solid food. 2. Too highly nutritious or concen- 
 trated food. 3. Insufficient fluid. 4. Astringent food and drinks. 
 5. Indigestible food. 6. Lack of digestive fluids. 7. Irregularity in 
 diet. 8. Obstruction from overeating. 9. Lack of peristalsis. 10. 
 Lack of exercise. 
 
 1. Insufficient food is one of the most common causes of consti- 
 pation. In prolonged starvation the bowels cease to move entirely. 
 Persons who eat but sparingly have too little bulk of food to excite 
 the normal peristaltic motion of the intestines, and the waste prod- 
 ucts accumulate in consequence. 
 
 2. Too highly nutritious or concentrated food, such as richly 
 seasoned meats, milk, meat extracts, peptonised fluids, etc., when 
 almost completely absorbed, leave insufficient residue of waste mat- 
 ter. Peristalsis is therefore either not excited or the contracting 
 intestinal wall has insufficient bulk of material to seize upon and 
 propel. 
 
 3. Insufficient fluid often causes constipation, and for three rea- 
 sons : (1) The chyme is not kept liquid enough to be thoroughly 
 mingled with the digestive juices. (2) The intestinal walls become 
 too dry and friction over the hardened fecal masses is increased, 
 making it difficult to propel them. (3) There is less fluid absorbed 
 by the blood, and consequently the digestive juices and intestinal 
 mucus are reduced in amount and altered in quality. 
 
 4. Astringent food or drinks, such as tea, brandy, or claret, con- 
 stipate by checking the mucous and other secretions, thereby in- 
 creasing friction within the intestinal wall. 
 
 5. Indigestible food may be so hard and bulky as to be imper- 
 fectly acted upon by peristalsis and incompletely mingled with the 
 digestive juices, or it may give rise to abnormal fermentation and 
 production of substances which inhibit absorption and peristalsis. 
 
 6. Lack of digestive fluids in normal proportion or serious alter- 
 ations in their composition retard digestion and lessen peristalsis. 
 
 7. Irregularity in diet or in the intervals of taking food, eating 
 too hastily, imperfect mastication, and great variations in the quan- 
 tity of food eaten, all tend to disorder digestion by disturbing the 
 
570 DIET IN DISEASE 
 
 natural rhythm of its various stages, and especially the periodicity of 
 defecation. 
 
 8. Obstruction from overeating, particularly in children, may 
 cause constipation from the accumulation of larger quantities of 
 waste matter than the intestinal muscles have power to propel. 
 
 9. Lack of peristalsis occurs through enfeebled intestinal muscles 
 or imperfect nerve stimulation. 
 
 10. Lack of exercise fails to stimulate the circulation, both gen- 
 eral and local, and to secure the abundant oxygen supply needed for 
 complete oxidation of the food. It also fails to stimulate peristalsis 
 by the natural movements of the body, especially of the abdominal 
 muscles, and by increasing the flow of bile. 
 
 Constipation is not infrequently a constitutional habit or family 
 peculiarity, running through several generations. It is provoked 
 by sedentary habits and neglect of the calls of Nature, and it is 
 the usual accompaniment of impoverished conditions of the blood 
 and malnutrition, and especially anaemia, neurasthenia, hysteria, 
 and chronic diseases of the liver and stomach. It is also fre- 
 quently present in connection with acute fevers, and the habit of 
 the perpetual consumption of drugs of many varieties may occa- 
 sion it. 
 
 Weakness of the muscles of the intestinal and abdominal wall are 
 common factors in the production of constipation. This symptom is 
 therefore present in obesity, overdistention of the abdominal wall 
 during pregnancy, and in atony of the large intestine and chronic 
 diseases of its mucous membrane. It is also produced by obstruc- 
 tion from the pressure of tumours, accumulation of scybalae from 
 impaction of foreign bodies in the bowel, stricture, and localised 
 atony of the sigmoid flexure. 
 
 Symptoms. — In all common cases the symptoms accompanying 
 constipation are debility and lassitude, while more or less mental de- 
 pression is present in persons of nervous or hypochondriacal temper- 
 ament. When it occurs in the course of chronic insanity it increases 
 languor, moroseness, and irritability of temper, and not seldom ex- 
 cites acute and violent symptoms. As a result of the accumulation 
 of waste matter in the lower bowel, internal misplacements may oc- 
 casionally result, or, if they already exist, they may be increased. 
 Sacral neuralgia is sometimes produced, and hemorrhoids from con- 
 gestion of the rectal veins may occur. Occasionally constipation 
 may result from malformations of the intestine — adhesions which 
 bind loops and coils of the intestine in abnormal positions and inter- 
 fere with peristaltic movement. The impacted feces accumulate in 
 the colon and are found chiefly in the sigmoid flexure, but they may 
 also form large tumours in the hepatic or splenic flexure, or even in 
 the right inguinal region. In aged persons sacculi of the colon 
 may become permanently distended, and scybalae become calcified 
 
THE ALIMENTARY CANAL 571 
 
 as enteroliths. A channel is sometimes bored through the impacted 
 masses of fecal material, and the long-continued constipation will 
 give rise to diarrhoea. The fecal mass acts as a local irritant, and 
 diarrhceal stools pass through the channel. 
 
 Chronic constipation may sometimes give rise to acute attacks of 
 localised pain and considerable fever (104 F.). These attacks may 
 simulate appendicitis, localised peritonitis, or other acute abdominal 
 diseases. 
 
 Dietetic Treatment. — Before ordering the diet for chronic con- 
 stipation, the patient must be minutely interrogated as to his daily 
 habits of life, such as occupation, hours for meals and for exercise, 
 recreation, and sleep, the kinds of foods and quantity usually eaten, 
 the amount and kinds of fluids drunk, hour for going to stool, the 
 use of stimulants and tobacco, and presence of mental worry or 
 anxiety. 
 
 The principles of dietetic treatment of chronic constipation are 
 based upon supplying digestible food, which will excite peristalsis 
 either by its bulk or its physical and chemical properties. Vegetable 
 food in general, as distinguished from nitrogenous diet, furnishes a 
 much larger proportion of waste matter. Herbivorous animals have 
 more abundant evacuations than do carnivores. 
 
 Following is a list of common foods discussed in their relation 
 to constipation : 
 
 Vegetables. — The cellulose of starchy foods is difficult of diges- 
 tion and of comparatively little nutrient value for man ; hence it 
 yields a considerable quantity of waste material. This is true of 
 the starch granules of potatoes, corn, peas, beans, etc. 
 
 Other vegetables which leave a large residue after digestion are 
 tomatoes, spinach, lettuce, asparagus, salsify, cabbage, and celery. 
 Tomatoes and spinach seem to possess slight special laxative proper- 
 ties. Spanish onions, boiled, are laxative. 
 
 Cereals. — The various cereals used for bread when coarsely 
 ground contain a large proportion of the external envelope of 
 the grains, which is more or less hard and rough, and by its pres- 
 ence in the intestine it stimulates peristalsis through mechanical 
 irritation. 
 
 For the above reasons the following articles of diet tend to over- 
 come constipation : Coarse Graham bread, rye bread, wheatena, 
 wheaten grits, cornmeal, Indian meal, oatmeal, brown or " whole- 
 meal " bread, Boston brown bread, shredded wheat. 
 
 Molasses and honey added to bread are laxative. Gingerbread, 
 especially for children, is sometimes efficacious. With some per- 
 sons the substitution of milk sugar (lactose) for cane sugar proves 
 laxative. 
 
 Beverages. — Coffee, beer, cider, and unfermented grape juice are 
 somewhat laxative. 
 
~$J2 DIET IN DISEASE 
 
 Oils. — Olive oil and cod-liver oil, if taken at bedtime into an 
 empty stomach, are laxatives for some persons, particularly children. 
 
 Adults may take a dessertspoonful of best Lucca oil with each 
 meal, eating it with fresh vegetables, such as beets or lettuce, or 
 mixing it with potatoes. 
 
 Fruit. — Fruits are laxative, either because they contain indiges- 
 tible seeds, which act mechanically in the intestine (e. g., figs, ber- 
 ries), or because the vegetable acids and salts which they furnish 
 upon being absorbed stimulate the digestive secretions and peri- 
 stalsis. 
 
 Fruits with seeds are laxative, such as figs, blackberries, straw- 
 berries, huckleberries, blueberries, and also grapes in large amount 
 without the seeds. 
 
 Fruits having special laxative properties through chemical action 
 are apples, pears, peaches, oranges, shaddock, cherries, prunes, 
 plums. Many fruits act in both the above ways, and raisins, figs, 
 prunes, and apples leave considerable bulk of waste matter after 
 digestion. 
 
 Fruit is always more laxative when eaten between meals or 
 some time — say, half an hour — before breakfast. It then enters the 
 intestine more promptly, and it is not retarded in its effect by the 
 presence of other articles of diet. Its action is furthered by drink- 
 ing a tumblerful or two of water. 
 
 With many persons constipation may be prevented by eating one 
 or two oranges or the juice of half a grape-fruit before breakfast. 
 The latter is very sour, and considerable sugar is required to make 
 it palatable. This is a decided disadvantage for those who have 
 flatulent dyspepsia or gout. Instead of sugar, the bitterness may be 
 disguised by a little sherry or rum poured upon the cut fruit. A 
 half dozen dried figs or a dozen or so of French prunes eaten at in- 
 tervals during the day, when the stomach is empty, produce a laxa- 
 tive effect. These fruits in smaller quantities are very good for 
 children. In some cases the breakfast may be confined exclusively 
 to fruits for two or three months. 
 
 Cooked Fruits. — With many persons having imperfect digestion 
 raw fruits disagree, and since their laxative properties are not much 
 weakened by being cooked, it is better to eat them in that form. 
 Stewed prunes, or apples either stewed or baked, are very easy of 
 digestion, and the latter may often be eaten by invalids in whom 
 the digestive organs are very weak. Cooking berries or other suit- 
 able fruits by stewing renders them much more digestible, and 
 does not impair their nutritive qualities. The principal objection to 
 cooked fruits is that they usually require so much sugar to make 
 them palatable that they may cause flatulency. A little bicarbonate 
 of sodium will neutralise the acidity, and saccharin may be added 
 instead of sugar. 
 
THE ALIMENTARY CANAL 573 
 
 Canned or dried fruits and fruits preserved in sirups are of little 
 value for constipation. 
 
 A few fruits, like the banana, are apt to cause constipation. 
 
 Owing to the prevalent idea that fresh fruit relieves constipation, 
 patients occasionally eat too much of it, with the result of producing 
 dyspepsia and increasing their original trouble. 
 
 Nuts. — Nuts, especially English walnuts and almonds, are excel- 
 lent laxatives, partly from their bulky residue and in part from the 
 oils which they contain. 
 
 Water. — Copious draughts of either very hot or cold water, two 
 or three tumblerfuls, should be taken before retiring and on rising. 
 Many persons, from a belief that water drunk with meals is injurious, 
 abstain from it and forget to take fluid between meals, and become 
 constipated in consequence. If they happen to lose water by free 
 perspiration also, the difficulty is enhanced. Such patients should 
 be advised to drink water freely, as above indicated. It also aids 
 digestion to take a tumblerful of hot water about an hour after a 
 meal unless the gastric juice is feeble in strength of acidity. The 
 stomach contents becoming somewhat thickened by loss of fluid 
 through the pyloric orifice or by direct absorption through its own 
 wall, are better digested by being diluted again. The temperature 
 of the water drunk makes but little difference as far as constipation is 
 concerned. Cold water is warmed and hot water is cooled by the 
 oesophagus, so that upon reaching the stomach it is nearly of the 
 normal body temperature, no matter how much it differed from this 
 when swallowed, provided it has been taken slowly. If swallowed 
 in large draughts it does affect the stomach temperature for a few 
 moments, but it is soon brought to the normal body temperature 
 again (p. 334). 
 
 When patients will not drink enough plain water, they can be 
 induced to take lemonade or water flavoured with some aromatic. 
 A few cloves put in a tumbler of boiling water and allowed to steep 
 overnight impart their flavour to the fluid, which may be drunk on 
 rising in the morning. 
 
 Summary of the most Useful Articles for Chronic Constipation. — 
 Abundant water, coarse brown or bran bread, oatmeal, butter, fresh 
 green vegetables (lettuce, spinach, sprouts, rhubarb, etc.), prunes, 
 figs, apples (cooked or raw), peaches, berries, buttermilk, apple cider, 
 koumiss, honey, English walnuts. 
 
 Foods to be Avoided. — Persons suffering from habitual constipa- 
 tion do well to give up the following articles : Eggs, milk, sweets, 
 pastry, puddings made of simple amylaceous substances — such as 
 rice, sago, etc. — fried foods, rich gravies, sauces, curry, strong 
 condiments, pickles, cheese, tea, sour or red wines. 
 
574 DIET IN DISEASE 
 
 AIDS TO DIETETIC TREATMENT 
 
 It is an important and infallible rule in cases of chronic constipa- 
 tion that hygienic as well as dietetic treatment should supersede the 
 use of medicine. It is very necessary to establish a uniform hour 
 for going to stool each day, and all efforts at straining should be 
 avoided. Exercise in moderation should be insisted upon, such as 
 walking at least an hour or two twice a day, but of exercise in the 
 open air, horseback riding is by far the most beneficial. One or 
 two rides a week are much better than none. Many persons find 
 improvement from bicycling. Tight lacing and constriction of the 
 abdomen by tight belts should be avoided, and also sitting long in 
 positions compressing the abdomen. Much good may be accom- 
 plished by elementary instruction in calisthenics, in which special 
 attention is paid to deep respiratory movements of the diaphragm 
 and abdominal muscles. 
 
 Regularity should be observed in habits of life, in hours of sleep, 
 and of meals. Many business men whose daily routine of early 
 rising, exact hours, and evening dinners is disturbed on Sundays by 
 late breakfast and a noon dinner, find that the regular habit of the 
 bowels is interrupted at the first of the week, and in consequence 
 may suffer for a day or two from headache and " biliousness." 
 
 Massage. — Massage is the process of manipulating the muscles 
 and subcutaneous cellular tissue. The aim of the treatment is to 
 mechanically compress and stimulate the structures beneath the 
 skin, and it is to be distinguished from the effects of merely rubbing 
 the surface of the body, which acts through excitation of the cuta- 
 neous nerves and circulation. 
 
 Massage promotes the movement of the blood through the veins 
 and of the lymph in the lymph spaces and capillaries, and favours 
 the removal of waste products from the tissues compressed, and the 
 increase of healthy metabolism in the muscles. It also stimulates 
 the latter in a slight degree to contraction. It aids the functional 
 activity of the liver, stomach, and bowels. The various manipula- 
 tions are complex, and when rightly performed require the skill and 
 experience of thoroughly trained operators. The chief manipula- 
 tions are classed as — 
 
 1. Percussion by short quick blows of the fingers or small rubber 
 hammers. 
 
 2. Rolling the muscles and subcutaneous tissues beneath the ex- 
 tremities of the fingers. 
 
 3. Kneading with the fingers and palms of both hands, placed 
 one above the other, on the patient's arm or leg. 
 
 Massage of the abdominal muscles is most useful for constipation, 
 and both percussion or mechanical vibration and kneading are to be 
 used. It should be performed in the direction of the colon, com- 
 
THE ALIMENTARY CANAL 575 
 
 mencing low down on the right side of the abdomen, ascending to 
 the ribs, crossing to the left, and descending upon the left side to 
 the sigmoid flexure. This mechanical movement not only pushes 
 along the intestinal contents, if the abdominal wall be not too fat 
 or rigid, but it stimulates peristalsis by reflex action. If possible, 
 it should be given in the morning before rising, and at first daily, 
 for fifteen or twenty minutes, but later every other day. The treat- 
 ment should be continued for a month or more. Obstinate cases 
 have been cured in this manner, and the method is especially serv- 
 iceable for very obese patients. 
 
 Some persons derive aid from manipulating the abdominal wall 
 for themselves while lying in bed in the morning. A large wooden 
 ball like a croquet ball or a heavy metal ball weighing four to six 
 pounds may be rolled over the abdomen for five or ten minutes 
 every morning, pressing it in deeply in the direction of the colon. 
 This sometimes, in thin subjects, promotes the movement of the 
 intestinal contents. 
 
 Medicines. — Discussion of the medicinal treatment of constipa- 
 tion is not within the scope of this work, but the practice of contin- 
 ually taking laxatives and strong cathartics cannot be too strongly 
 condemned. The constant daily overexcitation of the bowels by 
 such remedies as aloes produces a deplorable condition in which the 
 bowels refuse to act at all without constantly increasing dosage. 
 
 The majority of such cases can be cured by diet, but the rules 
 must be very distinctly laid down, and the patient must exercise 
 patience and care in adhering to them. I have sometimes been able 
 to relieve patients who for several years had depended wholly upon 
 strong cathartic pills or enemata, by stopping all medicine, and en- 
 forcing simple dietetic rules, especially in regard to drinking abun- 
 dant fluid and eating laxative and bulky food. They often think 
 that a daily movement is absolutely necessary, and the worry and 
 nervousness which its absence occasions increases the difficulty. 
 They should be reassured, and told not to be concerned if the 
 bowels do not move at first for two or three or even four days, and 
 that if they do not have an unaided passage in that interval they can 
 certainly be relieved, and diet and regimen will succeed in time if 
 persistently followed. 
 
 In very obstinate cases when diet does not succeed alone, atten- 
 tion to its regulation will enable the patient to obtain the desired 
 result with mild and decreasing doses of simple saline laxatives such 
 as Congress, Crab Orchard, Mt. Clemens, Apenta, or Rubinat water, 
 in lieu of strong cathartic pills, or patent medicines. 
 
 Tobacco. — Tobacco smoking increases peristalsis. Some men 
 become constipated when deprived of their after-breakfast cigar. 
 The effect of tobacco is not constant, however, and by disordering 
 digestion too much smoking may be an indirect cause of constipa- 
 
5/6 DIET IN DISEASE 
 
 tion. In those in whom it acts favourably upon the bowels, a good 
 cigar is usually more active than any other form of the weed. 
 
 Bathing. — A daily morning cold bath followed by vigorous fric- 
 tion of the skin is of great service. 
 
 Electricity. — Faradisation of the abdominal walls is frequently 
 useful, but, owing to the fact that the electric current when applied 
 superficially radiates over the skin without penetrating to any ex- 
 tent beneath the surface, it cannot be expected to reach the intes- 
 tinal wall. Any benefit derived from such application must be purely 
 of a reflex character from excitation of the cutaneous nerves trans- 
 mitted through the cord to the sympathetic nerves. A much better 
 method of applying a faradic current consists of introducing one 
 electrode for several inches into the rectum, while the other is 
 moved about over the surface of the abdominal muscles. In this 
 manner these muscles may be made to contract and move the intes- 
 tines to some extent, and it is possible for a portion of the current 
 to pass through the sigmoid flexure. If carefully adjusted, the ap- 
 plication of the current gives rise to no pain or discomfort. 
 
 Bandaging. — In very obese persons, who are liable to suffer 
 from constipation, the pendulous and relaxed abdominal wall should 
 be supported with an abdominal bandage. The same treatment may 
 give comfort when the wall is much distended in childbearing or by 
 the presence of large abdominal tumours or accumulations of ascitic 
 or ovarian fluid. 
 
 Constipation in Infants and Children 
 
 In earliest infancy from two to three daily evacuations from 
 the bowels are considered a normal number, but in childhood, as 
 in adults, one passage is normal. In later infancy constipation is 
 exceedingly common on account of the milk diet, and bottle-fed 
 babies are more subject to it than sucklings. The small intestine 
 is relatively longer than in the adult, the large intestine easily 
 becomes distended, the pelvis is more contracted, and peristalsis 
 is usually less vigorous, owing to a less powerful musculature than 
 obtains in adults. 
 
 When constipation is present in an infant at the breast the milk 
 may be too rich in casein and deficient in fat, salts, and sugar. This 
 may be due to a constipated habit of the mother, and laxative foods 
 should be given to her rather than medicines to the child. If the 
 child is nursing a wet nurse, it may be best to change to another in 
 perhaps an earlier stage of lactation, or one whose milk is less rich 
 in proteids. 
 
 If the infant's stools consist of dry and brittle scybalse it should 
 be given more water to drink, or a little oatmeal water, which 
 is laxative. Other simple and oftentimes effectual remedies are 
 
THE ALIMENTARY CANAL 577 
 
 from half to a teaspoonful of olive oil, molasses, melted sugar, or 
 butter. 
 
 In the case of hand-fed babies when the milk forms large and 
 hard curds, and when the proportion of cream is too small, the addi- 
 tion of water and cream will often remedy the evil. 
 
 As an occasional, but not habitual, simple remedy for constipa- 
 tion in such cases relief may be obtained by making a mixture of a 
 tablespoonful of whole-meal gluten flour in a pint of water, boil- 
 ing for three hours to a thick mass, and adding a teaspoonful of the 
 mixture, unstrained, to each feeding bottle. 
 
 Artificial foods, " prepared " foods, and condensed milk are more 
 apt to excite diarrhcea than constipation, but it should be remem- 
 bered that they may cause the latter, and the continued use of 
 coarse food or cathartics, or of large enemata, overstimulates the 
 bowel and results in constipation. 
 
 When it is necessary to use enemata they should be small, and 
 not too frequently given. From ten to thirty drops of glycerin in 
 two teaspoonfuls of water is quite sufficient for a young nursing 
 infant. The glycerin, by virtue of its hygroscopic power, abstracts 
 water from the rectal mucous membrane, causing hypersemia, which 
 in time excites peristalsis. A simple injection of two teaspoonfuls 
 of cold water containing a pinch of salt is often successful. 
 
 Suppositories may also be used. They should be small, conical 
 in shape, and well oiled before being inserted. They may be made 
 of glycerin, soap, molasses candy (Fruitnight), or gluten. 
 
 For older children, from three years up, some one or more of the 
 following articles should be included in the menus. By this means it 
 will be possible to do without castor oil, senna, rhubarb, strong ene- 
 mata, and other remedies which are constantly abused. 
 
 Foods Recommended.— Oatmeal, corn bread, cracked wheat, por- 
 ridge, wheaten bread made of unbolted flour, bran bread soaked 
 in warm milk, gingerbread, bread and molasses (not sirup), 
 brown bread and honey, stewed prunes, baked apples, figs, olive 
 oil and olives, cod-liver oil, fresh green vegetables, orange juice, 
 peaches, and whey. 
 
 Foods Forbidden. — Certain foods should be absolutely forbidden 
 to older children, such are cheese, dry fruits (except figs and prunes), 
 fruits having small seeds, spices, pickles, nuts, raisins, dried, salted, 
 or preserved foods of all kinds, canned corn, sweets, candies, cakes, 
 and excess of farinaceous foods. All articles likely to produce flatu- 
 lent dyspepsia must be avoided. Children on a mixed diet do well 
 to avoid starchy foods and take more broths and soups. Variety 
 in the diet is desirable. 
 
 Children should be trained to go to stool at regular hours, and 
 should be early taught the evil consequences of neglect to respond 
 to the calls of Nature. School-teachers should not detain them at 
 
57$ DIET IN DISEASE 
 
 their lessons when they are inclined to seek the closet. Water-closets 
 or privies are often dark, cold, and otherwise disagreeable, so that 
 children dread going to them. 
 
 Abdominal massage is very helpful in overcoming chronic con- 
 stipation in young children. It may be performed two or three 
 times a day for five minutes. The movements should be made with 
 the fingers of a warm, dry hand, which move the integument and 
 abdominal wall over the intestine. The treatment must be very 
 gentle, and if the muscular wall is tense, it may be conducted while 
 the infant is nursing or feeding, as suggested by Fruitnight. 
 
 Hemorrhoids 
 
 Hemorrhoids usually complicate cirrhosis of the liver sooner or 
 later, but they also result from chronic constipation and other causes. 
 The dietetic treatment is substantially that of chronic constipation 
 (p- 57 1 )- Much depends upon preventing the stools from becom- 
 ing hard or bulky. Large quantities of coarse vegetables and cereals 
 should therefore be avoided as well as milk. Alcohol is injurious, 
 especially in the cirrhotic cases. Fresh fruits and abundant fluids 
 are serviceable in uncomplicated cases. Regularity in meals and in 
 time of going to stool should be enjoined, with abundant outdoor 
 exercise. Straining at stool must be avoided. 
 
 Appendicitis 
 
 Causation. — Appendicitis is mainly interesting from the dietetic 
 standpoint on account of the possible causative relation of certain 
 food residues. In about one third of the cases fecal concretions are 
 found in the appendix, and in one thirteenth foreign bodies have 
 been discovered. It is a popular belief that the disease is often es- 
 tablished by the presence in the intestine of grape seeds or skins, 
 lemon, orange, or mustard seeds, cherry pits, bits of chicken bone or 
 clam shell, etc., but such is not the case. Substances of this nature 
 are no doubt often swallowed, but they seldom make their way to 
 the appendix or do any harm ; and it is now known that the disease, 
 while it may exceptionally be produced by such irritants, is com- 
 monly caused in other ways, and is often of bacterial origin. I have 
 known of one fatal case resulting from eating a large number of 
 soft-shell crabs, but such accidents are very rare. On the other 
 hand, both overeating and overdrinking may indirectly cause ap- 
 pendicitis as well as the consumption of too highly seasoned foods, 
 for these factors provoke catarrh of the intestine, distending the 
 bowel with feces and gas, and making it easy for the catarrhal pro- 
 cess or for bacteria of various sorts to enter the appendix and set 
 up local inflammation there. The recurrent cases are more apt to 
 be excited directly by overeating and improper food. 
 
THE ALIMENTARY CANAL 579 
 
 Dietetic Treatment. — The dietetic treatment of appendicitis which 
 has not yet passed into the surgeon's hands should consist in giving 
 only such food as will be thoroughly absorbed, leaving as little 
 residue as possible to irritate the lower bowel and excite peristalsis. 
 Until the outcome of the attack is decided it is best to put the patient 
 upon a fluid diet, consisting chiefly of nutritive broths. Beaten eggs 
 may be allowed, and a moderate quantity of pancreatinised milk, 
 whey, or buttermilk. Cocoa may be given, and strained gruels of 
 rice or barley. 
 
 In recurrent cases the patient should be cautioned to eat moder- 
 ately and avoid all coarse or hard food, such as grits, coarse oatmeal, 
 tough meats, fibrous vegetables, the skin of fruits or potatoes — in 
 short, everything likely to overload the intestine with accumulated 
 waste. 
 
 The operative cases should have the diet recommended after 
 laparotomy. Usually the digestive organs require almost absolute 
 rest for twenty-four hours after the operation, and hot water may be 
 sipped. No food at all should be given for fully six hours before 
 operation. 
 
 Acute Peritonitis 
 
 Acute peritonitis, if due to causes within the alimentary canal, 
 demands absolute rest of the stomach and intestines, and this is 
 secured by giving all nourishment, stimulants, and medicines in 
 the form of nutrient enemata (p. 408). Any food in the stomach 
 is likely to excite vomiting and aggravate the pain and other symp- 
 toms. 
 
 Most cases of acute peritonitis demand laparotomy, and the die- 
 tetic treatment is given under that heading. 
 
 In other cases a very little fluid nourishment may be cautiously 
 administered per os, such as peptonised milk, light gruels of pearl 
 barley or arrowroot, plain meat juice squeezed from a fresh steak, or 
 one of the forms of peptonised meat or Qgg albumin in sherry 
 should be tried. Only one or two teaspoonfuls should be given once 
 in fifteen minutes or half an hour, and every effort must be made 
 to prevent the occurrence of vomiting or meteorism. Twelve or 
 fifteen ounces per diem of predigested food given by the mouth 
 is all that should be prescribed in such cases. The resumption 
 of a full diet should be extremely gradual, occupying several 
 weeks. 
 
 It is well to avoid the use of aerated waters of all kinds on ac- 
 count of their tendency to increase meteorism and render the patient 
 still more uncomfortable. Alcoholic stimulation is usually required 
 in severe cases, and if the stomach is intolerant it should be given 
 in the form of dry champagne or dilute whisky or brandy. The 
 latter mav be added to rectal enemata. 
 
580 DIET IN DISEASE 
 
 The reader is referred to the section upon the diet for convales- 
 cent typhoid-fever patients (p. 435) for hints as to selection of a 
 menu for convalescents from peritonitis. 
 
 Chronic Peritonitis 
 
 In chronic peritonitis the outcome of chronic tuberculosis, or 
 other disease, plainly cooked animal food agrees best. Starches 
 and sugars, from their tendency to ferment and dilate the bowels 
 with gas, should be avoided. Broiled tender chop, steak, chicken, 
 or white meat of fish may be given. Eggs, milk, and cream are 
 permitted when they do not cause dyspepsia. Bread should be eaten 
 sparingly, and must always be stale or toasted. Zwieback and crack- 
 ers are given for variety. All food should be eaten very slowly and 
 in very moderate quantities at a time. 
 
 DIET IN LIVER DISEASES IN GENERAL 
 
 Biliousness 
 
 Symptoms. — " Biliousness " is an unscientific but very convenient 
 term employed to express functional disorder of the liver, usually 
 accompanied by an oversecretion of bile, which is often vomited. 
 The condition is characterised by headache, nausea, vomiting, con- 
 stipation, a furred tongue, anorexia, offensive breath, malaise, and, 
 if it continues, by a sallow, yellowish, or pasty complexion. 
 
 Causation. — The most common cause of biliousness is eating too 
 much food or too rich or badly cooked food combined with seden- 
 tary habits. 
 
 Sir Henry Thompson, speaking of the habit of overeating, says : 
 " The surplus fund of nutrient material unused is stored up in some 
 form. When a certain amount has been thus disposed of — the ca- 
 pacity for storage varying greatly in different persons — an unde- 
 sirable balance remains against the feeder, and in young people is, 
 mostly rectified by a ' bilious attack.' This relieves the system for 
 a month or six weeks, when the process may be repeated." 
 
 " In functional derangements of the liver much more perma- 
 nent benefit is to be expected from careful regulation of the ingesta 
 than from physic " (Murchison). 
 
 Continued disregard of the warnings of bilious attacks is liable 
 to lead in time to more serious trouble, such as habitual lithsemia 
 or oxaluria, and in some cases gout. It is possible, although it 
 is not absolutely proved, that diabetes may be placed in the same 
 category. 
 
 Persons spending a holiday at the seaside, who breathe more 
 invigorating air than that to which they are accustomed in inland 
 cities, often are tempted to eat too much and exercise but little, 
 
LIVER DISEASES IN GENERAL 58 1 
 
 with the prompt result of overloading the liver and inducing a bilious 
 attack, for, as Harley says, the liver " acts like a wise horse when 
 overloaded — simply stands still until part of its burden is removed." 
 
 Those who have a tendency — often hereditary — to biliousness 
 frequently exhibit idiosyncrasies in regard to special articles of diet, 
 the eating of which, even in moderation, may quickly precipitate an 
 attack. 
 
 A bilious condition is sometimes induced by absorption of pto- 
 maines from food in the alimentary canal, which are taken up in 
 such quantity that the liver fails to destroy them. 
 
 Bouchard has attempted to show that the ptomaine-destroying 
 function of the liver is aided by glycogen, and is consequently 
 favoured by ingestion of starches. 
 
 Dietetic Treatment. — The digestive functions of the liver are so 
 varied that it is difficult to arrange any diet for either functional or 
 organic diseases of that organ which meets all the requirements of 
 theory, but clinical experience has abundantly proved the value of 
 certain general principles, the most essential of which is that the 
 liver should be taxed as little as possible, and a non-stimulating 
 diet is required. 
 
 Food in general after it has reached the duodenum acts as a 
 stimulant to the liver, and two or three hours after a full meal the 
 bile secretion is increased ; but there are a few foods to which a 
 special stimulating effect has been attributed, although their influ- 
 ence, if any, is slight. These are chiefly the succulent vegetables, 
 like tomatoes, and also spinach and cresses. Strong alcohol, condi- 
 ments, such as pepper, mustard, spices, and especially curry, have 
 the same effect, and should be avoided. Fats and sugars eaten too 
 freely are very apt to disturb the action of the healthy liver, espe- 
 cially during hot weather. 
 
 Coffee and tea may be allowed only in such moderation as one 
 cup a day. Alcohol had better be prohibited entirely. Beer, ale, 
 porter, strong liquors, liqueurs, and all sweet wines, such as cham- 
 pagne, sherry, Madeira, port, and Tokay, must be absolutely for- 
 bidden. If necessary as a tonic, a little Rhine wine, hock, or Moselle 
 may be used (not over a couple of glasses daily), or much-diluted 
 whisky. Of all the organs of the body, none is more often poisoned 
 and made cirrhotic by alcohol than the liver, and the moral needs 
 no further emphasis. Many other chemical stimuli, such as opium, 
 derange the liver functions and interfere with the elaboration of food. 
 
 More or less intestinal dyspepsia always results from alterations 
 in the quantity or composition of the bile, and on this account as 
 well the food must be carefully selected, and all sugars and most 
 starchy aliments must be forbidden as well as fats. 
 
 Among the articles especially prohibited in all cases of liver 
 disease are condiments, spices, curries, pickles, sauces, rich soups, 
 
582 DIET IN DISEASE 
 
 fried food of every kind, veal, pork, sausages ; salt foods, such 
 as corned beef and salt fish ; crustaceans, new bread, preserves, 
 and sweets of all sorts ; pastry, puddings, cakes ; all the heavier 
 starchy vegetables, such as potatoes, corn, peas, beans ; salad oil ; 
 oily fish, like salmon and sardines. Only fresh food should be 
 given. 
 
 In acute functional derangement of the liver, whether there is 
 imperfect or diminished secretion of bile or hypersecretion, it is best 
 to considerably reduce all food in quantity. At first, if there are 
 vomiting and headache, only light broths, beef tea, and perhaps dry 
 toast or a cracker should be given. 
 
 In acute hepatic disease the tongue becomes furred and the ap- 
 petite is apt to fail. The latter, in a manner, keeps guard over the 
 liver, for when that organ is overloaded or incapacitated to work a 
 failing appetite leads to taking in less food until proper functional 
 activity is restored. But there are many chronic cases in which con- 
 tinued absence of appetite leads the patient to take less nourishment 
 than is really needed, and in such cases it is not a reliable guide. It 
 is not desirable to restrict the diet too closely or allow it to become 
 monotonous. The palate should rather be tempted by reasonable 
 variety. 
 
 In regard to the suggestions given below, it must be remembered 
 that they are very general, and are applicable rather to the chronic 
 types of hepatic disease, although they will serve also for those 
 afflicted with recurrent or intermittent attacks of biliousness, and 
 should be followed between the attacks. In very active disease, 
 such as acute congestion, acute yellow atrophy, abscess of the liver, 
 etc., obviously the diet must be much more limited. In ordinary 
 uncomplicated bilious attacks induced by high living, a day or two 
 of practical starvation with the use of a mercurial cathartic is wholly 
 curative. 
 
 The following articles can usually be allowed in moderation ex- 
 cepting in very severe cases : 
 
 Animal Food. — Fish, such as sole, flounder, halibut, smelt, white- 
 fish ; the soft part of oysters, liver, sweetbread ; lean meat, such as 
 roast beef, broiled beefsteak, mutton chops, or chicken (lean beef 
 is better than poultry or game) ; eggs, milk and its preparations, such 
 as koumiss, whey, buttermilk, junket, malted milk. Many persons 
 with hepatic disorder insist that milk always makes them bilious. 
 If this proves to be true of natural milk, it should be predigested 
 or given with sodium bicarbonate or Vichy, or in one of the numer- 
 ous ways described on p. 78. 
 
 In advanced cases of hepatic disease milk constitutes an excel- 
 lent food, and may be used abundantly, provided the proper form 
 for its administration in a given case is determined. Baked custard 
 and blancmange or other forms of gelatin may be eaten. 
 
LIVER DISEASES IN GENERAL 583 
 
 Vegetable Food. — Of fresh green vegetables the following may be 
 eaten : Spinach, asparagus, tomato, squash, pumpkin, celery, oyster 
 plant, beet tops, cresses, lettuce (without oil). 
 
 Cereal Foods. — Bread should be eaten in small amount. It must 
 be stale or toasted. Zwieback is good, and dry rusk, not too sweet. 
 Graham, gluten, or wheaten crackers may be permitted. Other 
 starchy foods should be eaten sparingly ; but boiled rice, rice pud- 
 ding, sago, and tapioca are admissible. 
 
 Fruits. — Fresh fruit in season is wholesome, and useful to over- 
 come the tendency to constipation. Grapes, oranges, strawberries, 
 peaches, and roast apples may be eaten. 
 
 Water should be drunk freely, except when ascites is present; 
 and light beverages, such as lime juice in aerated water, lemonade, 
 or dilute raspberry vinegar, may be serviceable. 
 
 Directions for Eating. — The manner of taking food is very im- 
 portant. There is apt to be hyperemia of the stomach and intes- 
 tines from time to time, as a result of engorgement of the portal 
 system, and catarrhal conditions are easily excited in these organs 
 by food which is hastily bolted without thorough mastication or 
 which is not well cooked or not perfectly fresh. The teeth should 
 always be examined to ascertain if the patient can masticate prop- 
 erly. Fluids should not be drunk with meals. The patient should 
 not eat directly after violent exercise or fatigue, but should first lie 
 down and rest for three quarters of an hour. If he suffers from 
 dyspepsia, he should rest after meals as well. In many cases three 
 meals a day suffice, but they should be given at intervals of about 
 six hours, to insure complete digestion between. In others, when 
 considerably enfeebled, or in cases of hepatic congestion and ad- 
 vanced cirrhosis, it is better to feed the patient four or five times a 
 day, or once in three hours, giving a smaller quantity of food which 
 is easily digested. It is advisable to take the principal meal at 
 noon. 
 
 From the fact that the bile is diminished in amount or altered in 
 composition, constipation is the rule, and proper laxatives should be 
 frequently given if the bowels cannot be kept in order by fresh 
 fruit. 
 
 Hot water in an empty stomach is quickly absorbed, and passes 
 directly to the liver through the portal vessels. If salts, such as 
 Carlsbad salt, are given, they are absorbed with the water, and 
 stimulate the liver cells. The water increases the portal blood pres- 
 sure, and thus indirectly the pressure of the gall ducts, and favours 
 the elimination of bile. 
 
 Moderate systematic exercise should be prescribed whenever 
 possible, and the best forms are horseback and bicycle riding. The 
 I jouncing " movements of the former shake and compress the liver, 
 and stimulate its circulation and the outflow of bile. 
 39 
 
584 diet in disease 
 
 Acute Catarrhal Inflammation of the Gall Ducts — 
 Angiocholitis — Catarrhal Jaundice 
 
 A bland or non-stimulating diet must be given in the acute stage 
 of angiocholitis. Vomiting is sometimes present, or it may be arti- 
 ficially induced as part of the treatment, so that the stomach is not 
 in a condition to bear solid food. Moreover, much food on entering 
 the duodenum will increase the local inflammation of the common 
 bile duct. Diluted or peptonised milk is to be given, or buttermilk, 
 whey, light meat broths, clam broth, pressed-beef juice, tgg albumin. 
 
 In a few days, if pain, tenderness, vomiting, and fever subside, the 
 diet is to be slowly increased, and such articles may be added as milk 
 toast, bread and milk, broths and light soups without vegetables, the 
 breast of chicken, oysters, sweetbread, meat jellies. Later, eggs, and 
 boiled or broiled fresh steak may be eaten. Fat and butter should 
 be avoided, and pains should be taken to prevent constipation and 
 putrescence of the intestinal contents. 
 
 Fatty, amylaceous, and saccharine food is to be avoided, and 
 for some time after the acute symptoms have subsided the basis of 
 diet should be whitefish, lean meats, and fresh green vegetables. 
 
 Cooked fruits, not too sweet, and to which sugar has not been 
 added, such as sour apples, prunes, etc., can be eaten. Considerable 
 fluid should be taken both as a diluent and to promote the action of 
 the kidneys and lessen the tendency to constipation. Water acidu- 
 lated with lemon juice or effervescent waters (soda water. Seltzer, 
 and Apollinaris) may be drunk three or four times a day between 
 meals. Coffee and tea are allowed only during convalescence. 
 
 Cirrhosis — Ascites 
 
 Causation. — Cirrhosis is a disease of the liver occasioned by 
 irritation of that organ by substances in the blood derived more par- 
 ticularly from the portal system after direct absorption from the 
 intestine. Among those irritants may be mentioned as the foremost 
 excitant alcohol, which produces fully 60 per cent of all cases. 
 Strong alcoholic stimulants often contain fusel oil or other especially 
 noxious impurities. The prolonged use of strong condiments, or 
 spices, such as curry and peppers, may occasion cirrhosis, as also may 
 chronic metallic poisoning by arsenic, antimony, lead, or phos- 
 phorus. Experimentally, ptomaines have been made to excite the 
 disease in the lower animals, and continued poisoning by such 
 agents may possibly produce it in man. Cirrhosis may be caused 
 in other ways, but the facts above mentioned show its frequent rela- 
 tion to dietetic errors. As a result of fibrous hepatitis, the terminals 
 of the portal vein are obstructed and the portal venous system is 
 congested, the blood being dammed back in the vessels of the stom- 
 
LIVER DISEASES IN GENERAL 585 
 
 ach, spleen, intestines, and pancreas. Owing to the congestion there 
 is frequent vomiting, sometimes of blood, and there is marked inter- 
 ference with the character of the digestive secretions as well as the 
 process of intestinal absorption. 
 
 Dietetic Treatment of Cirrhosis without Ascites. — Cirrhosis with- 
 out accompanying ascites is often best treated by a milk diet for two 
 or three weeks. Bread and crackers may be allowed with the milk, 
 but nothing else. Hot water and aerated waters should be drunk 
 in large quantities, fasting, to " flush " the liver. Subsequently a 
 light diet is to be prescribed in accordance with the suggestions 
 given for the treatment of liver diseases in general (p. 581). All 
 condiments, relishes, sauces, fats, fried food, pastry, and sweets 
 must be withheld, as well as alcohol in every form. The skin and 
 bowels must be kept active. 
 
 ASCITES 
 
 Pathological Physiology. — A further important symptom which 
 is seldom absent towards the close of a protracted cirrhosis, if the 
 patient lives long enough, is ascites. This is an accumulation of 
 serum in the peritoneal cavity, which has been produced by the 
 altered blood pressure of the portal system and the altered compo- 
 sition of the blood itself. The fluid accumulates with considerable 
 rapidity, and may reach an enormous quantity — sometimes as much 
 as twenty-four quarts — greatly distending the abdominal walls, float- 
 ing the viscera out of position, and by pressure interfering with di- 
 gestion and absorption. In addition the loss of so large a quantity 
 of fluid from the blood is a serious detriment to nutrition, inasmuch 
 as the ascitic fluid not only contains water in large amount, but 
 scrum albumin, which may be present in the proportion of from I 
 to 2 per cent to over 6 per cent. In the ascites accompanying 
 cirrhosis the loss of albumin in this manner may be somewhat less 
 than when the serous accumulation is due to other causes. 
 
 These facts should be borne in mind in relation to the dietetic 
 treatment of the disease. Repeated aspiration of the abdominal 
 cavity not only abstracts large quantities of water from the system, 
 but also abstracts considerable albuminous material. In those cases 
 in which fluid refills the peritoneal cavity promptly after aspiration, 
 it is a question whether the nutrition of the body may not suffer by 
 drawing off so much serum albumin. On the other hand, when once 
 transuded, it is of no further service to the organism unless it can be 
 reabsorbed. The point for consideration is whether too frequent 
 removal of the ascitic fluid will cause greater drain on the blood 
 than would be consequent upon letting it accumulate in the abdom- 
 inal cavity. Much will depend upon the relative pressure within the 
 peritoneal sac and the blood vessels, which will affect the rate of 
 
586 DIET IN DISEASE 
 
 osmosis of albumin. This discussion leads to the query, whether it 
 is not necessary to supply the constant loss of albumin by an in- 
 creased allowance of animal food, and, secondly, to what extent 
 water should be withheld from the dietary. 
 
 Dietetic Treatment of Cirrhosis with Ascites. — When uncompli- 
 cated ascites is present it is generally best to restrict the quantity of 
 fluid ingested and put the patient upon a " dry diet," consisting of 
 bread and meat chiefly. By simply withholding fluid and stimu- 
 lating the force of the heart and the action of the kidneys I have 
 sometimes seen large quantities of fluids disappear from the abdom- 
 inal cavity ; but this treatment is not always successful. There is 
 more hope of success when the disease occurs in young persons, or, 
 as it sometimes does, in children. Cirrhosis and ascites are very 
 apt to be associated with renal and cardiac lesions and gastric ca- 
 tarrh, which make it much easier to say what food the patient must 
 not eat than what he can have. If the urine is very scanty it may 
 not be wise to withhold fluids, and some clinicians of wide experi- 
 ence believe in giving fluids in unrestricted amount, holding the view 
 that this will increase diuresis to such an extent that not only will 
 all the fluid drunk be promptly eliminated, but that the active kid- 
 neys will drain more from the blood, which will in time be replaced 
 by reabsorption of the ascitic fluid. The same reasoning is often 
 applied to cases of pleurisy, general anasarca, etc. It seems much 
 more rational to endeavour to promote diuresis when possible by 
 medicinal measures than to add a large bulk of fluid to an already 
 overbalanced circulation. 
 
 It is of importance in every case to measure and estimate care- 
 fully the total amount of fluid ingested both in beverages and as 
 food and make a comparison with the quantity of urine voided, and 
 if possible with the weight of the patient and girth of the abdomen 
 at different levels. 
 
 If the fluid diet is followed by rapid reaccumulation of ascitic 
 fluid after aspiration, for example, within a fortnight, it is desirable 
 to replace it by as much simple solid nutriment as the patient can 
 digest, or by predigested and concentrated foods. An outline of the 
 appropriate diet for such cases will be found upon p. 431. 
 
 The " grape cure " and " milk cure " have been strongly recom- 
 mended in Europe for the treatment of cirrhosis and ascites. They 
 are said to ameliorate the symptoms and promote reparative pro- 
 cesses, both acting largely through diuretic influence. 
 
 Fatty Liver 
 
 Pathological Physiology. — The liver is the great storehouse of 
 latent energy in the body, which is accumulated in glycogen and 
 fat. A certain proportion of fat is to be regarded as a normal con- 
 
LIVER DISEASES IN GENERAL 587 
 
 stituent of the parenchyma of the liver. This varies considerably 
 within normal limits, depending upon the character of the food in- 
 gested and the degree of its oxidation in the liver and other tissues. 
 After a diet consisting largely of fats and oils or of carbohydrates 
 the accumulation of fat in the liver is considerable. Lack of exer- 
 cise and unfavourable hygienic conditions, by retarding oxidation 
 processes, also promote its accumulation. Persons addicted to con- 
 stant overeating of carbohydrates are therefore liable to this affec- 
 tion. They become stout, take less and less exercise, and the second 
 condition favouring fatty infiltration of the liver — namely, lack of 
 oxidation — is added. Fatty liver is also caused by various diseases 
 in which the composition of the blood is altered and the metabolism 
 of oxidation is interfered with. Such are advanced anaemia, chronic 
 alcoholism, and tuberculosis. It is suggested by Fitz that the fatty 
 diet often recommended for the latter disease — consisting of cod-liver 
 oil, rich milk, butter, cream, etc. — is productive of fatty disease of 
 the liver. 
 
 Dietetic Treatment. — The dietetic treatment is indicated by the 
 previous considerations, but since the local condition is commonly 
 merely an accompaniment of more serious general disease, it may be 
 unwise to advise too sudden or extreme alterations in the accustomed 
 diet of the patient. In general, all forms of sugar, starch, and fat 
 should be reduced gradually to a minimum, and, if possible, finally 
 omitted entirely, excepting in tuberculous patients whose general 
 bodily nutrition is of more importance than the danger of local fatty 
 infiltration. In these cases the object desired is better promoted by 
 increasing oxidation processes by climatic and hygienic treatment 
 rather than by withholding the carbohydrates. Malt liquors and 
 alcoholic drinks in general must be forbidden. In other cases, espe- 
 cially in the alcoholic form, the diet should consist of nitrogenous 
 food, fresh green vegetables, and fresh succulent fruits. The fol- 
 lowing articles may be taken : Lean meat, boiled or broiled fresh 
 fish, lettuce, spinach, celery, tomatoes, gluten bread, and toast. 
 
 Amyloid Liver 
 
 The condition of amyloid liver after it has become sufficiently 
 pronounced for diagnosis is usually fatal within a short period, and 
 consequently but little aid can be derived from dietetic treatment. 
 The diet should be so regulated as to burden the digestive organs as 
 little as possible, and in advanced cases such predigested foods as 
 peptonised meat or milk ought to be given. If the stomach diges- 
 tion is fairly active, nitrogenous food will agree better than the 
 carbohydrates. 
 
588 diet in disease 
 
 Syphilis of the Liver 
 
 In advanced syphilitic hepatic disease non-stimulating food only 
 is permissible, such, for example, as milk and eggs, chicken, beef 
 or mutton broths, fresh fish, oatmeal, boiled rice, semolina, reva- 
 lenta, bread, and light farinaceous puddings — such as tapioca, sago, 
 blancmange, and custards. Alcohol in all forms is prohibited. 
 
 Abscess of the Liver 
 
 In hepatic abscess the same general dietetic treatment is to be 
 followed as that indicated for syphilitic disease of the liver. The 
 aim should be to carefully avoid overloading the digestive organs at 
 any time, and to give assimilable and predigested food in small 
 quantities at frequent intervals, at least once in three hours. Animal 
 broths and light vegetable purees, with various combinations of milk 
 and eggs, should form the staple articles. No solid foods should be 
 given, excepting such as a little fish, such as sole or haddock, a few 
 oysters, sweetbread, and milk toast. 
 
 Fats in all forms are forbidden. Malt liquors, port, sherry, and 
 all forms of strong alcohol must be prohibited. If any stimulant is 
 required, a little hock, Moselle, or champagne may be taken, or very 
 weak brandy, diluted with Apollinaris or Vichy. 
 
 Gallstones 
 
 Pathological Physiology. — Gallstones are formed in the gall 
 bladder or larger bile ducts by precipitation from the bile of choles- 
 terin, mixed with more or less mucus. Occasionally they contain 
 the bile pigment (bilirubin) or calcium carbonate. Cholesterin is an 
 alcoholic substance which may be extracted in varying amount from 
 the blood or nervous tissues, especially the brain, and from the bile. 
 It may be obtained in flat, rhombic, colourless crystals. Somewhat 
 rarely it is excreted in the urine. It also exists in the waste matter 
 contained in the lower bowel. Cholesterin is maintained in solution 
 in the bile by alkaline salts, the sodium and potassium taurocholate 
 and glycocholate. Calcium unites with the latter substances, form- 
 ing new compounds with the biliary acids which are insoluble salts 
 that no longer keep cholesterin in solution. When organic acids 
 exist in excess in the tissues calcium is liberated, and on reaching 
 the liver produces the above reaction. 
 
 An excessive accumulation of cholesterin in the system will re- 
 sult in its precipitation from the bile, and this occurs when for any 
 reason the bile has long been retained in the gall bladder, where it 
 has been concentrated by reabsorption of some of its fluid ingre- 
 dients. Bacteria are undoubted agents in the formation of many 
 
LIVER DISEASES IN GENERAL 589 
 
 stones. The precipitation of cholesterin is favoured by the presence 
 of a pre-existing hepatic stone or any foreign body in the gall blad- 
 der, such as an intestinal parasite, or its ovum, or thickened mucus. 
 
 Gallstones are oftenest present in advanced life and among those 
 who adopt sedentary habits which lead to accumulation of bile in the 
 bladder. On the latter account they are more common among 
 females, and their occurrence is often related to excesses of the table, 
 in regard to both food and drink. 
 
 All diseases of nutrition, such as long-continued dyspepsia, 
 chronic rheumatism and gout, diabetes, and obesity, may be accom- 
 panied by the formation of biliary calculi. 
 
 Among other explanations given for the formation of gallstones 
 is an excessive proportion of fat in the diet, although cholesterin is 
 not true fat, but is really an alcohol allied to fats in some of its 
 properties. Lack of exercise is a contributing factor. 
 
 Harley, who has given more careful attention than any other 
 writer to the prevention of a return of gallstones by dietetic treat- 
 ment, called attention to their greater prevalence in cold latitudes 
 than elsewhere, and attributed this fact to the influence of certain 
 foods, especially meat fat and suet. He wrote : " Starchy puddings 
 and fat bacon cause more gallstones in this country [England], I 
 believe, than all the other kinds of food put together." 
 
 The hydrocarbons are more completely consumed in early years 
 than after middle life, and hence the greater prevalence of gallstones 
 in the latter period, as above mentioned. 
 
 Bauer believes that " the formation of gallstones may often be 
 referred to a faulty diet, for an excessive consumption of meat or 
 free indulgence in fat and in spirits would probably favour their 
 formation." 
 
 Less often gallstones are composed of pigment or of calcium 
 carbonate, or of various mixtures of these substances with one an- 
 other or with mucus. Individual stones sometimes attain the size 
 of a small Qgg, and they may cause suppuration and the formation 
 of a fistula from the gall bladder which opens into some other ab- 
 dominal organ, or externally. 
 
 In many cases the stones exist in considerable number and size 
 without giving rise to any symptoms or discomfort, but the smaller- 
 sized stones occasionally find their way into the common bile duct, 
 and their passage provokes intense agonising local pain, known as 
 biliary colic. 
 
 Dietetic Treatment. — From the above account of the manner of 
 formation of bile stones it is evident that patients who have once 
 suffered from biliary colic or other symptoms of the presence of 
 concretions should exercise care in their diet and habits of life, in 
 order to prevent the further formation of stones, and, if possible, to 
 aid in dissolving those already present. The diet must be regulated 
 
590 DIET IN DISEASE 
 
 with the object of lessening the production of cholesterin and of 
 diluting the bile. Animal food may in itself contain cholesterin, and 
 should therefore be taken very sparingly. A diet of concentrated 
 animal food, by diminishing the alkalinity of the fluids of the body, 
 favours the deposition of cholesterin from the bile, although this 
 ingredient may not be present in abnormal amount in such food. 
 Patients should be cautioned against excessive indulgence in any 
 particular article of food, all richly cooked food must be given up, 
 and if they are in the habit of eating nitrogenous food in excess, a 
 larger proportion of fresh vegetables or farinaceous food should be 
 substituted. 
 
 Calves' brains and the viscera of animals used as food in general, 
 and particularly the liver, should be wholly interdicted. Sugars and 
 fats must be forbidden in every variety. 
 
 Some vegetables, such as peas and carrots, are believed to con- 
 tain material which closely resembles cholesterin. Carrots, more- 
 over, are sweet, and sweet vegetables and fruits should be avoided, 
 and also egg yolks, on account of the fat they contain. 
 
 Fresh green vegetables and acid fruits which, by virtue of their 
 alkaline salts and organic acids, easily combine in the blood with 
 alkaline bases should make the basis of the diet. The potassium 
 salts which are contained in potatoes and other vegetables in abun- 
 dant quantity are believed to be serviceable, because they retard the 
 liberation of calcium, which, it has been shown, precipitates choles- 
 terin. Bread and well-cooked cereals and fresh fish, except salmon 
 and mackerel, may be eaten. Chicken or lean beef may be allowed, 
 but all meat should be taken sparingly and not oftener than once 
 a day. 
 
 For the purpose of diluting the blood and, through it, the bile, 
 large quantities of fluid should be ingested, but it is best to avoid 
 aerated waters and mineral waters which contain salts of lime. A 
 tumblerful of hot water should be drunk at night, and another on 
 rising in the morning. Champagne and other beverages which hold 
 much carbonic-acid gas in solution must be avoided, as must malt 
 liquors. Coffee, tea, and claret may be drunk in moderation. If 
 the case is one in which considerable gastric catarrh or dilatation of 
 the stomach is present, it is inadvisable to give much fluid by the 
 mouth, and sometimes the desired result may be obtained by inject- 
 ing salt water through a long flexible rubber tube into the colon. 
 Intestinal irrigation as well as active purgation favours removal 
 of the bile and prevents its accumulation in the gall bladder. Prout 
 gives one or two drachms of sodium phosphate or sulphate daily 
 to prevent concentration of the bile. For purgation the Carlsbad 
 Sprudel salts and Saratoga salts are valuable. In women tight 
 lacing should be prevented, and the habit of sitting long in cramped 
 positions which interfere with free hepatic circulation. 
 
THE NERVOUS SYSTEM 591 
 
 Large doses of olive oil, several ounces at a time, have been 
 recommended for use during the passage of a gallstone, with the 
 idea apparently of in some mysterious way lubricating the channels 
 through which the stone is carried. But the oil, if absorbed, is taken 
 up by the lacteals and emptied into the thoracic duct without going 
 anywhere near the liver or bile passages, so that such an explana- 
 tion of its use is absurd. The foreign bodies which it is claimed 
 appear in the stools after giving oil in this manner have proved to 
 be not stones, but inspissated masses of oil. 
 
 PANCREATIC DISEASES 
 
 Disease of the pancreas is usually impossible to diagnosticate 
 with accuracy until it is far advanced, and but little can be ex- 
 pected from dietetic treatment. Since the pancreatic juice is on 
 every account the most important of all the digestive fluids, being a 
 universal digestive agent for all foods, and the most vigorous one, 
 its absence or deterioration results promptly in emaciation, which 
 becomes extreme. When the presence of disease of this gland, such 
 as a cyst, is established, it is best to withhold all fats and carbo- 
 hydrates from the diet. They are not digested in the stomach, and 
 when the pancreatic juice fails, they merely ferment in the small 
 intestine and do positive harm. Milk, pancreatinised meat prepara- 
 tions, beef peptonoids, and tgg albumin, with alcoholic stimulants, 
 must constitute the chief reliance for nourishment. 
 
 It is of interest to note that the continued presence of fat or oil 
 in the stools is regarded as a strong diagnostic point in favour of the 
 absence of pancreatic fluid. As a positive test this may have some 
 value, but not as a negative one, for if bile is present in normal 
 quantity the fat of food may still be emulsified and, to some extent, 
 absorbed. In a half dozen cases of undoubted pancreatic cyst in 
 which the diagnosis was established by aspiration or autopsy, I have 
 known doses of several ounces of olive oil administered for diagnos- 
 tic purpose to give no residue in the stools. The absence of fat in 
 the feces does not therefore necessarily exclude pancreatic disease. 
 
 DIET IN DISEASES OF THE NERVOUS SYSTEM 
 
 Neuralgia — Gastralgia — Enteralgia 
 
 Causation. — Neuralgia is a term applied to a variety of nerve 
 pains which may be associated with organic lesions of various struc- 
 tures which irritate the peripheral nerves, or which may be purely 
 functional and temporary excitations of the nerve trunks or their 
 end organs. Lesions involving the nerves themselves are not de- 
 scribed as neuralgias. The irritability and conductivity of nerve 
 fibres is so dependent upon nutrition that debility resulting from 
 
592 DIET IN DISEASE 
 
 imprudent living and improper or insufficient food would naturally 
 be expected to rank among the chief predisposing causes of this 
 affection. 
 
 Persons undergoing severe mental worry or strain, physical 
 fatigue, prolonged exposure to cold, prolonged lactation, etc., are apt 
 to suffer from indigestion or malassimilation of their food, and the 
 one condition reacts upon the other in altering the tone of the 
 nervous system. 
 
 Moreover, many diseases which may be called dietetic in that 
 they are so closely associated with or influenced by dietetic errors 
 (acting eventually through the composition of the blood) are very 
 commonly accompanied by neuralgic pains. Such are gout, rheu- 
 matism, lithaemia, arthritis deformans, diabetes, and chronic alco- 
 holism. To benefit the diseased condition by appropriate diet, 
 among other means, is to cure the neuralgia. 
 
 Neuralgic pains are often connected immediately with the digest- 
 ive tract, especially in cases of neurasthenia and hysteria among 
 women, and are excited by irritating foods or by fermentative pro- 
 cesses. 
 
 Dietetic Treatment. — The dietetic treatment of neuralgia is 
 based upon certain general principles which may be observed where- 
 ever they do not conflict with the special disease of which the pain 
 may be merely an incidental symptom. This treatment is liable to 
 be overlooked while attention is wholly given to devising new reme- 
 dies for the immediate, though often merely temporary, relief of 
 the pain. 
 
 It is of the utmost importance to early ascertain the cause of 
 the pain and learn whether it be not due to one of the conditions 
 above mentioned, which may be found to exist in a latent form. 
 Careful examination of the urine should in all cases be made to 
 ascertain the possible presence of the uric-acid diathesis, of sugar, of 
 phosphaturia, etc. 
 
 Since a majority of cases are accompanied by general debility 
 and occur in anaemic, constipated women who take little outdoor 
 exercise, the blood also should be examined for anaemia. A nutri- 
 tious and ample diet should then be prescribed, accompanied by 
 moderate exercise and abundant fresh air, to insure more perfect 
 oxidation. Anstie says correctly that " neuralgic patients require, 
 and greatly benefit by, a nutrition considerably richer than that which 
 is needed by healthy persons." This is particularly true of the ex- 
 tremes of age. 
 
 Fats and oils are most serviceable, and under this heading cream, 
 Devonshire cream, butter, bacon, fat meat, salad oil, olives, and cod- 
 liver oil may be used. 
 
 Neuralgic patients usually dislike fats, perhaps on the general 
 principle that people are likely to prefer different food from that 
 
THE NERVOUS SYSTEM 593 
 
 which they most need for disordered conditions of the system. 
 Some are even made bilious by fat, but with a little tact and perse- 
 verance in selecting the proper kind of fatty food and directing the 
 mode of taking it these objections may be overcome. Patients may 
 take more butter than usual, though they refuse cream, or they will 
 take cream though they refuse cod-liver oil. Salad oil and fat bacon 
 are not apt to provoke objection. 
 
 In neuralgia due to general debility or anaemia without lithiasis, 
 nitrogenous foods are indicated in addition to the fats above men- 
 tioned, and good roast beef, beefsteak or chops, eggs, milk with 
 bread and butter, light starchy foods, and fresh vegetables should be 
 ordered. Meat should be eaten two or even three times a day, and 
 additional lunches may be given between meals, consisting of milk, 
 a glass of claret and a sandwich, a cup of cocoa and a biscuit, or 
 broth thickened with beef meal or an egg. 
 
 Gowers says that he has sometimes known " severe neuralgia to 
 occur first on the patient commencing a purely vegetable diet, to 
 disappear when meat was taken, and recur with severity on each of 
 four successive attempts to return to vegetarianism." 
 
 If the nervous system has been greatly overtaxed or the digest- 
 ive organs are exceptionally feeble, it may be advisable to put the 
 patient for a few days on a diet consisting largely of milk, eggnog. 
 beef broth, and purees, accompanied by rest and passive exercise 
 (massage). After a few days the more substantial nitrogenous foods 
 may be added. In cases associated with lithaemia or rheumatic 
 diathesis, however, the quantity of such foods should be reduced, 
 and the special regulations described under the heading of rheuma- 
 tism and lithaemia must be followed. 
 
 Coffee and tea should be used only in moderation, and in bad 
 cases had better be prohibited altogether. 
 
 Alcohol in restricted dosage benefits many anaemic cases. Claret 
 or Burgundy may be drunk with meals, but alcohol should never be 
 taken merely to relieve pain or otherwise than a food, for there is 
 danger of becoming too much addicted to its use. 
 
 Substances to be especially forbidden are pastry, sweets, and 
 confectionery of all kinds, griddle cakes, condiments, fried food, 
 and rich, highly seasoned sauces and foods. 
 
 All meats should be eaten at regular intervals, and, except as 
 directed above, eating between meals must be prohibited. 
 
 VISCERAL NEURALGIAS 
 
 The visceral neuralgias are produced in the sympathetic nerves 
 chiefly. The digestive viscera — stomach, intestines, liver, etc. — in a 
 normal state are free from sensory impressions, but their nerves are 
 constantly conveying reflex impressions, which, however, are to be 
 
594 DIET IN DISEASE 
 
 distinguished from ordinary tactile sensibility. Hypochondriasis, by 
 concentrating mental attention upon the various abdominal viscera, 
 undoubtedly develops hypersensitiveness to such nerve currents. 
 
 The condition described as ptomaine poisoning and various 
 forms of auto-intoxication may excite a severe neuralgia as a 
 symptom. 
 
 Dietetic Treatment of Visceral Neuralgias. — Neuralgias of any of 
 the abdominal viscera are apt to be excited by functional activity 
 (although they also may occur independently of it), and hence the 
 diet should be made as simple and nutritious as possible, in order 
 that digestion shall not be unduly prolonged. If any one article of 
 food is found to excite the paroxysms it should be abandoned. It 
 is often advisable in severe cases to limit the diet for a few weeks 
 to two or three simple articles of food, such as beef, bread, milk, 
 and rice. 
 
 GASTRALGIA 
 
 Causation. — In neuralgia of the stomach, called gastralgia, or 
 gastrodynia, the pain is situated in the epigastrium, penetrating to 
 the back. It is distinctly localised and intense. It may be par- 
 oxysmal, or there may be dull constant aching with exacerbations 
 of a moderate lancinating character. It is usually relieved some- 
 what by moderate gentle pressure, but intensified by deep pressure. 
 Such pain is not infrequently associated with anaemia, chronic con- 
 stipation and hysteria, and in a severe form, accompanied by violent 
 vomiting, it constitutes the " gastric crisis " of locomotor ataxia. 
 Gastralgia may also be occasioned by the continued excessive use of 
 stimulants, such as alcohol, strong tea and coffee, and chewing 
 tobacco, and by the inordinate use of sweets. An excessive forma- 
 tion of hydrochloric acid in the gastric juice may occasion a very 
 painful variety of gastralgia. 
 
 Dietetic Treatment. — In all cases of gastralgia careful inquiry 
 must be made in regard to irregularities of diet, and the relation be- 
 tween eating and the occurrence of the pain. If the pain is worse 
 while the stomach is empty and is mitigated by taking food, it is 
 suggested by Gowers that it is due to morbid action of those nerves 
 which normally excite hunger. Such cases should be treated by 
 giving nourishment in frequent small quantities. In addition to the 
 three regular meals of the day, which should be light, a glass of 
 wine or a cup of hot bouillon and a biscuit or two, or a glass of 
 milk punch or eggnog, may be taken at n a. m., 4 p. m., and again 
 before retiring. A tumbler of milk or a few crackers may be kept 
 by the bedside and taken in the middle of the night should the pa- 
 tient be awakened by the pain. The pain itself is an indication of 
 impoverished nutrition, and the nervous system requires rest while 
 the tissues need food. In still other cases food intensifies the pain 
 
THE NERVOUS SYSTEM 595 
 
 and excites immediate emesis. This is especially true of the gastric 
 crises of locomotor ataxia. Here sedatives, such as bismuth, cocaine, 
 or anodynes must be given to relieve the irritation of the gastric 
 mucous membrane while food is temporarily withheld until the pain 
 has subsided. The diet subsequently should be gradually increased, 
 commencing with small quantities of peptonised albuminous food. 
 In gastralgia the appetite is very capricious, and there may be ex- 
 cessive craving for certain articles of diet, such as pickles, condi- 
 ments, etc. 
 
 In all forms of gastralgia the pain is aggravated by distention of 
 the stomach. If starchy food tends to produce flatulency it should be 
 avoided, together with sugars and fats. Tea and coffee and tobacco 
 must be given up. The bowels should be kept freely open. 
 
 Enteralgia — i. e., a true neuralgic pain in the intestines — is not 
 common if " peristaltic unrest " be excluded. It does occur, how- 
 ever, and most frequently in the lower rectum, in which case it is to 
 be relieved by local treatment rather than dieting. 
 
 Hepatalgia, or neuralgia of the liver, is an indication of func- 
 tional overwork of that organ, which may be relieved by a careful 
 inquiry into the dietetic habits of the individual and correction of 
 errors in addition to purgation. 
 
 In severe forms of neuralgia which do not yield to dietetic and 
 medicinal control prompt relief is often secured by change of scene 
 and sea bathing, or a course of mineral baths. Hygienic measures 
 improve functional activity and promote oxidation and assimilation 
 by the tissues of the products of digestion, as well as the elimination 
 of waste. 
 
 Migraine 
 
 Migraine, or " sick headache," is a neurosis characterised by pain 
 in the course of the fifth nerve, often accompanied by nausea, vomit- 
 ing, mental depression, and local vasomotor disorders. 
 
 There are many causes assigned to this affection, among them 
 heredity, the gouty diathesis, improper food, etc. Some obstinate 
 cases are unaffected by diet, but others are much benefited by atten- 
 tion to it. and it is always worth while to attempt a cure by it. The 
 patient should be very closely interrogated in regard to all the habits 
 of diet and hygiene, such as the hours for eating, the kind of food 
 eaten, its method of cooking, bathing, exercise, mental work, hours 
 and frequency of the stools, etc. In this way only can possible faults 
 be detected and corrected. The gouty should be forbidden the use 
 of wines, malt liquors, sugars, and starches. The anaemic should be 
 ordered more animal food and fats and cod-liver oil. The dyspeptic 
 should abstain from carbohydrates. The neurotic should give up 
 tea, coffee, and tobacco. It has been shown by Roberts that both 
 tea and, to a lesser extent, coffee may materially retard starch diges- 
 
596 DIET IN DISEASE 
 
 tion, even when drunk in very small quantities. Yet there are some 
 patients who can ward off an impending attack of migraine by taking 
 two or three cups of strong tea or black coffee. 
 
 Plain cereal foods may be allowed, such as wheaten grits, " ger- 
 mea," hominy, and oatmeal, but the addition of milk and sugar to 
 them may cause fermentation and make them undesirable. In this 
 case saccharin may be substituted, or an extract of malt. 
 
 Fresh green vegetables, such as asparagus, young peas, French 
 beans, string beans, sea-kale, and stewed celery may be eaten, but 
 potatoes, corn, cabbage, tomatoes and rhubarb should be avoided. 
 
 Excepting anaemic patients, those suffering from migraine should 
 not eat much meat. It is best to take it not oftener than once a day, 
 and the white meat of poultry and broiled fresh fish are better than 
 much red meat. 
 
 Milk may disagree and cause headache through lactic-acid fer- 
 mentation, interfering with digestion. 
 
 New bread, pastry, richly cooked food, condiments in excess, 
 shellfish, crustaceans, cheese, sauces, and desserts in general are for- 
 bidden. Many of these foods may produce ptomaines by putrefac- 
 tive fermentation, which act as poisons to the blood and nerves. 
 Vinegar and acid fruits should not be eaten, especially in connection 
 with amylaceous foods (Roberts). 
 
 Obviously no rules of diet apply to all cases of a disease which 
 may originate from so many different causes, and in chronic cases 
 careful observation and experimentation will be necessary to estab- 
 lish the best course. 
 
 Overeating, irregular eating, and late suppers should be forbid- 
 den. Outdoor exercise, bicycling, or horseback riding should be 
 prescribed to aid digestion, and the bowels should be kept active by 
 eating fruits. 
 
 Patients are often found who, as a result of following every one's 
 advice, have gradually cut down their diet, one article at a time, 
 until they are actually suffering from inanition, and it requires no 
 little tact and firmness to convince them that they can eat anything 
 at all. They will live on nuts and fruit alone, or on hot water and, 
 raw beef, or follow the latest dietetic " fad," whereas they really need 
 a common-sense diet of plain, nutritious food, such as that prescribed 
 above for neuralgia or anaemia. 
 
 Decayed teeth are a frequent cause of facial or other neuralgias, 
 and the pain is often directly excited through the food or liquid 
 taken being too hot or too cold, or strongly sweet or sour. Many 
 persons experience temporary but severe frontal pain after swallow- 
 ing iced beverages or ice cream too rapidly. In some persons the 
 site of the pain is in the vault of the pharynx or in the throat itself. 
 It is often relieved by momentarily compressing both carotid arter- 
 ies. Brunton suggests that cold excites the sympathetic plexuses 
 
THE NERVOUS SYSTEM 597 
 
 about the carotids and alters their calibre, putting them into a state 
 of spasm. These forms of neuralgic pain are, however, usually triv- 
 ial, and are to be avoided by proper care of the teeth and regulating 
 the temperature of the food. 
 
 Neurasthenia 
 
 Causation. — Neurasthenia is a condition of loss of tone of the 
 nervous system which is of a functional rather than an organic char- 
 acter. It is also called nervous exhaustion or nervous prostration. 
 Strictly speaking, it is not a disease, but rather a functional derange- 
 ment of considerable duration, which, however, with proper care and 
 dietetic treatment results usually in complete recovery. The most 
 apparent cause of neurasthenia is overwork of the nervous system 
 due to continued excitement or strain or prolonged emotional de- 
 pression and anxiety. It is far more apt to be produced by overwork 
 of the nervous system than of the muscular system, although it may 
 be occasioned by the latter. Different individuals are endowed with 
 varying degrees of nerve force, and the complex demands and great 
 activity of highly developed civilisation tempt or compel many peo- 
 ple to draw upon their physiological capital of energy at the expense 
 of its income, with the result of exciting the entire central nervous 
 system, including both brain and spinal cord, to an unwonted and 
 sometimes dangerous degree. For this reason neurasthenia is 
 essentially an affection incident to the occupations and customs of 
 city life, rare or comparatively unknown in the repose of the coun- 
 try. It is a curious but undeniable fact that there appears to be 
 more or less fashion in regard to some diagnoses, in nomenclature at 
 least, if not in the diseases themselves, and of late years " nervous 
 prostration " has taken rank among ordinary functional disorders. 
 
 The general name neurasthenia includes a large variety of nerv- 
 ous symptoms, and while all of the physiological processes of the 
 body are more or less impaired, the symptoms may predominate in 
 one or more mechanisms, as, for instance, that of the circulation, 
 gland secretion, or absorption. 
 
 Men who find themselves in business straits or in circumstances 
 of prolonged anxiety feel that they are straining their vital powers, 
 and resort to an increased or excessive use of stimulants, such as 
 alcohol, tobacco, coffee, and various drugs, to excite their overtaxed 
 mental and physical powers into greater activity. By means of this 
 substitution of force, especially with the use of alcohol, they are en- 
 abled to work on, and still further excite a debilitated nervous system 
 until finally the limit of endurance is reached, and some slight addi- 
 tional strain reduces them to utter prostration. Not infrequently 
 local functional disorders, such as writer's cramp, neuralgia, etc., give 
 warning that a general neurasthenic condition is imminent, and if 
 
598 DIET IN DISEASE 
 
 this warning be not heeded in time, more serious symptoms inevi- 
 tably follow. 
 
 Neurasthenia reacts on the digestive system, producing malnutri- 
 tion and a variety of functional disorders, for so dependent is the 
 whole alimentary canal upon a normal vigorous blood supply and 
 nerve regulation that it necessarily suffers profoundly. 
 
 General Treatment. — The treatment of neurasthenia is funda- 
 mentally based upon two absolutely essential conditions: First, 
 complete body rest, with the necessary absence of the original ex- 
 citing cause of the difficulty, which will enable the impoverished 
 tissues to become regenerated and have the balance of their energy 
 properly retarded ; secondly, a nourishing diet, which will supply 
 the material for this energy and tissue metamorphosis. Various 
 tonics, such as strychnine, iron, and arsenic, are of recognised bene- 
 fit to the nervous system, but the main reliance in all treatment 
 must be placed upon rest and food. The milder cases may be re- 
 lieved by a change of occupation and the enforcing of strict rules 
 in regard to the hours of sleep, the methods and time of eating and 
 taking exercise, bathing, etc. Many persons with functional nervous 
 disorder have no appetite early in the day, but towards evening can 
 eat a substantial meal, and they should dine late. 
 
 Patients who for years have been accustomed to exceedingly 
 active mental work find it almost impossible to endure confinement, 
 absence from social intercourse, and lack of occupation, and in such 
 cases the advantages of dietetic treatment may be enhanced by cheer- 
 ful surroundings and diversion. As a rule, it is far easier for the 
 fatigued or worried business man or " brain worker " to break off 
 completely his accustomed occupation for a period of several weeks 
 or months, to be spent in travel or at some foreign spa, than it is 
 for him to continue his ordinary occupations in moderation, and take 
 exercise and proper food and sleep in accordance with the rules laid 
 down by the physician. 
 
 In many cases of this nature travel affords a certain and fairly 
 prompt relief, but it has the disadvantage that it involves consid- 
 erable irregularity in the hours of rest, character of diet, etc., as well 
 as the fact that many are deterred from this means of cure by the 
 expense involved. In another class of cases too active travelling 
 is stimulating and fatiguing, and if such people are not made ill 
 at sea nothing gives more benefit than the isolation, invigorating 
 air, and enforced idleness of a sea voyage. For others, in whom 
 the digestive system is comparatively little impaired, camping or 
 living an outdoor life in the woods affords the same advantage. 
 Whatever journey is undertaken, therefore, should be in the direc- 
 tion of rest and moderate diversion without the sight-seeing which 
 is involved in visiting new cities. The physician should not only 
 study carefully the previous habits of the patient, but should con- 
 
THE NERVOUS SYSTEM 599 
 
 suit his tastes in regard to occupations and amusements. When 
 this is done and his confidence has been thoroughly gained, it is 
 far easier to have the rules for diet which are prescribed carefully 
 adhered to. In still another class of cases of neurasthenia the gen- 
 eral nerve breakdown is so sudden and the exhaustion so ex- 
 treme that absolute rest at home and in bed is imperative. To 
 this class of cases belong a large number of overworked society 
 women whose lives of constant excitement and mental activity or 
 stimulation, combined with the number of charitable interests or 
 other occupations to which they give much energy, wear them out 
 in time. 
 
 The most severe cases of neurasthenia require special treatment, 
 the principles of which are, first, complete rest for body and mind ; 
 secondly, systematic feeding; and thirdly, massage. This treatment 
 is applicable to those cases in which the nervous system is so 
 greatly exhausted that the patient suffers continual depression from 
 the least exercise, exertion, or emotional excitement. In some in- 
 stances insomnia is a predominant and serious symptom ; in others 
 the patient is drowsy in the daytime and unable to perform any 
 concentrated mental labour ; in others again inanition is the most 
 pronounced feature, and the rapid loss of weight and failure of 
 strength alarms the patient, or the body may even increase in weight, 
 while the muscles become soft and so feeble as scarcely to support 
 the frame. Many cases are complicated with pronounced hysteria, 
 hypochondriasis, or unnatural irritability. 
 
 One of the first requisites in treatment is to secure a faithful 
 and intelligent nurse and to isolate the patient from well-meaning 
 but oversympathetic friends whose constant inquiries and sugges- 
 tions are apt to aggravate existing conditions by focusing the 
 attention of the patient upon them. In general, it is best to allow 
 no one to see the patient excepting the trained nurse, the physician, 
 and perhaps some one trusted member of the family. All business 
 matters and domestic news of an exciting or depressing character 
 should be carefully kept from the patient, and such connection as 
 may be allowed with the outside world should be only of a cheer- 
 ing and encouraging nature. 
 
 It is very important that the nurse, who is so constantly with the 
 patient, should be congenial and possessed of the requisite tact and 
 cheerfulness of disposition. Many of these details may seem 
 trivial, but their importance is appreciated after experience, which 
 shows how easily infringement of the rules, such as the untimely 
 reception of exciting news or the visit of an untactful friend, may 
 react upon the digestive system and interrupt the favourable prog- 
 ress of the case for several days. This is particularly true of all 
 hysterical cases. On the other hand, there are some instances in 
 which patients with active minds do decidedly better if mild, pleasur- 
 40 
 
600 DIET IN DISEASE 
 
 able occupation or entertainment, such as reading aloud, is provided 1 
 for them, which is carefully limited to prevent fatigue. 
 
 It is necessary to explain the general plan of cure and its 
 object to both patient and family in order to secure their coopera- 
 tion, and this having been done, the treatment which has received 
 the name of " rest cure " should be outlined by definite rules in a 
 most careful and systematic manner. To be of any service, the rest 
 cure should last six weeks or more, and in severe cases it should be 
 explained that this treatment by no means completes the restora- 
 tion of the normal nerve functions, but is to be regarded as a basis 
 for a further regimen of exercise and outdoor life. While the rules 
 for diet for individual cases must be distinctly laid down, and con- 
 scientiously adhered to, there is scarcely any other variety of disease 
 in which the physician is called upon to exercise more tact and dis- 
 cretion, and the success of the treatment will depend very largely 
 upon the extent to which he adapts its provisions to the needs of in- 
 dividual cases. It is comparatively easy to prescribe definite regula- 
 tions for the treatment of neurasthenia, but practically there is no 
 case which does not present individual peculiarities which require 
 special consideration. 
 
 THE "REST CURE" 
 
 At the commencement of treatment in severe cases the patient 
 must lie absolutely quiet in bed and not be even allowed to raise 
 the arms or head to take food. After a week or ten days of such 
 enforced and absolute rest, the patient may gradually be allowed to 
 sit up and feed herself, but usually a full month or six weeks should 
 be spent in bed with no further exertion. The lack of voluntary 
 exercise must be supplied by the tonic effect of bathing and mas- 
 sage. The patient should receive a sponge bath every morning soon 
 after breakfast, which is to be given with hot water, or hot sea 
 water if it can be obtained. A portion of the body only is to be 
 sponged at a time, and friction with a coarse towel should immedi- 
 ately follow. In some cases benefit results from rubbing a piece of 
 ice or a cloth dipped in ice water over the skin for a moment after 
 the hot-water sponging. The alternate stimulation of the cutane- 
 ous nerves by strong degrees of heat and cold always produces a 
 tonic effect, and the influence of the ice water and friction is analo- 
 gous to that produced by the Brand system of cold bathing. 
 
 After the bath, which, if properly given, may consume a half or 
 three quarters of an hour, the patient must be allowed to rest, and 
 at noon or in the early afternoon massage is to be given, at first 
 every day, and later on alternate days. At the commencement of the 
 case the massage should be exceedingly mild, and caution is required 
 in this respect, for neurasthenic patients are often injured by the 
 too vigorous or prolonged efforts of the massage operators. For 
 
THE NERVOUS SYSTEM 6oi 
 
 the first day ten or fifteen minutes will suffice, and if the effect is 
 favourable, the time may be gradually extended to an hour. Owing 
 to the nature of the diet, which at first is of milk, and from the 
 lack of exercise and loss of tone of the intestinal walls, neurasthenic 
 subjects are uniformly constipated, and the massage should be par- 
 ticularly adapted to remedy this difficulty. 
 
 Massage of the abdominal muscles should be performed by 
 gently rubbing and kneading the abdomen, commencing in the right 
 iliac fossa and following the direction of the colon upward to the 
 free border of the ribs across to the opposite side and downward 
 to the sigmoid flexure. By this means peristaltic action is undoubt- 
 edly stimulated, and the contents of the large intestine are mechan- 
 ically propelled in the proper direction. 
 
 Dietetic Treatment. — The feeding of the patient must be based, 
 upon the principle of giving all the nourishment which can be as- 
 similated. The stools should be carefully watched from day to day 
 to make sure that the milk or other articles of food are thoroughly 
 digested. Nourishment should be given at brief intervals, which 
 must depend somewhat upon the amount of time allotted to sleep, 
 but in cases of great exhaustion patients should not be permitted 
 to go more than four hours at any time without food, and sleep 
 must be interrupted for feeding, if necessary. In other cases when 
 sleep so interrupted is readily resumed, food may be given with 
 regularity once in two hours throughout the day and night, as in 
 typhoid fever. When improvement is attained, the intervals of 
 sleep will naturally be longer, and it will be both unnecessary and 
 unwise to awaken the patient for feeding. The basis of the diet 
 in most cases should be milk, and by studying the taste and 
 digestion of the patient it is usually possible to prepare it in such 
 a manner that it is well borne. (See Adaptation of Milk for the 
 Sick, p. 73-) 
 
 In commencing the milk diet the objection of the patient often 
 has to be overcome, and it is advisable to begin slowly, giving 
 skimmed milk in tablespoonful doses four or five times a day for 
 two or three days until the patient is accustomed to it. Other 
 food is of course allowed at first, but this is to be gradually reduced 
 and the milk substituted for it in increasing quantity until four 
 ounces of skimmed milk are taken every two hours. It is finally 
 given up to eight or ten ounces at the same intervals. The taste, if 
 disagreeable, may be overcome by the addition of a little black 
 coffee or caramel. If it produces weight and epigastric oppression 
 or causes flatulence and eructations it is to be diluted by one half or 
 one third with lime, barley, or rice water or Vichy. One of the 
 I prepared foods," such as Nestle's or Mellin's, may be added, or the 
 milk may be pancreatinised or temporarily replaced by koumiss or 
 zoolak. The exclusive milk diet tends to make the patient drowsy 
 
602 DIET IN DISEASE 
 
 and to allay irritability in all the organs of the body, and it is actively 
 diuretic. 
 
 The constipation which the milk occasions may be overcome by 
 a pill of ox gall or a dose of bitter water in the morning, or by 
 enemata of warm soapsuds, when the latter do not produce the ex- 
 haustion which occasionally follows their use. 
 
 Many patients do very well on the exclusive milk diet for a 
 week or two, and they may be fed very much as typhoid-fever pa- 
 tients are, excepting that they may take more milk. If they can 
 digest it, two and a half or three quarts a day should be given as 
 recommended by Weir Mitchell, who was the pioneer of this method 
 of treatment in this country. After five or six days of such treat- 
 ment a chop or a poached egg may be added at noon. The next 
 day bread and butter or bread and milk is given, besides, for supper, 
 and then an egg or a little meat at breakfast, until the patient is tak- 
 ing three good meals of plain food daily, but in addition at least two 
 quarts of milk. The exclusive milk diet is believed to prepare the 
 digestive system for the assimilation of other foods. 
 
 Play fair's Diet 
 
 Playfair's diet for neurasthenia is a good example of a milk diet, 
 soon combined with other foods, as follows : 
 
 First Day. — Twenty-two ounces of milk in divided doses. 
 
 Second Day. — Fifty ounces of milk in divided doses. 
 
 Third Day. — Fifty ounces of milk in divided doses. Massage, 
 half an hour. 
 
 Fourth Day. — Fifty ounces of milk in divided doses ; egg, bread 
 and butter ; dialysed iron, forty minims in two doses. Massage, 
 one hour and a half. 
 
 Sixth Day. — Fifty ounces of milk in divided doses ; mutton chop. 
 Massage, one hour and fifty minutes. 
 
 Eighth Day. — Fifty ounces of milk in divided doses ; mutton 
 chop ; porridge and a gill of cream ; maltine, twice daily. Massage, 
 three hours ; electricity, half an hour ; continued to end of treat- 
 ment. The solid food is now gradually increased until such a diet is 
 reached as the following for the 
 
 Tenth Day. — 6 a. m., raw meat soup, ten ounces ; 7 a. m., a cup of 
 black coffee; 8 a. m., a plate of oatmeal porridge, a gill of cream, a 
 boiled egg, three slices of bread and butter, and cocoa; 11 a.m., 
 milk, ten ounces; 2 p. m., rump steak, one half pound of potatoes, 
 cauliflower, a savoury omelet, milk, ten ounces; 4 p.m., milk, ten 
 ounces; three slices of bread and butter; 6 p.m., a cup of gravy 
 soup; 8 p. m., a fried sole, roast mutton (three large slices), French 
 beans, potatoes, stewed fruit, and cream ; milk, ten ounces ; n p. m., 
 raw meat soup, ten ounces. 
 
THE NERVOUS SYSTEM 603 
 
 Fifteenth Day. — Three full meals daily of fish, meat, vegeta- 
 bles, cream, and fruit; two quarts of milk and two glasses of Bur- 
 gundy. 
 
 Twenty-second Day. — Amount of food lessened. 
 
 Ley den's Diet 
 
 Leyden's diet for neurasthenia is a modified form of milk treat- 
 ment which gives excellent results in some cases : 
 
 At 7 a. m., half a litre of milk, slowly sipped in half an hour, a 
 small cup of coffee with cream, eighty grammes (nearly three ounces) 
 of cold meat, a mealy baked potato; 10 a.m., a litre of milk with 
 three biscuits; 12 a.m., the same; 1 p.m., broth, two hundred 
 grammes (about seven ounces) of fowl, puree of potatoes, green 
 vegetables, one hundred and twenty grammes (nearly four ounces) 
 of compote, and pastry; 3.30, 5.30, 8, and 9.30 p.m., half a litre of 
 milk, making a daily consumption of three litres and a half of milk. 
 In the after part of the day, two meals each of eighty grammes 
 (three ounces) of roast meat with bread and three biscuits. 
 
 Keating s Diet 
 
 Keating's diet for neurasthenia is adapted to patients who need 
 not be kept constantly in bed. It is as follows : 
 
 At 6 a. m., a tumblerful of strong hot beef tea ; 8 a. m., a half tum- 
 blerful of iron water, and breakfast of fruit, steak, coffee, and a 
 goblet of milk ; 8.30 a. m., a goblet of milk with a dessertspoonful of 
 malt extract, six grains of citrate of iron and quinine ; 10 a. m., elec- 
 tricity ; 12 a. m., a goblet of milk and malt ; 2 p. m., dinner, preceded 
 by a half tumblerful of iron water and a third goblet of milk and malt ; 
 6 p. m., third dose of iron water. Light supper of fruits, bread 
 and butter, and cream ; a fourth goblet of milk and malt ; 10 p. m., 
 beef soup, four ounces, preceded by massage with cocoa oil for 
 an hour. 
 
 Two quarts of milk are taken daily, in addition to all other food. 
 The patient on this diet is allowed to be out of bed for four hours 
 every day, one of which may be spent in business. 
 
 If milk can not be made to agree with the patient in any form, 
 meat broths and purees and light farinaceous food may be prescribed. 
 Eggs may be given dropped into bouillon or any of the preparations 
 of egg albumin. Meat essences and extracts, such as Liebig's or 
 Valentine's, are serviceable, but the latter are so merely for their 
 stimulating effect upon digestion. If the condition of the stomach 
 is good, the constipation resulting from so concentrated a diet may 
 be overcome by the use of oatmeal porridge for breakfast, whole- 
 meal bread, and fresh fruits, such as the juice of the shaddock or 
 dried or stewed prunes. A reference to the receipts given at the 
 
604 DIET IN DISEASE 
 
 end of this book for the several kinds of fluid food will enable the 
 physician to prescribe sufficient variety to stimulate the appetite of 
 the patient, and in many cases a slightly different menu can be or- 
 dered for each day in the week. Most patients after a fortnight to 
 three weeks of semisolid diet are able to digest meat and other 
 solid foods. As an example of an excellent typical dietary for this 
 stage of the treatment, the following is given by H. C. Wood : 
 
 At 8 a. m., rolls or toast, cocoa, weak coffee or roasted wheat cof- 
 fee, beefsteak, tenderloin, or mutton chop ; 9 a. m., bathing ; 1 1 a. m., 
 oatmeal porridge with milk or else a half pint of molasses ; 12 noon, 
 massage ; 2 p. m., dinner, bouillon with or without agg, beefsteak, 
 rice, white potatoes roasted ; dessert of bread pudding, blancmange, 
 or similar farinaceous articles ; 4 p. m., electricity ; 5 p. m., milk toast ; 
 9 p. m., a half pint of skimmed milk or koumiss. 
 
 Bilfinger believes that a modified vegetable diet is most useful in 
 the treatment of neurasthenia, being less irritant to the nervous sys- 
 tem than a preponderance of animal food, and for anaemic subjects 
 who require proteids he prescribes milk and oatmeal porridge and 
 preparations of ground meal of legumes. He allows chocolate and 
 cocoa for beverages. A vegetable diet is useful in certain chronic 
 cases in which the patient is much worried over the smallness and 
 infrequency of the stools. Accompanied by large draughts of water 
 such diet gives copious and ready evacuations. For this purpose 
 such vegetables should be prescribed as celery, string beans, spinach, 
 peas, and potatoes and beans in purees. Sago, rice, and cracked or 
 shredded wheat may be also eaten. Meat should not be allowed 
 more than once a day. Milk, butter, and cream toast are excellent 
 foods for these patients. 
 
 Electricity. — The use of the electric current is of service in pro- 
 moting the nutrition of the body during the period of absolute rest 
 from voluntary movement. It should be distinctly remembered that 
 the electric current itself possesses no special nutritive value or 
 "vitalising" influence, such as is often claimed for it, but that it 
 acts favourably upon the muscular system by causing the muscles to 
 contract, and in that way also quickens the circulation. The con- 
 traction of muscles compresses the contents of their lymphatic ves- 
 sels and venous radicles, thereby aiding circulation, while the phe- 
 nomena are accompanied by metabolism which involves the appro- 
 priation of the ingredients of the food which have been absorbed. 
 The faradic current is used for this purpose. It may be applied 
 to special groups of muscles at first, and subsequently to the entire 
 body. Care should be taken not to fatigue individual muscles, and 
 the current should be carefully regulated and applied in accord- 
 ance with the condition of the patient. The use of electricitv in 
 relation to the treatment of constipation has been referred to under 
 that heading. It is doubtful whether the local application of elec- 
 
THE NERVOUS SYSTEM 605 
 
 tricity over the abdominal wall exercises any definite influence upon 
 the digestive processes which may be going on in the viscera beneath 
 the electrodes. 
 
 Insomnia and Disordered Sleep 
 
 Insomnia is due to many causes, but those which concern die- 
 tetics are the opposite extremes of overfeeding and starvation or in- 
 anition. Overfeeding or eating improper food may cause disordered 
 sleep, nightmares, or temporary insomnia from attacks of acute in- 
 digestion, dyspepsia, or biliousness, but inanition or malnutrition is 
 more apt to cause true insomnia from exhaustion. Neurasthenic 
 subjects whose nerve energy is insufficient to conduct their digest- 
 ive and absorptive functions completely are very liable to suffer 
 from insomnia. They unfortunately resort to hypnotic drugs in- 
 stead of first trying the efficacy of dietetics. 
 
 It is a good rule in such cases to improve the nutrition by care- 
 fully regulated feeding at frequent intervals. In addition to three 
 good meals a day, the patient should be made to take one or two 
 quarts of milk, with beef tea and one or two ounces of malt extract. 
 By gradually increasing the diet according to such rules as those 
 given for the treatment of neurasthenia, in a week or ten days the 
 patient can often be made to reach the maximum above given, and 
 improvement is almost certain to follow. It is best to take the 
 heaviest meal of the day in the early afternoon not as late as six 
 o'clock, for an overloaded stomach with indigestion is itself a cause 
 of insomnia, but, on the other hand, going to bed with a perfectly 
 empty stomach is usually undesirable. In mild cases a glass of hot 
 milk, a couple of teaspoonfuls of meat extract in hot water, or a 
 cup of good beef tea and a biscuit, or a cup of cocoa, or chicken 
 broth, or a light sandwich and a glass or two of beer or ale, taken 
 just before retiring, will serve to divert the blood current from the 
 brain to the stomach and induce cerebral anaemia and sleep with- 
 out the use of medicines, stimulants, or " nightcaps," and if anodynes 
 have to be given, a little food taken in this manner increases their 
 efficacy and makes a smaller dose possible. 
 
 Vertigo 
 
 Vertigo, although it arises from many causes, may be occasioned 
 by digestive disorders, such as the production of flatulency and pal- 
 pitation, or by the absorption of products of indigestion which act 
 as irritants of the vascular system. Such products, for example, are 
 developed in some persons by eating shellfish, strawberries, etc. 
 (p. 378). Lack of sufficient food may cause it. 
 
 The dietetic treatment is that of dyspepsia (p. 521). Fats, sugars, 
 and starches are forbidden, and alkaline and laxative waters, such as 
 
606 DIET IN DISEASE 
 
 Vichy, Congress, or Hathorn water, are of service to open the bow- 
 els and increase the activity of the kidneys. Lithsemic cases should 
 be kept for a week or two upon a vegetable diet (p. 504). 
 
 Chorea 
 
 Mild cases of chorea require no special regulation of diet beyond 
 that which is directed towards the prevention of flatulent dyspep- 
 sia (p. 525) and constipation (p. 571). In more pronounced cases 
 it is sometimes advisable to put the patient for a time upon a 
 milk diet. Sweets and farinaceous foods should, as a rule, be for- 
 bidden for fear of increasing palpitation through exciting flatulence. 
 Other patients do better with a diet of animal food, consisting of 
 meat, fish, eggs, and oysters with bread and milk, koumiss, or mat- 
 zoon. They are apt to be anaemic, and they should be encouraged 
 to take as much food as the digestive organs will tolerate. Cod- 
 liver oil is very useful in these cases. 
 
 Epilepsy 
 
 Epilepsy is a functional nervous disorder, which may often be 
 considerably improved by careful attention to diet. A very large 
 proportion of cases occur in childhood at a period when existing 
 functional derangements of the nervous system are readily aggra- 
 vated by improper food. Many rhachitic children with imperfect 
 development of the teeth, feeble digestive organs, and consequent 
 malnutrition develop epilepsy while teething. Of twenty-seven 
 cases occurring among children recently analysed by Osier, more 
 than one half developed before the fifth year and more than three 
 fourths before the tenth year. Very many cases are closely asso- 
 ciated with errors in diet or affections of the alimentary canal, and 
 while such conditions may not cause the disease, they readily precip- 
 itate epileptic seizures. This statement applies to grand mal and 
 petit mal rather than to the localised or partial convulsions known 
 as Jacksonian epilepsy, which are due to local and definite cortical 
 motor irritation. Of the varieties of epilepsy, petit mal is more 
 favourably influenced by diet than are the other forms. 
 
 Patients should have their eating supervised with care. They 
 should be well fed, but must eat only easily digestible food and have 
 their meals at regular intervals, and the principal one must be in 
 the middle of the day in order that digestion at night may be com- 
 pleted before going to sleep. All food should be eaten slowly, and 
 meat, if given, must be very thoroughly masticated, and the stomach 
 should never be overloaded. 
 
 As a rule, meat should be allowed but once a day. Some chil- 
 dren with petit mal, or even grand mal, improve rapidly on a strictly 
 vegetarian diet or on a bland diet of which milk, bread and butter, 
 
THE NERVOUS SYSTEM 607 
 
 and simple starchy foods, such as rice pudding, cornstarch, Indian- 
 meal pudding, etc., form the basis. I have seen cases of epilepsy 
 among young children in which, while the medicinal treatment re- 
 mained constant, a return to meat diet was invariably followed by 
 convulsions, which were absent on a vegetable or exclusive milk 
 regimen. 
 
 As a rule, adults do not seem to be aided by dieting to such a 
 degree as children ; nevertheless, they do well to take but little 
 meat and to be abstemious and regular in their habits of eating. 
 Dr. Mersan, of the West Riding Asylum, in England, tried the ex- 
 periment of putting a number of chronic epileptics for some weeks 
 first upon a diet of flesh and then upon a vegetable diet, and vice 
 versa. The results showed that their convulsions were not materi- 
 ally lessened in number or severity, but it was noticed that while 
 their food consisted largely of meat their mental condition was more 
 stupid. At the epileptic colony of Chalfont St. Peter, the patients 
 are allowed meat once a day, but all the inmates are men, leading an 
 active outdoor life, and hence better able to digest stimulating pro- 
 teid food. Gowers allows his patients meat twice a day, and asserts 
 that he has seen cases in which fewer epileptic seizures occurred 
 while eating flesh than when abstaining from it. One patient had 
 paroxysms only after eating beef, but not in connection with other 
 varieties of meat. It is evident that no definite rule should govern 
 all cases. It is worth while to reduce the nitrogenous food for a 
 month or two, and if improvement does not follow, or nutrition be- 
 comes less active, it may again be added to the dietary. 
 
 Dr. Whitmore Steele, formerly of the Utica State Asylum, in 
 speaking of the treatment of chronic epilepsy at that institution, 
 informs me : " We endeavour to reduce the amount of albuminous 
 foods, giving a more liberal and easily assimilated diet also. Invari- 
 ably overalimentation in our epileptics produces attacks." Epi- 
 leptics will often gorge themselves with food and drink if allowed 
 to do so. 
 
 Some of the carnivores, as well as animals accustomed to a 
 mixed diet, develop convulsions from a too liberal allowance of 
 meat, if at the same time they are kept in confinement. In these 
 cases, however, the convulsions may be due to reflex irritation from 
 the stomach or bowels, produced by large masses of slowly digested 
 food, rather than to the chemical nature of the food. The same 
 thing may occur in young children who are allowed to gorge them- 
 selves with any hastily eaten bulky diet, and the resulting convul- 
 sions should not be confounded with genuine epileptic seizures 
 accompanied by loss of consciousness, and recurring periodically- 
 Some patients have a distinct epigastric aura preceding the convul- 
 sions. 
 
 It is extremely desirable to prevent intestinal putrefaction. 
 
<6o8 DIET IN DISEASE 
 
 Should the stools become offensive, or much flatulence or indi- 
 canuria appear, the patient should be given a milk diet for a week or 
 two, and cathartics and intestinal antifermentatives should be em- 
 ployed, such as salol, creosote, or guaiacol carbonate. 
 
 Many are obliged to take large doses of the bromides and other 
 medicines. It will be found that the disagreeable symptoms of 
 bromism are much less apt to occur if the diet be so regulated as to 
 carefully avoid constipation and to insure the consumption of abun- 
 dant fluid diluents. Vichy or carbonic-acid water and water should 
 be drunk freely between meals, and especially after taking medicine, 
 and daily thorough evacuations of the bowels should be secured by 
 the use of fresh vegetables and fruits, prunes, figs, apples, oranges, 
 etc. Adults should abstain from agents which are likely to over- 
 stimulate the nervous system, such as alcohol and strong tea and 
 coffee. The use of tobacco should also be interdicted. 
 
 Beri-beri 
 
 Beri-beri is a form of multiple neuritis very rarely imported into 
 this country by Chinese, Ceylonese, Japanese, or Philippine Island- 
 ers, who have acquired it in their native countries or on the voyage. 
 It is characterised by anaemia, general oedema, and more or less 
 stiffness and paralysis of the extremities, with dyspnoea and serous 
 effusions. Sometimes there are muscular spasms. 
 
 Beri-beri has been attributed to the absence of fresh animal food 
 from the diet, a sort of antithesis to the cause often assigned to 
 scurvy. It has more specifically been attributed to the excessive 
 consumption of rice and adzuki beans to the exclusion of other food ; 
 but these views are incorrect, for upon the authority of Baelz it is 
 stated that the best fed and best nourished are frequently subject to 
 the disease. In the Japanese navy, where the disease was formerly 
 not seldom encountered, it has been practically exterminated by in- 
 creasing the nitrogenous-food ration and lessening the carbo- 
 hydrates. 
 
 The latest view of the disease is that it is not caused by bad food, 
 but by a micro-organism, and that bad food and bad hygiene are 
 merely predisposing factors. 
 
 Locomotor Ataxia 
 
 Locomotor ataxia is a disease which cannot be said to be particu- 
 larly influenced by any system of dietetic treatment, although it is 
 believed by some writers that the quantity of meat ordinarily eaten 
 should be reduced. As in many other forms of very chronic nervous 
 disease, a generous diet is desirable, with an abundance of fat, butter, 
 cream, cod-liver oil, etc., when the stomach will tolerate it. Strong 
 liquors should be forbidden, but light wines, malt liquors, tea, and 
 
THE NERVOUS SYSTEM 609 
 
 coffee may be allowed in moderation. A reasonable use of tobacco 
 need not be proscribed. 
 
 In those cases in which the " gastric crises " predominate the 
 diet must be restricted for a few days when the crises occur, upon 
 the principles established for the treatment of gastralgia. (See Gas- 
 tralgia.) It may be necessary at such times to put the patient upon a 
 simple milk diet. 
 
 Other diseases of the spinal cord do not usually demand particu- 
 lar dietetic treatment, but Bauer says that " some diseases of the 
 spinal cord lead to an extraordinary falling off of the demand for 
 nutriment." This is due to alterations in general metabolism, which 
 is further evidenced by a marked reduction in temperature. 
 
 Apoplexy 
 
 The several forms of cerebral haemorrhage may interfere with 
 nutrition in a variety of ways. If coma is present, voluntary degluti- 
 tion being suspended, great care must be exercised in feeding the 
 patient. Liquid food is best given in teaspoonful doses, and the 
 effect of each spoonful must be carefully watched to see that it is 
 successfully swallowed before another is given, otherwise fatal chok- 
 ing may result from food passing over an insensitive epiglottis and 
 larynx, when particles of food may be drawn into the lungs and ex- 
 cite local disease. Concentrated meat extracts, beef peptonoids, and 
 peptonised milk may be given in this manner. 
 
 In extreme cases, when rigidity of the jaw interferes with feeding, 
 or when paralysis involves the mechanism of deglutition, a long, 
 slender catheter may be introduced through the nose and passed 
 into the stomach, through which fluid nourishment is poured, after 
 the manner of feeding patients suffering from melancholia. (See 
 Melancholia, p. 610.) 
 
 The rectum may also be utilized for nutrient enemata (p. 408). 
 In unilateral facial paralysis without unconsciousness patients may 
 be willing and able to swallow, but mastication is difficult or impos- 
 sible. The food constantly gets into the buccal cavity behind the 
 teeth of the paralysed side, and the tongue, perhaps also partially 
 paralysed, dislodges it with great difficulty. The retention of food 
 is accompanied by a copious secretion of saliva, which, dribbling 
 from the depressed angle of the mouth, adds greatly to the discom- 
 fiture of the patient. All nourishment should therefore be given in 
 fluid form, or in such finely divided state that it does not require 
 mastication, and can be readily washed down with water. Milk, 
 thick broths, purees thickened with macerated vegetables, long-boiled 
 rice, sago, or barley with cream, custards, soft-cooked eggs, etc., 
 may be given. The patient should be fed very slowly to prevent 
 the food from running out of the mouth. The mouth should be 
 
6lO DIET IN DISEASE 
 
 frequently cleansed with listerine or a saturated aqueous solution 
 of boric acid. In cases of hemiplegia without facial paralysis the 
 patient can masticate and swallow, but the mental condition or loss 
 of appetite makes the use of food which can be swallowed with the 
 least possible effort desirable. Convalescent hemiplegic cases which 
 run a very protracted course naturally suffer from lack of exercise, 
 and almost invariably become constipated. It is well in such in- 
 stances to recommend simple and non-nitrogenous diet, containing 
 laxative food, cooked fruit, and coarse cereals, to regulate the 
 bowels. It is important to reduce arterial tension, to prevent, if pos- 
 sible, a repetition of the intracranial haemorrhage. Large draughts 
 of fluid rapidly absorbed tend by adding to the volume of the blood, 
 to temporarily increase the intravascular pressure. The blood ves- 
 sels, however, show a very remarkable ability to maintain an aver- 
 age pressure of the fluid within them, and the possible danger from 
 this source of an exclusive fluid diet may be averted by increasing 
 the functional activity of the kidneys by diuretics and reducing the 
 arterial tension by the remedies in common use, such as chloral, 
 nitroglycerin, and the nitrites. When the tension is very high, it 
 is well to give a non-stimulating diet without much meat, and milk 
 should form the basis of it. Alcoholic stimulants should be for- 
 bidden. 
 
 Acute Insanity — Melancholia — Primary Dementia — 
 
 Mania 
 
 Acute insanity may result from overwork or severe mental strain, 
 or from numerous diseases. It overtaxes the vital powers and causes 
 wasting, inanition, and exhaustion. As the symptoms may result 
 quite suddenly, often within a few hours after intense emotional 
 strain or excitement, the digestive system is at first not necessarily 
 disturbed to any considerable extent, although the appetite may be 
 entirely absent. Subsequently various digestive disorders and mal- 
 nutrition may supervene. 
 
 The insane, especially the melancholic, often refuse food abso- 
 lutely, or can be induced to take it only very sparingly. 
 
 Forced Feeding. — When food is absolutely refused by the pa- 
 tient, the question of forced feeding must be considered in order to 
 tide him over the emergency and support life until confusional in- 
 sanity or delirium subsides. 
 
 Concerning this problem opposite views are held. Some alien- 
 ists regard the operation of compulsory feeding as good mental dis- 
 cipline, others decry it, and defer it as long as possible. It must be 
 understood that the refusal of food may be either a complication or 
 a symptom of the special form of insanity in which it occurs, and the 
 patient should be carefully studied to determine which condition is 
 
THE NERVOUS SYSTEM 6ll 
 
 present. As a complication, it may be caused by central nerve 
 lesions that hinder deglutition, such, for example, as those found in 
 either acute or chronic paralytic dementia. Or digestive disturb- 
 ances, dyspepsia, or gastric catarrh may cause a loss of appetite 
 which in the patient's disturbed mental state is exaggerated into a 
 refusal of all food. Such local disorders may themselves cause hal- 
 lucinations or delusions, giving rise to " sitophobia," or horror of 
 taking food. Obviously in such cases cure of the complication may 
 be sometimes effected by treating the local condition. Lavage will 
 sometimes relieve it entirely. 
 
 When the refusal of food is purely a symptom of the disease, as 
 it occurs in melancholia or delusional insanity, an attempt should 
 always be made to learn the exact nature of the delusion, and to try 
 if it cannot be dispelled or offset, as in the case of some paranoiacs. 
 For example, the delusion may apply merely to food cooked in par- 
 ticular ways, or served in a certain manner or by certain persons, 
 and the patient may have no real loss of appetite, but may even try 
 to obtain food by stealth and be pleased at his success in that direc- 
 tion, and his food should be placed where he can find it unobserved. 
 
 Some patients will refuse all fluid foods who are willing to take 
 solids, or vice versa, or they may refuse food offered by an attendant 
 and yet accept it from a fellow-patient. 
 
 If their delusions take the form of suspicion of poisoning, they 
 may sometimes be overcome by showing them eggs in the shell, 
 unpeeled potatoes and fruits, which obviously can not have been 
 poisoned beforehand, and which are then cooked in their presence. 
 Some patients will only eat if left alone or after others have fin- 
 ished, because they feel unworthy to eat with them. Others who per- 
 sistently refuse food will take it greedily if an apparent show of 
 force is made in placing it within their mouths. 
 
 Patients with chronic or asthenic mania may refuse food from 
 inattention, although able to eat if their surroundings are quiet and 
 their attention can be momentarily obtained. If they can be in- 
 duced to take but a few mouthfuls at a time they should be fed re- 
 peatedly at short intervals. 
 
 Food should be cooked and served as temptingly as possible, and 
 the patient, if unable to keep himself in order, should have his 
 mouth cleansed and clothing protected from soiling. 
 
 The appetite is seldom a safe guide in insanity, and when it fails 
 completely forced feeding should not be postponed until the patient 
 has become too exhausted to rally. Cases of depressive insanity are 
 very apt to require it sooner or later, and sometimes it is practised 
 continuously for a year or more. In acute mania, however, it may 
 be only necessary to employ the method for a few days, after which 
 the patient will eat of his own accord if given the opportunity. 
 
 In cases of melancholia, after one or two feedings with the stom- 
 
6l2 DIET IN DISEASE 
 
 ach tube, I have often, by a little firmness and patience, satisfied the 
 patient that swallowing a glass of milk for himself was more agree- 
 ble than having it poured in through a tube. When voluntary star- 
 vation is the fixed intent, if the patient can be convinced that he has 
 got to take food in some manner, he may yield to the inevita- 
 ble and choose the lesser of what he regards as two evils. With a 
 stomach tube in one hand and a glass of milk in the other the argu- 
 ment can be made very forcible. 
 
 The physician himself should always direct the passage of the 
 tube for the first few times. Afterwards, if the patient is not refrac- 
 tory, an attendant may do it. Occasionally the aid of two or three 
 assistants is necessary to overcome resistance. The patient should 
 be made to sit down or lie upon his back, and either an oesophageal 
 or nasal tube may be used, according to the directions given on p. 
 539. There are certain advantages in the use of each tube. The 
 oesophageal tube does not so readily admit of regurgitation alongside 
 of it as the nasal tube does (although occasionally patients can re- 
 gurgitate through the tube itself). If it be filled before it is inserted, 
 and if a little fluid be squeezed out of it when part way down the 
 oesophagus, reflex swallowing occurs, which may be taken advantage 
 of to further propel the tube. The disadvantage of this method of 
 feeding is that the patient often struggles and must be gagged. A 
 wooden gag shaped like a bit, with a central perforation through 
 which the tube is passed, prevents it from being compressed by bit- 
 ing. But the gag is disagreeable, it may slip and break a tooth, and 
 the head and arms must be rigidly held by two assistants. I have 
 known a refractory patient with melancholia to bite off and swallow 
 eleven inches of stiff oesophageal tube, which remained in the stom- 
 ach for eleven days before it was ejected by vomiting ! 
 
 The nasal tube possesses the advantage that it can be more 
 easily introduced with much less struggling, but it has the disad- 
 vantage that greater care is required to prevent passing it into 
 the larynx, for the insane are sometimes strangely insensitive. The 
 former difficulty can be obviated by getting the patient to speak, 
 or by closing the tube after it has been inserted and before fluid is in- 
 troduced, in order to make sure that breathing is not obstructed. 
 This form of tube should be of as large a size as can be conveniently 
 passed. A No. 8 catheter will serve. 
 
 For forced alimentation it is necessary to give food in fluid form, 
 and a quart of milk, with one or two beaten eggs, either raw or 
 slightly cooked or made into eggnog, may be prescribed two or three 
 times a day. Nutritious meat broths, thickened with barley, rice, or 
 vermicelli and strained, or potato puree, may also be given through 
 a large tube. Cream and cod-liver oil should be added to the diet. 
 In a case reported by H. C. Wood, for six weeks the patient lived 
 with the greatest benefit on six pints of milk and sixteen raw eggs 
 
THE NERVOUS SYSTEM 613 
 
 taken daily. If an ounce of malt extract be added to oatmeal or po- 
 tato gruel in milk, it soon makes the mass sufficiently fluid to pass 
 through the tube. As this method of feeding prevents the saliva 
 from commingling with the food, there is additional advantage in 
 giving malt or diastase to replace it. 
 
 For obstinate patients, feeding with the tube twice a day — at say 
 8 a. m. and 5 or 6 p. m. — is sufficient, and a quart of food can be intro- 
 duced at once, but more feeble patients may require feeding three or 
 four times a day. If gastric catarrh or dyspepsia is present, pre- 
 liminary lavage may be employed, and then food and medicines 
 may be poured through the tube. 
 
 Both hypnotism and primary anaesthesia under chloroform have 
 been utilised in extreme cases to enable food to be given to the in- 
 sane, but the latter method is only necessary or justifiable in very 
 exceptional cases. 
 
 Nutrient enemata are of little value in the feeding of the insane 
 who resist feeding, for if the patient realises their use he can make it 
 more difficult to be nourished in this way than by the stomach or 
 nasal tube. 
 
 Suralimentation. — Suralimentation is to be recommended when 
 feasible. (See p. 464.) 
 
 Brush says : " In acute delirious mania, in melancholia with 
 frenzy, and in some of the maniacal seizures incident to the aged, the 
 great importance of a liberal persistent use of milk, eggs, and animal 
 broths cannot be overestimated." 
 
 If patients will eat they should be given abundant nutritious food, 
 such as tender meats, custards, cereals with butter, sirup, or cream, 
 eggnog, thickened broths, purees, beef jelly, gruels, etc., which are 
 made palatable to tempt the appetite, and the number of daily meals 
 may be increased or nourishment may be given once in three hours. 
 By diverting the blood current and nervous energy for digestive pro- 
 cesses, the general nervous system and mental condition become 
 soothed and quieted. Fresh fruit and fruit juices should be offered 
 occasionally. 
 
 Special Precautions. — In acute insanity there is a tendency for the 
 body temperature to fall two or three or more degrees below the 
 normal. This is especially true of those cases of primary dementia 
 which are due to exposure and privation accompanied by severe 
 mental strain, such, for example, as occur from shipwreck or from 
 any form of severe sudden shock. While regulating the diet, there- 
 fore, attention must be given to the preservation of the body heat, 
 and the patient should be surrounded by uniform temperature, to 
 be maintained in an overheated room or by hot-water bottles and 
 warm clothing. Sustaining the normal temperature will facilitate 
 the digestive functions. 
 
 The insane must be closely supervised while eating. They often 
 
■6l4 DIET IN DISEASE 
 
 bolt their food, when given too much at a time, in a manner that 
 soon destroys digestion. In such cases all food should be given in 
 a state of fine subdivision or fluid or semifluid form. Patients with 
 advanced general paresis or different paralytic diseases may easily 
 suffocate by getting a piece of meat in the larynx. Patients with 
 mania gravis, or suicidal melancholia, etc., should of course never be 
 intrusted with knives or with plates or dishes which can be easily 
 broken into sharp fragments with which to cut themselves. 
 
 DIET IN SKIN DISEASES 
 
 It has long been known that a relation exists between various 
 errors in diet and certain skin diseases, but it is only within the past 
 ten or fifteen years that attention has been directed to the importance 
 of systematic dietetic treatment to aid the cure of such ailments, and 
 a more thorough investigation of this subject is much to be desired. 
 
 Skin Diseases which are caused by Improper Diet. — The skin dis- 
 eases commonly referable among other influences to dietetic causes 
 are erythema, urticaria, acne, eczema, and scorbutic eruptions. 
 
 Many chronic skin diseases, if not originally caused by dietetic 
 errors, are undoubtedly much protracted and made worse by them. 
 This is particularly true of eczema, impetiginous and seborrhceic 
 ecthyma, strophulus, and the cutaneous lesions of the tuberculous 
 diathesis, and sometimes of psoriasis. 
 
 The very important alimentary substance alcohol, when taken in 
 excess, greatly aggravates many forms of chronic cutaneous lesions, 
 notably those of syphilis and rosacea, and the capillary congestion 
 and muddy complexion of chronic alcoholism is well known. 
 
 The modes of production of cutaneous eruptions by dietetic 
 errors are various. Probably in the majority of instances such erup- 
 tions are due to malfermentation products, ptomaines, etc., which are 
 absorbed through the digestive tract. In other cases they may be 
 due to an effort to eliminate incompletely oxidised food products or 
 poisons from the cutaneous glands (as in the case of drug rashes), 
 and it has been suggested that they may be sometimes caused by re- 
 flex nerve irritation from the alimentary canal, although the latter 
 theory is less tenable. It is, however, interesting to observe the fact 
 that an intimate relation often exists between irritation and inflamma- 
 tion of the skin and of mucous membranes. Overeating, and especial- 
 ly the overfeeding of infants, is a common cause of skin eruptions, 
 and the attempted elimination by the sweat glands of fatty acids is 
 irritant. 
 
 General Principles of Dietetic Treatment. — There are certain gen- 
 eral principles of dietetic treatment which are applicable to a major- ' 
 ity of all severe cases. The food should be of simple kind, restricted 
 in variety, and plainly cooked. Milk, meat, and stale bread are more 
 
SKIN DISEASES 6l$ 
 
 desirable than amylaceous or saccharine food. If fever is present at 
 the outset, a milk diet must be ordered. The tuberculous and gouty 
 require fats in some form. Chronic cases with malnutrition and anae- 
 mia must have abundant nourishing animal food. In the case of 
 scorbutic eruptions the trouble arises sometimes (but not always) 
 from malnutrition from withholding certain articles, such as fresh 
 fruit and vegetables, from the diet. 
 
 Substances to be particularly avoided in skin diseases are raw and 
 unripe fruits and vegetables, sweets and pastry of all kinds, condi- 
 ments and highly seasoned dishes, veal, pork, and alcoholic bever- 
 ages. Other injurious foods will be mentioned under the treatment 
 of the several varieties of skin diseases described below. 
 
 Erythema — Urticaria 
 
 Either acute erythema or urticaria may be caused in some per- 
 sons by eating fish, and particularly shellfish and crustaceans, as oys- 
 ters, clams, lobsters, shrimps, and crabs. It is also produced by straw- 
 berries, bananas, and other forms of fruit. Crustaceans and straw- 
 berries are perhaps the most common excitants. 
 
 The action of the food poison is wholly different from that of 
 ptomaines (p. 374), for it originates from fresh as well as stale 
 food, and may be derived, as in the case of strawberries, from vege- 
 table food. Some persons have an attack regularly every spring 
 when strawberries first appear on the table. Others show occasional 
 immunity, depending upon their condition at the time. Those per- 
 sons who are hurt by one kind of poisonous food are not necessarily 
 affected by the others. The whole matter seems to be influenced 
 solely by idiosyncrasy. 
 
 Other alimentary substances which have been observed to some- 
 times poison are pork in various forms, sausages, mushrooms, 
 cheese, and even mutton (Jackson). 
 
 Symptoms. — The eruption develops suddenly and within from 
 two to six hours after ingestion of the food. It is commonly a typ- 
 ical urticaria with large pink wheals, which quickly come and go over 
 all parts of the body. They are accompanied by intense itching and 
 burning. This affection usually lasts but a few hours, or possibly for 
 two or three days, though sometimes it may continue for several 
 weeks. 1 
 
 Treatment. — The eruption usually disappears upon withdrawing 
 the offending article from the diet, and giving a saline cathartic and 
 some simple remedy to regulate digestion and prevent fermentation, 
 such as salol, salicin, or rhubarb and soda. Large quantities of water 
 should be drunk. 
 
 The troublesome itching is best relieved by sponging with com- 
 mon baking soda, a teaspoonful to a quart of water, or a solution may, 
 41 
 
6l6 DIET IN DISEASE 
 
 be applied to the wheals of menthol and chloral, each a drachm, in a 
 couple of ounces of a mixture of equal parts of alcohol and camphor 
 water. A 1-40 carbolic-acid solution may be similarly applied. 
 
 Acne 
 
 Causation. — The larger number of cases of acne are produced by 
 improper food. The papules and pustules which constitute acne 
 are caused by inspissation of the oil of the sebaceous glands, which 
 plugs their orifices and irritates the glands and the hair follicles, ex- 
 citing inflammation in them. The disease is usually first observed 
 during puberty, a period in which important changes in the nutrition 
 of the body are in progress, and, once established, it is apt to last for 
 some time — often for several years. It is easy to conceive how 
 slightly altered composition of the blood, due to imperfect assimila- 
 tion of food, may alter the composition of the sebum and irritate the 
 sebaceous glands. 
 
 In some people the papules appear as a result of eating buck- 
 wheat cakes or oatmeal. In others they are caused by greasy food — 
 doughnuts, sausages, cheese, fried meats, ill-cooked and rich pastry — 
 excess of sweets, nuts, and other indigestible substances. 
 
 Dietetic Treatment. — In addition to local means, the dietetic 
 treatment of acne is most important. G. T. Jackson says : " The well- 
 to-do are all prone to eat too much, and it is remarkable how rapidly 
 acne will improve by reducing their diet to the simplest elements. In 
 many of them a milk diet for a few days, provided milk agrees with 
 them, will accomplish a marked benefit. It is a good rule to cut off 
 from the dietary all pastry, cake, candy, sweets, hot breads and pan- 
 cakes, greasy soups, articles fried in fat, twice-cooked meats, rich 
 gravies — in fact, all those things that are most apt to tempt the 
 palate." Alcohol in all forms should be prohibited, as well as tea 
 and coffee. A tumblerful of hot water or a glass of Vichy should be 
 drunk before each meal. With meals but little fluid should be taken, 
 never over four or five ounces, but between meals water or aerated 
 water should be drunk freely for its diuretic effect. Naturally, exer- 
 cise, bathing, and the use of laxatives should be adjuncts to the die- 
 tetic regimen. 
 
 Eczema 
 
 Causation. — Eczema, both acute and chronic, which constitutes 
 so large a proportion of all cases of skin diseases, is provoked by 
 different causes, but in a great number of instances its origin is 
 directly traceable to dietetic faults. These may be of three kinds — 
 namely, the eating of (1) too much food ; (2) insufficient food ; (3) 
 improper food. 
 
 1. Cases due to Overeating. — The ills of overeating have been 
 elsewhere described (p. 366). Its relation to eczema consists in 
 
 , 
 
SKIN DISEASES 617 
 
 the additional burden thrown upon the skin of attempting to elimi- 
 nate waste products, which are accumulated in the blood faster than 
 they can be got rid of. The cutaneous glands, like the kidneys, are 
 constantly stimulated and overworked, and the character of their 
 secretion is altered. The skin, for a long time irritated, finally suc- 
 cumbs to a definite eruption. 
 
 It is for this reason that robust persons apparently in the best 
 of health and with too vigorous appetites will sometimes be sur- 
 prised with the sudden appearance of eczema, which they have al- 
 ways attributed solely to " bad blood." 
 
 Treatment. — This class of cases is to be treated by reducing the 
 quantity of food, and by prescribing a very simple diet. In bad cases 
 of general eczema it may be best to put the patient upon a milk or 
 bread-and-milk diet for one, two, or three weeks. From two to two 
 and a half quarts are taken daily with toast or crackers. Marked 
 improvement will occasionally follow this course. For others, sim- 
 ply reducing the diet by excluding meat and desserts for a time, may 
 be all that is necessary. Meats — either beef, mutton, or chicken — 
 should not be allowed more than once a day. Piffard reports that 
 56 per cent of his patients were accustomed to eat meat in excess 
 three times a day. 
 
 Fish, either boiled or broiled, may be substituted for meat to 
 advantage in neurotic subjects (Bulkley), for though it may excite 
 urticaria, it does no harm in eczema in spite of the popular belief 
 to the contrary. I have known the eating of shellfish, however, to 
 intensify chronic cases considerably. 
 
 Typical Diet for Eczema. — The following simple diet may serve as 
 an example : 
 
 Breakfast. — Bread and milk, or porridge, or wheaten grits, or 
 cracked wheat, without cream, and salt or lemon juice may be added 
 if preferred. Every other day a soft-cooked egg may be eaten. 
 
 Dinner. — No soup, entrees, or dessert. Roast beef or mutton or 
 chicken may alternate with broiled fresh fish with white meat, one 
 or two green, light vegetables, such as haricots, spinach, lettuce, 
 green peas, or macaroni. As Jackson says : " It is a good rule to 
 tell the patient he may eat what he likes, but not of more than two 
 dishes at a meal. It is unlikely that he will then overeat." Fresh, 
 ripe fruits, except apples, may be allowed. 
 
 Stepper. — Bread or toast or crackers and milk, custard, or simple 
 rice pudding, not too sweet. A little fresh fruit. Stimulants are 
 not usually required, but if needed for nutritive or tonic effect, di- 
 lute liquor, brandy, whisky, or Hollands is the best form. 
 
 Malt liquors of all sorts, as well as wines, should be forbidden. 
 It is generally believed that tea and coffee are harmful in eczema, 
 and drunk in excess they certainly are so, not only from disordering 
 and retarding digestion, but from their undue stimulating effect. 
 
6l8 DIET IN DISEASE 
 
 Unless they are taken in great moderation and but once a day, it is 
 better to forbid their use entirely. The same is true of sweet choco- 
 late, but cocoa may be allowed. 
 
 2. Cases due to Insufficient Food. — Too little food results in im- 
 poverished nutrition, and the skin, being one of the most sensitive 
 organs of the body, is among the first to suffer. The habits of filth 
 which so often accompany semi-starvation among the poor are con- 
 tributing causes which combine to provoke skin eruptions. 
 
 The diet required for these cases does not essentially differ from 
 those of the preceding class. An effort should be made to restore 
 the impoverished nutrition of the body as quickly as possible by 
 suralimentation if necessary (p. 464). 
 
 3. Cases due to Improper Food. — Improper food is also capa- 
 ble of exciting outbreaks of eczema, and this is particularly true of 
 chronic or relapsing cases. Oatmeal, for example, while it may not 
 cause the disease, is generally believed to be capable of intensifying 
 it. It is not possible to always forewarn against the particular arti- 
 cles of diet which will do this, as they vary in different persons 
 and often in the same person at different times, but, in general, food 
 which is called " rich " is to be avoided, such as highly seasoned 
 meats, soups, sauces, gravies, strong condiments, sweets, pastry, hot 
 breads, pickles, preserves, and fancy desserts of all kinds. Bulkley 
 especially forbids sweet potatoes, fried eggplant, cabbage, cheese, 
 bananas, apples, soda water with sirups, as well as salt food, such 
 as ham, corned beef, and salt pork. A little bacon or a salt herring, 
 however, is permissible. All fried food, with the above exceptions, 
 is strictly forbidden, and " fritters," fried oysters, etc., are highly in- 
 jurious. In a word, all those articles which are liable to excite tem- 
 porary dyspepsia and overload the urine with phosphates, urates, 
 and calcium oxalate must be avoided. The staple diet should con- 
 sist of whole-meal bread, fresh, plainly cooked vegetables, eggs, 
 milk, and a little chicken, fresh fish, or meat not oftener than once 
 a day. 
 
 There are obstinate cases of chronic eczema which fail to yield 
 to any dietetic regulations, but it is always desirable to thoroughly 
 try the value of dietetics, and very often the result will be surpris- 
 ingly gratifying. In conjunction with dietetic treatment the urine 
 should be always carefully examined, and the bowels must of course 
 be regulated. 
 
 It is very important to control the general habits of the patient 
 in regard to meals. He should eat at regular and proper hours and 
 observe uniformity in the quantity of food consumed. He should 
 be very careful to eat slowly and thoroughly masticate his food, and 
 not drink so much fluid with meals as to dilute the gastric juice 
 excessively. The general rules for the treatment of dyspepsia (p. 
 525) and its avoidance are especially applicable to all skin diseases 
 
SKIN DISEASES 619 
 
 which are in any way amenable to dietetic influence. It should also 
 be remembered that eczema frequently is associated with gouty and 
 strumous diatheses, and the reader is referred to the sections upon 
 these subjects. 
 
 ECZEMA IN NURSING INFANTS 
 
 Bulkley points out that eczema in nursing infants is mainly due 
 to dietetic errors of the mother, for whom, rather than for the child, 
 treatment should be instituted. He prohibits the drinking of all 
 forms of malt liquors and wines and rich chocolate. Anything 
 which provokes indigestion and biliousness in the mother reacts un- 
 favourably upon the skin disease of the infant. This is a very im- 
 portant truth too often overlooked. If the mother becomes con- 
 stipated, has dyspepsia and a furred tongue, and excessive deposit 
 of urates and oxalates in the urine, her diet must be chang*ed, the 
 bowels must be regulated, and tonics should be given. Other cases 
 in infants are caused by the mother's milk being poor and thin, and 
 the breast milk should be supplemented by cow's milk properly pre- 
 pared, or it may become necessary to wean the baby completely. 
 Mothers often nurse their infants too long, hoping thereby to post- 
 pone conception. When the breast milk is too poor in quality Bulk- 
 ley believes in adding fat to the baby's nourishment in the form of 
 a few drops of cod-liver oil or a little cream, and he recommends 
 inunctions of almond, sweet, linseed, or cod-liver oil. Cod-liver oil 
 is cited by some authorities as causing eczema, but this refers to its 
 use in excess when the digestion is deranged and dyspepsia is aggra- 
 vated by it. Eczema is often cured by adding fat to the food. 
 
 The common mistake of nursing infants too often is particularly 
 apt to occur with eczematous babies, whose mothers mistake the 
 child's crying for a manifestation of hunger, whereas it is often ex- 
 cited by the extreme itching of the eruption, which the infant is too 
 young or too feeble to scratch. If fed oftener than once in two hours 
 or more, the infant's digestion becomes deranged, and any existing 
 eruption is made more unbearable. Bottle-fed infants are more 
 likely to have eczema than sucklings, probably because they oftener 
 have gastro-intestinal disorders. Underfed infants are less subject 
 to the disease than are the overfed. 
 
 ECZEMA IN CHILDREN 
 
 Eczema in young children is often due to dietetic errors, and in 
 all cases care should be exercised to cure it by regulation of the 
 food. The commonest fault in feeding young children consists in 
 giving them too much starchy food, which they cannot as yet digest, 
 and the innumerable prepared infant foods, consisting largely of 
 starches and sugars, are responsible for much of this trouble. Some 
 parents, aware of this fact, go to the other extreme, and give the 
 
620 DIET IN DISEASE 
 
 child too much animal food in the form of meat juice, broths, and 
 eggs. A diet improperly balanced in either direction induces an 
 anaemic condition with a special tendency to the development of 
 eczema. Older children should be denied candy, chocolate, and 
 indulgence in sweets of all sorts, and must be fed upon the simplest 
 diet, in which starch, and especially sugar, should be reduced, and 
 pure fat increased. The latter is to be prescribed in the form of 
 cream, fresh uncooked butter, fat beef, and cod-liver oil. Bulkley 
 recommends the use of whole-meal bread, cracked wheat, hominy, 
 and corn grits with salt and butter or cream. Oatmeal is prohibited ; 
 likewise tea and coffee. 
 
 EXFOLIATIVE DERMATITIS 
 
 Exfoliative dermatitis should be treated upon substantially the 
 same dietetic plan as eczema. An exclusive milk diet for a month 
 or six weeks may prove beneficial. Jackson advises chewing flax- 
 seed or taking, in milk, several ounces of flaxseed tea every day. 
 
 Rosacea 
 
 Causation. — Rosacea is a chronic skin affection disfiguring the 
 middle parts of the face, about the nose, mouth, cheeks, and some- 
 times the forehead, by red patches of dilated capillaries. . 
 
 It is regarded as a reflex neurosis of the local vasomotor nerves. 
 It is oftenest caused by erroneous diet, and especially by strong 
 drink, which dilates the facial arterioles and also excites gastric 
 catarrh. Jackson says : " The inordinate use of strong tea acts in 
 the same way, and probably gives rise to as many cases as does 
 alcohol." 
 
 Dietetic Treatment. — The dietetic treatment is very important. 
 It involves the prohibition of all alcoholic drinks, as well as hot 
 beverages of every kind, such as tea, coffee, and soup. Existing dys- 
 pepsia should be treated, and all rich food, desserts, sauces, pick- 
 les, strong condiments, dried, salted, or canned foods, fried sub- 
 stances, and sweets should be withheld. The patient must be kept 
 for several weeks or months upon a low, non-stimulating diet of 
 plainly cooked food, such as that advised for the treatment of eczema. 
 
 Psoriasis 
 
 Causation. — Psoriasis is a chronic skin disease characterised by 
 the appearance of isolated red patches of considerable size, covered 
 by shining white scales. The aetiology of this eruption is not under- 
 stood. It may be hereditary or follow nerve shock, but in many 
 cases it is directly attributable to imperfect assimilation of nourish- 
 ment, and accumulation of waste products in the system, such as 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 62 1 
 
 occur in gout and rheumatism. The excessive consumption of oat- 
 meal has been observed to cause it (Hardaway). 
 
 Dietetic Treatment. — This disease is less amenable to dietetic 
 treatment than are some other skin affections ; nevertheless, this 
 must not be neglected, as it may prove a valuable aid to local meas- 
 ures. The diet should always be restricted both in quantity and 
 variety. Obese and plethoric patients improve upon a purely vege- 
 table regimen. In bad cases it will be best to put them upon a 
 bread-and-milk diet for a week. Vegetable food may then be added, 
 but sweets and meats should be withheld. Feeble, anaemic patients 
 usually improve upon an animal diet, consisting largely of milk, 
 with eggs, beef, and mutton. Bread may be allowed. Elaborately 
 cooked and highly seasoned food must be forbidden, as well as all 
 forms of malt liquors. If any alcohol is required it should be pre- 
 scribed in the form of well-diluted whisky and taken only with 
 meals, but as a rule patients are better without it. 
 
 Pruritus 
 
 Patients suffering from pruritus should partake only of non-stim- 
 ulating food. They must particularly avoid tea, coffee, alcoholic 
 drinks of every variety, condiments, fish, pastry, cheese, sauces, 
 pickles, made dishes, and fried food. Tobacco should be tempo- 
 rarily withheld. 
 
 FURUNCULOSIS, OR BOILS 
 
 Furunculosis is often wrongly attributed to dietetic errors or high 
 living, but it is now known to be of germ origin due to the action of 
 the Staphylococcus pyogenes and other micro-organisms which pene- 
 trate the skin, through abrasions or otherwise, so that the supposed 
 influence of diet is only remote, in that poor living tends to lower 
 the general vitality and make the body more susceptible to any form 
 of inoculation. Special dietetic treatment becomes necessary only 
 in debilitated cases, such as complicate anaemia, diabetes, or conva- 
 lescence from protracted infectious diseases, and the rules for it will 
 be found under those headings. 
 
 DISEASES ESPECIALLY INFLUENCED BY DIET 
 
 Obesity (Polysarcia) 
 
 Causation. — Obesity is a diseased condition of the body, depend- 
 ing upon alteration in the proper balance of nutrition, with an accu- 
 mulation of fat in and between the tissues. 
 
 It may affect either sex, but is much more common among 
 women, in whom it is particularly noticed during and after the cli- 
 macteric. 
 
622 DIET IN DISEASE 
 
 It may develop at any age after early childhood. When appear- 
 ing early it is usually the immediate result of heredity. It is, how- 
 ever, most common after middle age, when the functional activity of 
 the body is diminished and when habits of systematic exercise are re- 
 placed by a sedentary life of luxury and ease, combined with over- 
 eating. 
 
 Aside from heredity, an important cause of obesity is excessive 
 eating, which is a fault among the majority of persons who have 
 passed middle life. When the growth of the body has been com- 
 pleted there is a stage of equilibrium in weight which lasts for sev- 
 eral years, and the waste matter of any excessive food taken is elimi- 
 nated through the emunctories, which are kept active by exercise 
 and work. After middle age, activity is considerably diminished, 
 while the habit of fully satisfying a vigorous appetite may be con- 
 tinued, resulting in the consumption of a larger amount of food than 
 is required for maintaining the vital functions. It is extremely diffi- 
 cult for people who feel in robust health and whose mental is pro- 
 portionately greater than their physical activity, to realise that they 
 not only require less food than they did ten, fifteen, or twenty years 
 earlier in life, but that eating as they do they may be producing posi- 
 tive harm by overloading the excretory organs. It is for this reason 
 that many persons accumulate weight after reaching a certain ad- 
 vanced period of life. 
 
 According to Sir Henry Thompson's view, overeating in the first 
 half or so of life may be relieved by occasional bilious attacks, which 
 enable the system to cast off accumulated waste, but later " the un- 
 employed material may be relegated in the form of fat to be stored 
 on the external surface of the body or be packed among the internal 
 organs, and thus he or she may become corpulent and heavy." 
 
 The constant use of alcoholic stimulation in its milder forms, such 
 as beer and ale, favours obesity, and in many individuals seems to 
 be a direct cause of it. There are other cases in which it is difficult 
 to attribute the accumulation of fat to any faults in either eating or 
 drinking. Very stout persons are occasionally extremely moderate 
 eaters, and in these cases the difficulty lies apparently in poor oxi- 
 dation and insufficient exercise. 
 
 The condition of obesity is somewhat modified by climate and 
 race. It is less common in the United States than it is among eld- 
 erly women in England and Germany. 
 
 Not infrequently obesity occurs in connection with pronounced 
 anaemia and hysteria. It prevents such patients from taking an ordi- 
 nary amount of exercise. This is owing to the increased weight 
 and difficulty of moving about, as well as to the lassitude and posi- 
 tive dislike for muscular exertion which is felt by them. Obesity 
 once established is likely to increase unless properly treated. 
 
 So long as the fat is simply stored up as adipose tissue, and be- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 623 
 
 tween and not within the cellular elements of the body, it is compara- 
 tively harmless, excepting as it indicates a disproportion between 
 functional activity and the amount of fuel taken in to develop force, 
 and excepting also as it may interfere with personal convenience in 
 movement and cause greater muscular fatigue from the increased 
 work thrown upon the muscles in supporting so heavy a body. In 
 other cases (and this may be the outcome of any advanced case of 
 polysarcia) the fat may invade the cellular elements of the body, 
 particularly the muscles, and fatty degeneration is produced in the 
 muscular tissues, which very seriously weakens and impairs their 
 functional activity. The special danger in all cases of this class is 
 that the heart muscle may become affected in this manner, which 
 renders it liable to cease beating whenever the slightest additional 
 strain is thrown upon the circulation. It follows that it is most de- 
 sirable in the dietetic treatment of obesity to determine the original 
 cause of fat accumulation, and to ascertain to what extent it is ac- 
 companied by fatty degeneration. 
 
 Bauer says : " The fat stored up in the body acts in like manner 
 with the fat contained in the food, since it likewise lessens the waste 
 of tissue and secondarily the oxidation. Thus we understand why 
 abstinence can be longer borne by organisms rich in fat than by 
 those poorly furnished with it, the former consuming less of the 
 albumin of their organs. The stock of fat stored up in the body is 
 moreover the cause why corpulent individuals frequently continue to 
 gain in bulk although they are not in the habit of indulging in food 
 immoderately. 
 
 " If an increase of albumin be desired without a considerable 
 addition to the store of fat, a liberal allowance of albumin with rela- 
 tively small quantities of carbohydrates must be provided. If, on 
 the other hand, a substantial addition to the fat appear desirable, the 
 food must contain less albumin and more carbohydrates, with a fair 
 proportion of fats." 
 
 Voit claims that albumin circulating in the blood is more readily 
 oxidised than either fats or carbohydrates, and that the fat existing 
 in the tissues acts like free circulating fat, not primarily by saving 
 proteids from oxidation, but by causing a larger proportion of them 
 to enter into the organised tissues, thus saving tissue waste. The 
 tissues use up the circulating albumin, and, not being exhausted 
 thereby, go on and oxidise the fat besides, and in this manner the 
 store of fat in the body is reduced on a meat diet. 
 
 An exclusive lean-meat diet increases the circulating albumin, 
 and, the nitrogenous waste being correspondingly increased, fat does 
 not accumulate in the body. If now fat be added to the diet, then 
 fat is deposited in the body. 
 
 The carbohydrates, like fat, can protect circulating albumin from 
 destruction and aid its transformation to organic albumin, but it is 
 
624 DIET IN DISEASE 
 
 not proved that they themselves make fat, as at first supposed, for 
 they are very completely destroyed even when eaten in excess. They 
 merely protect other foods from oxidation under such conditions. 
 
 Meat and carbohydrates alone increase the fat in the body with- 
 out the aid of fatty food, for fat, which originates from splitting up 
 albumin, is spared further metabolism. Hence fatty metabolism in 
 the body may be quite independent of fat indigestion. 
 
 Dietetic Treatment. — The question of the treatment of obesity, 
 owing to the frequency with which the physician has to deal with it, 
 is a matter of great importance, and demands special consideration. 
 The best results from treatment are obtained in patients less than 
 thirty years of age. For a long time it was believed that excessive 
 consumption of carbohydrates was the cause of increased fat produc- 
 tion within the body. The pig is fattened on corn, and cattle upon 
 various cereals. Undoubtedly, many persons who are of spare habit 
 can increase their weight by eating a larger proportion of starches 
 and sugars. It is a fact, moreover, that starches contain oxygen in 
 the exact proportion necessary for the formation of water and carbon 
 dioxide, and on being disintegrated in the body, they naturally pro- 
 duce these two forms of waste matter which are promptly elimi- 
 nated from the surface of the lungs and kidneys respectively. The 
 proteid material of the food requires a larger percentage of oxygen 
 for the metabolism involved in its complete conversion into urea. 
 
 It is an undoubted physiological fact that the fat of the body 
 may be made from a variety of different foods, and that some indi- 
 viduals are capable of producing it from a particular class of food 
 materials more readily than from others. Thus one person may 
 become fat from overindulgence in saccharine food and another from 
 eating purely starchy foods and taking large quantities of malt and 
 beer, and still another from the excessive use of quantities of fat 
 meat. Accordingly the rules which are formulated for the treat- 
 ment of obesity must be regarded as referring to the majority of 
 cases only, whereas there are many exceptions which must be indi- 
 vidually studied. 
 
 Many special dietetic systems are in vogue for the treatment of 
 obesity. In some cases if the total quantity of food is diminished 
 no special diet is necessary, but in many persons obesity is not due 
 to overeating, but to other causes. Some patients improve at once 
 when they give up all alcoholic beverages. An ounce of food eaten 
 daily in excess of that which is eliminated, and which is capable of 
 being stored in the tissues in the form of fat, very soon produces a 
 considerable increase in the body weight, which in a year's time 
 would amount to many pounds. 
 
 Among the different systems which have been advocated for the 
 cure of obesity the best known are those of Banting, Ebstein, and 
 Oertel. Schweninger's cure is practically OerteFs method by with- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 625 
 
 holding fluid from the meals, and giving all fluid at least two hours 
 after ingestion of food. Schleicher's system is also similar to 
 Oertel's. 
 
 The principal systems which have been especially devised for the 
 treatment of obesity will be separately discussed in detail. Nearly 
 all of these systems agree in two principles : First, to reduce the 
 total quantity of food ingested as much as possible without impair- 
 ing the strength of the patient. Secondly, to diminish the amount 
 of fluid drunk by prescribing what is called a dry diet. The treat- 
 ment, moreover, is usually accompanied by systematic exercise or 
 bathing, and it is highly important to keep the bowels active. 
 
 Some persons attempt to cure obesity by allowing the patient to 
 eat any food he chooses, but insisting that he shall eat only one kind 
 of food at any one meal. As a natural result, the appetite soon palls, 
 and he eats less than he otherwise would. This is an unscientific 
 method, and an unwholesome one for serious cases. 
 
 As a general principle, corpulent persons should restrain them- 
 selves to as great an extent as possible from drinking fluids, espe- 
 cially with meals. Exceptions to this rule occur when obesity com- 
 plicates certain other diseases, such as gout or rheumatism, where 
 the use of an increased quantity of fluid may temporarily be neces- 
 sary in order to act vigorously upon the kidneys. 
 
 Hot-water beverages taken half an hour before meals, and again 
 at night and on rising in the morning, are beneficial, and less fluid is 
 required with the meals. 
 
 As a rule, never more than five ounces of fluid should be taken 
 with a meal, or fifteen ounces per diem, and this amount may be still 
 further curtailed by giving water between meals instead. 
 
 Soups of all kinds should be forbidden as well as alcoholic bev- 
 erages, and what little fluid is allowed should consist of plain or 
 aerated water. But little, if any, milk should be taken. The food 
 should be as dry as possible without interfering with its flavour and 
 nutrient value. Highly succulent fruits, such as watermelons, and 
 vegetables like raw tomatoes, which consist largely of water, should 
 not be eaten. Sugar should be absolutely forbidden, and fat must 
 be used very sparingly, and only in the form of a little butter. The 
 allowance of farinaceous food must also be cut down as much as pos- 
 sible. It will not usually be found practicable to do without bread 
 for any length of time, but patients are often willing to restrict them- 
 selves to a very rigid diet for two or three weeks if the positive hope 
 of cure or amelioration of symptoms can be held out to them, if they 
 are made to understand the rationale of the treatment, and if they 
 are given some objective point to anticipate when a promised im- 
 provement will admit of greater laxity in regard to diet. If desirable, 
 gluten bread may be substituted for wheaten bread. 
 
 The deprivation of starchy foods can always be better and 
 
626 DIET IN DISEASE 
 
 longer tolerated if a little fat is given, and the obese do not well en- 
 dure deprivation of all fats, even when starchy food is supplied in 
 moderation. 
 
 This is more often true of those engaged in mental work than of 
 those employed in- muscular exercise. Salts and fresh green vege- 
 tables — " vegetables which grow above the ground," except the 
 legumes — should not be withheld. 
 
 Lean meat should form the basis of all diet, but an unrestricted 
 flesh diet in obesity may give rise to dyspepsia and gastric and intes- 
 tinal catarrh. 
 
 THE BANTING SYSTEM 
 
 The diet which Mr. Banting practised upon himself and others 
 with considerable success, and which bears his name, was exceeding- 
 ly rigid in regard to restricting the quantity of food and in forbid- 
 ding starches and sugars to the greatest degree possible. The pa- 
 tients were starved to the extent of being allowed only between 
 twenty-one and twenty-seven ounces of dry food in the twenty-four 
 hours, about one half of which was meat. Only two ounces of bread 
 could be taken, and the balance of the diet was composed of fresh 
 fruits and the lighter forms of green vegetables. The fluid drunk in 
 each twenty-four hours was reduced to thirty-five ounces. It should 
 be remembered that the normal quantity of urine passed by an adult 
 is, on the average, fifty-two ounces in addition to the water lost by 
 perspiration and respiration. His dietary, which was based on the 
 suggestions of his physician. Dr. W. Harvey, has been found too 
 severe in many cases, and is apt to enfeeble the digestion, especially 
 when patients are too quickly restricted in their food ; it is not pre- 
 scribed in this country, excepting in modified forms. The fats and 
 albuminoids are not well balanced in this diet, and it may cause con- 
 stipation and malnutrition. 
 
 Mr. Banting began his treatment upon himself in 1862, and in a 
 single year lost forty-six pounds in weight. Sudden restriction in 
 diet in obesity may sometimes precipitate attacks of renal or hepatic 
 colic from the presence of calculi. Their deposition is brought about 
 by altering the composition of the blood, and while practising any 
 dietetic system for obesity one should be certain that the elimina- 
 tion of waste matter from the system is not impaired, as it is if water 
 is too suddenly withheld. On this account largely, the stricter diets 
 for corpulency, such as the Banting system, sometimes result in fail- 
 ure by producing a condition of the system which is far worse than 
 the original corpulency. 
 
 THE EBSTEIN SYSTEM 
 
 The Ebstein treatment, as originally employed in Germany, has 
 been attended with considerable success. The theory of this system 
 is that animal as well as carbohydrate food is capable of being con- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 
 
 627 
 
 Comparison of Dietaries for Corpulence with Ordinary Dietaries (Atwater) 
 
 Dietaries. 
 
 Banting system j 
 
 Ebstein system i 
 
 Playfair's standard for "subsistence! 
 
 diet" I 
 
 Playfair's standard for adults withj 
 
 moderate exercise 
 
 Voit's standard for labouring man at 
 
 moderate work 
 
 Atkinson's standard for man withj 
 
 light exercise 
 
 Atkinson's standard for labouring man 
 
 at moderate work 
 
 Poor sewing girl, London ; diet barely 
 
 sufficient for subsistence 
 
 University professor, Germany; very 
 
 little exercise J 
 
 Well-to-do family, Connecticut ; foodj 
 
 actually eaten 
 
 Mechanics and factory operatives, 
 
 Massachusetts ; food purchased. . . . 
 Food actually eaten by college students: 
 
 From Northern United States 
 
 From Eastern United States 
 
 
 NUTRIENTS. 
 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Total. 
 
 Lr?'tZ7?l71ieS. 
 
 171 
 
 102 
 
 Grammes. 
 
 8 
 85 
 
 Gramines. 
 
 75 
 47 
 
 Gra7ni7ies. 
 254 
 234 
 
 57 
 
 14 
 
 34i 
 
 412 
 
 119 
 
 5i 
 
 53i 
 
 70I 
 
 118 
 
 56 
 
 500 
 
 674 
 
 100 
 
 IOO 
 
 360 
 
 560 
 
 125 
 
 125 
 
 45o 
 
 700 
 
 53 
 
 33 
 
 316 
 
 402 
 
 IOO 
 
 IOO 
 
 240 
 
 440 
 
 128 
 
 177 
 
 466 
 
 77i 
 
 127 
 
 186 
 
 53i 
 
 844 
 
 138 
 
 104 
 
 184 
 136 
 
 622 
 
 421 
 
 944 
 
 661 
 
 Potential 
 energy in 
 
 Calories. 
 1,085 
 1,400 
 
 I,76o 
 
 3.I40 
 
 3,050 
 
 2,8l5 
 
 3,520 
 
 1,820 
 
 2,325 
 
 4,080 
 
 4,430 
 
 4,825 
 3,415 
 
 verted into fat, especially when used in combination with starches 
 and sugars. The latter are believed to furnish force for the body, 
 and by their combustion to spare the complete oxidation of albu- 
 minates, which are therefore stored in the tissues in a suboxidised 
 form. It is a part of this theory that fatty food does not give rise 
 to or promote the storage of fat in the body, and hence it may be al- 
 lowed in the dietary ; in fact, Ebstein recommends its use on account 
 of its effect in producing satiety. By sooner diminishing the ap- 
 petite, there is less craving for other food and drink. In accordance 
 with this belief, he proscribes the use of sugar, potatoes, and all 
 forms of farinaceous food with the exception of three ounces and a 
 half of bread, which is allowed each day. He permits the use of fats, 
 such as fat meat, cream, butter, and fatty soups. Among vegetables 
 he allows asparagus, spinach, cabbage, peas, and beans. A moderate 
 amount of meat of any kind is also included. The quantity of fluids 
 allowed is restricted. Ebstein allows the patient to take three meals 
 a day. 
 
 Breakfast consists of a cup of black tea without sugar or milk 
 and two ounces of buttered toast. 
 
 Dinner, which is given at noon, comprises a meat soup or broth, 
 four to six ounces of boiled or roasted fat beef with meat gravy, not 
 thickened, one or two fresh vegetables, in moderation, and for des- 
 
628 DIET IN DISEASE 
 
 sert salads and fresh or dried fruits. He allows a little light wine 
 and black tea without milk or sugar. 
 
 Supper includes tea as before, a soft-cooked egg and a moderate 
 allowance of fish, ham, or cold fat meat, an ounce of thin buttered 
 bread or toast, and fresh fruit. , 
 
 THE OERTEL SYSTEM 
 
 A more recent system for the dietetic treatment of obesity is that 
 practised by Oertel and modified by Schweninger. The distinctive 
 feature of the Oertel treatment is the attention which is paid to im- 
 proving the condition of the circulation by strengthening the heart 
 action, and this, he claims, so much improves the general condition of 
 the patient that the fat once eliminated is not reformed. According 
 to his theory, corpulent patients may be subdivided into two different 
 classes, whose diet is regulated accordingly. They are : 
 
 " (a) Cases of fat accumulation in which the respiratory and cir- 
 culatory apparatus have undergone no special derangement, and the 
 patient is capable of muscular effort and locomotion. A much more 
 serious form is that in which the condition of fatty heart is present, 
 with consequent enfeeblement of circulation and visceral engorge- 
 ment. 
 
 " (b) Cases in which, in consequence of advanced stasis and 
 hydraemia (with deficiency of haemoglobin), the amount of oxygen 
 taken up from the lungs is extremely reduced, and the slightest 
 muscular efforts are enough to disturb the respiration and provoke 
 dyspnoea. " 
 
 For the first class his maximum allowance of fat is fifty grammes 
 and of carbohydrates two hundred grammes, with a minimum of one 
 hundred and fifty grammes of albumin. For the second class the 
 maximum allowance of fat is twenty-five to thirty grammes, with one 
 hundred grammes of carbohydrates, but the albumin must consider- 
 ably exceed one hundred and fifty grammes. In this class especially 
 the amount of fluids drunk must be curtailed. By withholding fluid, 
 Oertel argues, blood pressure is reduced, venous stasis is lessened, 
 the vessels of the body will adapt themselves to the reduced quan- 
 tity of fluid, and to supply the glandular organs and muscles with 
 their normal proportion fluid will be " drained away from places 
 where the tissue changes are less energetic, and which are less 
 favourably innervated. Such vessels are, above all, in the fatty tis- 
 sues — vessels branching in the panniculus adiposus." 
 
 Nutritive changes ensue in the fatty tissues, the fat is disinte- 
 grated, conveyed away, and burned up. 
 
 This is certainly an ingenious, and withal very plausible theory 
 which has many facts of clinical observation to recommend it. 
 
 Besides holding the view that the fluid in the body must be re- 
 duced before the accumulated fat can be diminished, Oertel says r 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 
 
 629 
 
 " Since the force required to raise the body through a great height 
 entails the destruction of large quantities of fat, the above exertion 
 [mountain climbing] will also lessen the fat accumulation, on condi- 
 tion only that we give less fat and carbohydrates in the food than are 
 used up in the work done." 
 
 He gives some fat and carbohydrate food, but not very much, 
 with proteids, for he believes that, anaemia being present, an exclu- 
 sive meat diet would not be completely oxidised. It is better, there- 
 fore, to restrict all three classes of foods, but not to entirely exclude 
 either, and the proteids must decidedly preponderate. 
 
 He also believes that anaemia has weakened the vascular tone 
 through supplying a blood deficient in circulating albumin, and 
 hence a diet rich in proteids is further indicated. 
 
 The Oertel system includes almost twice the quantity of animal 
 food allowed in the Ebstein diet, and double the quantity of carbo- 
 hydrates and less than half the quantity of fats. It is distinguished 
 from the Banting system also by the greater preponderance of fats 
 and starches. The following table from Yeo contrasts these differ- 
 ent systems of diet. For comparison, the diet of Voit is added, 
 which gives the proportion of the three chief varieties of foods upon 
 which a man in health will decrease in weight. The figures repre- 
 sent grammes : 
 
 Daily 
 
 Diet 
 
 
 
 
 Albuminates. 
 
 Fats. 
 
 Carbohydrates. 
 
 
 130 
 140 
 170 
 IOO 
 
 155-179 
 
 84 
 44 
 10 
 
 85 
 25-40 
 
 404 
 165 
 
 80 
 
 Voit, " " 
 
 Banting, " " 
 
 Ebstein, " " 
 
 50 
 70-IIO 
 
 Oertel, " " 
 
 
 It will be observed that in all these diets the starches and sugars 
 chiefly are proportionately much reduced, and the more liberal 
 dietary of Oertel is particularly suitable for those classes of cases in 
 which exercise can be joined with dietetic treatment. The combined 
 effect of the diet with exercise results in the absorption and oxida- 
 tion of the fat deposited between the muscular tissues and in the 
 renewal of more vigorous action of the muscle fibres, which are 
 shielded from waste by the liberal proportion of proteid food which 
 is admitted. The whole treatment is aimed especially at increasing 
 the vigour and force of the heart action, and in many cases it suc- 
 ceeds admirably. In the more serious type of obesity the deposition 
 of fat around the base of the heart as well as between and within 
 the heart muscle fibres enfeebles the strength of the cardiac systole 
 and results in engorgement of the venous circulation. The heart is 
 unable to propel the blood through the arteries and capillaries, and 
 
630 DIET IN DISEASE 
 
 there is very little vis a tergo remaining for the blood in the veins. 
 Lack of exercise also retards the venous circulation. As a result, 
 there is a constant venous congestion which is particularly notice- 
 able in the viscera, and there may be dropsical accumulations in the 
 different serous cavities or general anasarca. 
 
 Exercise. — In the treatment of such cases Oertel withholds 
 fluid from the diet as much as possible, and to assist the elimination 
 of water from the body the patient is made to exercise by climbing 
 carefully graded paths, which are measured and adapted with refer- 
 ence to use by patients of different strength. During muscular exer- 
 tion the destruction of non-nitrogenous food stuffs is increased. 
 
 Palpitation and dyspnoea, which are so frequent accompaniments 
 of excessive obesity, are not especially dreaded, and exercise is 
 pushed until these symptoms occur — that is, the patients are made to 
 climb the graduated ascents, walking slowly and systematically and 
 covering a prescribed distance each day. As soon as they experi- 
 ence palpitation, or if shortness of breath appears, they are to stop 
 and rest standing until the breath is regained. In this way it is 
 believed by Oertel that the heart action is actually strengthened, 
 and the fat is certainly reduced. Of course, due care must be ob- 
 served to prevent exhaustion, and the patients must be warned 
 against any sudden movement or overexertion which might occasion 
 fatal heart strain. This exercise by climbing ascents is sometimes 
 called the " terrain cure." 
 
 In case the patient is unable to take any exercise at all, the ob- 
 ject is attained by massage and friction, and the promotion of per- 
 spiration is secured by baths of different sorts. In the treatment of 
 such cases, among the solid ingredients of the food, the fats and 
 starches are still further reduced. 
 
 Anaemia is believed to be counteracted by the use of albuminous 
 food, and the following articles are allowed when this is a prominent 
 symptom : Lean roast and boiled beef and veal, mutton, game, and 
 eggs. Vegetables, spinach, and cabbage may be eaten. From four 
 to six ounces of bread per diem are given, and fats and starches are 
 restricted as much as possible, and sugars are withheld altogether. 
 The fluid prescribed consists of a moderate cup (about six ounces) 
 of coffee or tea or milk twice a day, with twelve ounces of wine with 
 an equal quantity of water, which may be taken at dinner. If pa- 
 tients perspire very freely, a somewhat larger quantity may be given, 
 and no other beverages of any kind are permitted. 
 
 The fluid allowed should not all be taken with the meals, but 
 may be drunk at intervals between the times of eating to allay thirst. 
 In the less serious type of cases, where the heart action is unim- 
 paired, Oertel allows the fluid to be gradually increased, and he 
 gives four to six ounces of wine at noon time, with a half bottle in 
 the evening. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 63 1 
 
 Bathing should be carried out systematically, and the patient 
 may be packed with cloths dipped in hot water in order to promote 
 perspiration. The baths are given at least twice a week through a 
 period of a month or more. 
 
 A typical menu under the Oertel treatment is the following: 
 
 OertcVs Diet for Obesity 
 
 Morning. — One cup of coffee or tea, with a little milk — altogether 
 about six ounces ; bread, about three ounces. 
 
 Noon. — Three to four ounces of soup, seven to eight ounces of 
 roast or boiled beef, veal, game, or not too fat poultry, salad or a 
 light vegetable, a little fish (cooked without fat), if desired, one 
 ounce of bread or farinaceous pudding (never more than three 
 ounces), three to six ounces of fruit, fresh preferred, for dessert. It 
 is desirable at this meal to avoid taking fluids, but in hot weather or 
 in the absence of fruit, six to eight ounces of light wine may be 
 taken. 
 
 Afternoon. — The same amount of coffee or tea as in the morning, 
 with at most six ounces of water, and an ounce of bread as an ex- 
 ceptional indulgence. 
 
 Evening. — One or two soft-boiled eggs, an ounce of bread, per- 
 haps a small slice of cheese ; salad and fruit, six to eight ounces of 
 wine with four or five ounces of water. 
 
 After patients have undergone a special course of treatment for 
 obesity and their weight has been sufficiently reduced, it is desirable 
 to establish a diet for them which will prevent a return of the fat. 
 For this purpose Oertel recommends the following regimen ; it is 
 intended for patients in whom obesity has complicated organic dis- 
 ease of the heart or lungs : 
 
 "Morning. — One cup of coffee or tea with some milk = 150 
 grammes (6 ounces), and bread = 75 grammes (2 \ ounces). 
 
 " Midday. — Soup =100 grammes (3 J ounces) ; lean meat, roast- 
 ed or boiled, game or fowl = 200 grammes (7 ounces) ; fish, not too 
 fat = 25 grammes (nearly 1 ounce) ; bread or starch stuffs =100 
 grammes at most (3J ounces) ; as dessert 100 to 200 grammes (3^ to 
 7 ounces) of fruit, fresh preferred — a smaller quantity if preserved, 
 especially by Nagelis's method. Liquids are better avoided. At 
 dinner time, only in very hot weather or in the absence of fruit, 
 perhaps -§- to J litre of light wine may be allowed (6 to 9 ounces). 
 
 " Afternoon. — The same quantity of coffee or tea as before, with 
 at most -J litre of water (6 ounces) ; occasionally 25 grammes of 
 bread (nearly 1 ounce). 
 
 "Evening. — One or two soft-boiled eggs; meat, 150 grammes 
 (nearly 5 ounces) ; bread, 25 grammes (nearly 1 ounce) ; a bit of 
 cheese, a little salad and fruit. As a regular drink, £ to \ litre of 
 wine (6 to 9 ounces), with perhaps J litre of water (4J ounces)." 
 42 
 
632 DIET IN DISEASE 
 
 Water should never be allowed in quantity, and what little is 
 drunk should be distributed through the day. 
 
 THE SCHWENINGER SYSTEM 
 
 Schweninger's system is essentially that of Oertel, but the former 
 absolutely forbids the use of drink of any kind with meals, and the 
 little fluid that is permitted must be taken fully two hours afterwards. 
 
 His treatment is substantially as follows : Moderate exercise for 
 an hour before breakfast, after a cold bath with friction. 
 
 Breakfast, 8 a. m. — Meat, eggs, or milk. A walk. 
 
 Second Breakfast, 10.30 a. m. — Meat or fish and a glass of white 
 wine. A walk. 
 
 Dinner, 1 p. m. — Meat, vegetables, and fruit compote. 
 
 Supper, 7 p. m. — Meat and fruit compote or salad, a glass of 
 white wine. 
 
 No other fluid is given with meals. Bread is eaten very spar- 
 ingly. 
 
 Schleicher's Diet for Obesity 
 
 Breakfast, 7 a. m. — A mutton or veal cutlet or a portion of sole 
 as big as the palm of the hand ; the same quantity of bread without 
 butter. 8 a. m. — A cup of tea with sugar. 10.30 a. m. — A sand- 
 wich of bread and meat or sausage. 
 
 Noon. — Meat, eggs, green vegetables, cheese, an orange. Two 
 glasses of white wine. (No soup, no potatoes.) 4 p. m. — Tea, with 
 sugar. 7 p. m. — A small quantity of bread and cheese. 9 p. m. — 
 Cold meat, eggs, salad. Two glasses of wine, and sometimes more. 
 
 This is practically the diet of Schweninger, but without the abso- 
 lute prohibition of drink at meals. 
 
 THE GERMAIN SEE SYSTEM 
 
 Germain See, who holds some original theories in regard to die- 
 tetics, declares that the use of abundant drink is distinctly indicated in 
 the treatment of obesity. He allows a diet of proteids and fats, with- 
 holding sugars and starches, and requires his patients to drink hot 
 weak tea and water in large amount. He prohibits alcohol in every 
 form, excepting a little dilute wine, which may be allowed in excep- 
 tional cases. His treatment is no doubt more serviceable in those 
 cases of corpulency which complicate gout and rheumatism and in 
 which, as above mentioned, it is desirable to eliminate the waste 
 matter from the system as completely as possible. 
 
 THE WEIR MITCHELL SYSTEM 
 
 Weir Mitchell, for the treatment of obesity, relies mainly on rest 
 and passive exercise in the form of massage and Swedish move- 
 ments with a skimmed-milk diet, which latter may be given at in- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 633 
 
 creasing rate, gradually replacing the accustomed food, until in a 
 week's time the patient is living wholly upon milk. Upon this diet, 
 the patient may lose half a pound or more in weight per diem. 
 Careful watch is kept of the strength. The patient should be fre- 
 quently examined with special reference to loss of weight and to 
 any unfavourable increase in the heart action or feebleness of the 
 pulse. If the latter conditions arise, it may be necessary to increase 
 the diet or to give stimulation. A small quantity of beef, chicken, 
 or oyster soup is allowed in such cases to relieve the monotony of an 
 exclusive milk diet. The patient is kept quiet in bed for ten days 
 or a fortnight, and afterwards permitted to move about the room, 
 but must spend most of his time upon a lounge. Massage is per- 
 formed once or twice a day at first, and subsequently the more 
 active Swedish movements are applied to the extremities. After 
 from four to six weeks of this treatment the weight is usually 
 reduced by a number of pounds, and the general condition and 
 strength are found to have improved. The diet is gradually in- 
 creased by the addition of lean meats, beef, mutton, poultry, shell- 
 fish, and boiled fish. For a long time, however, milk plays an 
 important role, four or five glasses being taken daily. 
 
 Weir Mitchell argues that so sudden a loss of weight as occurs 
 in his treatment would be serious were the patient walking about, 
 but when resting quietly in bed the danger of sudden exhaustion 
 of the heart action is reduced to a minimum. His patients bear 
 the treatment fairly well, and are frequently much pleased with the 
 pronounced improvement in appearance and condition which they 
 recognise. The treatment is not adapted to persons leading active 
 lives who are unable to relinquish their business or other duties, 
 for it requires a considerable length of time and the entire abandon- 
 ment of all labour. 
 
 THE YEO SYSTEM 
 
 The diet recommended by Yeo is as follows : All fats and animal 
 food are to be strictly limited, and farinaceous and starchy foods 
 should be reduced to a minimum. Sugar must be entirely prohibited, 
 but a moderate quantity of fat is allowed to secure the proper dilu- 
 tion and digestion of the food. Hot water and hot aromatic drinks 
 may be taken freely in the intervals between meals, especially in 
 gouty cases. He allows the patient to drink a little hock and still 
 Moselle, or light claret with alkaline table water. Beer, porter, and 
 sweets of all kinds are to be prohibited, and no spirits should be 
 drunk unless for some special need as a tonic. Meat is not to be 
 eaten more than once a day, and not more than six ounces should be 
 taken at any one time. The meat which Yeo allows is lean beef, 
 mutton, lamb, poultry, game, and sometimes fish and eggs. Two 
 lightly cooked or poached eggs may be taken once a day, or a little 
 grilled fish. He allows thoroughly toasted bread in thin slices and 
 
634 DIET IN DISEASE 
 
 crackers. Soups in general and milk, unless skimmed, milk pud- 
 dings, farinaceous puddings, pastry, salmon, and mackerel must all 
 be avoided. Fresh vegetables and fruits are allowed. He believes 
 it is useless to attempt to give rules in regard to the actual quantity 
 of dry food permitted, because it must necessarily vary in accord- 
 ance with the weight and strength of the patient in each case. A 
 quantity of food which might constitute an excess for one person 
 would perhaps be insufficient to support the strength and activity 
 of another. 
 
 Later a full diet of meat may be allowed, but sugars and starches 
 must still be excluded to as great an extent as possible. The patient 
 may be taught to supplement passive exercise by calisthenics. 
 
 THE DUJARDIN-BEAUMETZ SYSTEM 
 
 Dujardin-Beaumetz believes that the diets allowed by Oertel and 
 Ebstein are too restricted to support the body in a condition of nor- 
 mal nutrition and activity, and his system of treatment is as follows : 
 For the milder cases in which fatty degeneration has not yet invaded 
 the heart and other viscera he gives half a pint of water or light wine 
 diluted with Vichy, or some alkaline effervescent water, with each of 
 the three meals of the day. Soup of all kinds is forbidden, wine or 
 tea being recommended instead. If the gastric juice is apparently 
 deficient, or if there is much dyspepsia, no fluid is allowed with the 
 meals, but the patient is ordered to take a pint of weak tea without 
 sugar or milk two hours after the completion of each meal. No 
 other beverages are permitted excepting a small cup of black coffee 
 with breakfast. Soup is also forbidden, and so is pastry. He allows 
 dry bread in moderation, such as the outer part of Vienna rolls, or 
 " soup sticks," which are chiefly crust, and he recommends animal 
 food of all classes and several varieties of fresh vegetables and juicy 
 fruits, such as oranges. For breakfast he gives three quarters of an 
 ounce of dry bread, one and a half ounce of meat, and a cup of weak 
 tea or a glass or two of light wine. Lunch is served at noon, and 
 consists of double the quantity of bread and meat permitted at break- 
 fast, with three ounces of fresh vegetables, salad, a small piece of 
 cheese, and fruit. Eggs may be substituted for the meat, or fish 
 may be given at either breakfast or luncheon. The quantity of the 
 several foods allowed may be varied slightly. 
 
 THE MEAT AND HOT-WATER TREATMENT 
 
 This method is a treatment for obesity and chronic gastric 
 catarrh, which consists in the restriction of the diet exclusively for 
 several weeks to large quantities of rare beefsteak, and salt codfish 
 and hot water for the first fortnight, three pounds of rump steak, one 
 pound of codfish, with six and one third pints of hot water, are subse- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 635 
 
 quently given for two or three weeks. The water is gradually re- 
 duced to four pints, and lean beef and fresh fish may be eaten 
 with dry toast or zwieback, and a very little green vegetable food. 
 After five or six weeks the hot water is still further reduced to a quart 
 a day, and dry crackers and dry toast and stale bread crusts, poultry, 
 and game are added to the diet, and the patient may be allowed to 
 drink hock diluted with carbonic or Seltzer water. The hot water, if 
 desired, may be flavoured with fresh lemon juice, and five or ten 
 grains of bicarbonate of soda are given twice a day. This treatment 
 is found impracticable by many persons, who rebel against the ex- 
 treme monotony of it, and are unable to eat so large an amount of 
 meat either with or without other food ; it is principally adapted to 
 persons who are habituated to overeating, and is not to be recom- 
 mended for the majority of cases. 
 
 THE BOUCHARD SYSTEM 
 
 According to Bouchard's method, the frequent observation of the 
 urine should form the basis of the treatment of obesity. When the 
 nitrogenous waste is increased in the urine he reduces the allowance 
 of animal food ; but he also believes, in opposition to many other 
 theories of treatment of obesity, that the total quantity of farina- 
 ceous and fatty food allowed should be five times greater than the 
 quantity of animal food, and asserts that giving vegetable acids with 
 the carbohydrates favours the oxidation of the latter. He therefore 
 prescribes such fruits and fresh vegetables as are rich in the potas- 
 sium salts of the organic acids. He forbids the use of vinegar and 
 other acids, which he claims diminish the alkalinity of the blood 
 and thereby increase the formation of fat. 
 
 The patient's exercise is also governed by the elimination of urea 
 and phosphates. When these salts are present in excess, he argues 
 that the oxidation of the tissues is being unduly stimulated ; but if 
 they are not present in too large quantity, exercise before meals is 
 recommended. A review of the principles involved in this theory 
 does not strengthen the belief in their value. 
 
 The oxidation processes in the body are still too obscure to en- 
 able one to take the urine as an absolute criterion of the conditions 
 of metabolism, especially in those cases where a large reduction in 
 the body weight is being obtained by the consumption of previously 
 stored-up material. It is true that superfluous fat, when fully oxi- 
 dised, leaves the body in the form of carbonic acid and water from 
 the lungs, and in the form of water and carbonates in the urine ; 
 but it is not definitely known to what extent this combustion spares 
 the proteid materials of the body from disintegration and allows the 
 animal food products to pass directly into the urine as urea or other 
 nitrogenous waste matter. While the urine should be carefully stud- 
 ied in these cases, a much better guide for the treatment of obesity 
 
636 DIET IN DISEASE 
 
 is found in the observation of other symptoms and in the disappear- 
 ance of previously existing abnormal conditions. 
 
 THE CHAMBERS SYSTEM 
 
 " Day's Regimen for a Three Weeks' Course. — Rise at 7. Rub the 
 body well with horsehair gloves, have a cold bath, take a short turn 
 in the open air. Breakfast at 8 or 8.30, on the lean of beef or mut- 
 ton, cutting off the fat and skin, with dry toast, biscuit, or oatcake, 
 a tumbler of claret and water or tea without milk or sugar, or 
 made in the Russian way with a slice of lemon. Luncheon at 1 
 on bread or biscuit, Dutch cheese, salad, water cresses, or roasted 
 apples (without sugar or cream), hung beef, or anchovies, or red 
 herring or olives, and such like relishes. Drink, after eating, claret 
 and water, unsweetened lemonade, or plain water, in moderation. 
 Dinner at any convenient hour. Take no soup, fish, or pastry, but 
 plain meat of any kind except pork, rejecting the fat and skin. Spin- 
 ach, French beans, or any other green vegetable may be taken, 
 but no potatoes, made dishes, or pastry. A jelly or a lemon water 
 ice, or a roast apple must suffice for sweets and dessert. Claret and 
 water at dinner, and one glass of sherry or Madeira afterwards. 
 
 " Between meals exercise, as a rule, in the open air, to the ex- 
 tent of inducing perspiration, must be taken. Running, when prac- 
 ticable, is the best form in which to take it." 
 
 Chambers also advised giving liquor potassae with the proteid 
 diet, or the remedy of Dancel, consisting of one half or a teaspoon- 
 ful of sodium bicarbonate added to five or ten grains of tartaric acid 
 in a small tumblerful of water, and drunk while effervescing. He re- 
 stricted sleep to seven hours a day, for it is weakening for the obese 
 to remain too long in bed in a close room. Turkish baths were also 
 recommended. Chambers's further directions to be observed by the 
 patient to prevent a possible return to corpulency were as follows : 
 Continue to avoid fat meats, rich milk, butter, malt liquors, sweet 
 wines, starches, especially pastry and puddings, and sweet vegeta- 
 bles, such as parsnips and beets. 
 
 The patient may have lean beef or mutton, venison, game, poul- 
 try, boiled fish, poor new cheese, green vegetables and fresh fruits, 
 oranges, lemons, almonds, roast apples, salads, olives, buttermilk, 
 claret, hock. Bread should be aerated or toasted. Captain's bis- 
 cuits may be eaten. Among the green vegetables which may be 
 eaten are tomatoes, celery, stuffed red and green peppers, radishes, 
 asparagus, artichokes, oyster plant, squash, and spinach. 
 
 Of the various systems above described, that of Oertel is, on the 
 whole, the best adapted for the greater number of cases. The Eb- 
 stein treatment diminishes the appetite and is useful for robust 
 patients, but if there is enfeebled digestion and weakness, this diet 
 is not to be recommended on account of the large proportion of fat 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 637 
 
 and the relatively small amount of proteid foods. Schweninger's 
 system has the disadvantage that although the withholding of all 
 fluid at mealtime lessens the capability of taking solid food in ex- 
 cess, there are many persons in whom the gastric juice is deficient in 
 quantity, and its proper action can only be secured by dilution with 
 a moderate amount of fluid during gastric digestion. The Banting 
 method, besides being too rigorous for many, has the disadvantage 
 of allowing no fat to be eaten. 
 
 The essential value of all methods of dietetic treatment of obesity 
 is based upon two objects to be attained : First, to enable the pa- 
 tient to fully oxidise and eliminate the fat which is already accumu- 
 lated in various parts of the body, and, secondly, to make it impos- 
 sible for it to be reformed. 
 
 From what has been said of the cause and nature of obesity, it 
 follows that no one system of treatment is applicable in every in- 
 stance. The effect of any treatment should be observed from day 
 to day, care being taken that the patient while losing flesh does not 
 at the same time lose in strength to a degree which may become 
 dangerous — i. e., more than two or three pounds per week. Fre- 
 quent examinations should be made of the heart action, the circula- 
 tion, and the urine. 
 
 The favourite baths in Europe for the treatment of obesity are 
 Carlsbad and Marienbad, but there are many others. 
 
 The thyroid-gland extract has a remarkable effect in reducing 
 obesity in some cases, even without accessory treatment. The cat- 
 abolism of the process is not understood, but the C0 2 elimination is 
 increased, and in addition to increased consumption of fat tissues 
 there is increased nitrogenous waste. The effect is not permanent, 
 and the lost weight is soon regained if the patient fails to persist in 
 dietetic treatment with exercise. The powdered gland is given in 
 tablet form, in doses not exceeding five grains three times a day. 
 It is best not to give more than five grains at first in twenty- 
 four hours, for the remedy sometimes produces serious cardiac 
 weakness and digestive disturbance. I have usually found that 
 after a reduction in weight of about thirty pounds the use of the 
 extract had to be discontinued. 
 
 "ANTI-FAT" REMEDIES 
 
 A host of quack nostrums are offered to a credulous public un- 
 der the claim that they reduce corpulency. Some of them have 
 achieved reputation because while they are taken the patient is also 
 induced to regulate his diet ; others merely because they have de- 
 stroyed the appetite or digestion and have made it impossible to eat 
 too much food. But the whole lot of " reduction pills," concentrated 
 salts and purges, extracts of phytolacca berries, Fucus vesiculosus, 
 and other so-called " specifics " for reduction of obesity, cannot be 
 
638 DIET IN DISEASE 
 
 too strongly condemned as thoroughly unscientific, if not positively 
 harmful or dangerous, as many of them are. 
 
 It cannot be expected that any chemical remedy can control the 
 complex processes involved, and the substances which are in exten- 
 sive use by credulous persons for this purpose diminish the appetite, 
 impair the digestion, and seriously interfere with nutrition. 
 
 Excepting the thyroid extract there is no drug or remedy known 
 which acts specifically either in retarding fat formation or in causing 
 its destruction in the body, and when any such remedy appears to 
 have that effect, it is acting indirectly by a general lowering of 
 vitality. 
 
 Diet for Leanness 
 
 The foods which tend to produce fat in the body are chiefly 
 sugars and starches. Eating fat in excess does not necessarily cause 
 fat to accumulate in the system, for it may be completely oxidised. 
 
 To increase the albuminous constituents of the body without the 
 accession of fat, a diet should be ordered in which proteid food pre- 
 dominates, with a moderate allowance of carbohydrates. To in- 
 crease the body fat, however, the proportion of carbohydrate should 
 considerably exceed the proteid food and a little fat should be added. 
 
 In seeking to remedy excessive leanness by dietetic treatment it 
 is obviously necessary to first ascertain, if possible, its cause. It 
 may be due to the use of improper food, to erroneous habits of eat- 
 ing, bad cooking, maldigestion or malassimilation, overwork and 
 nervous exhaustion, disease of the various organs connected espe- 
 cially with nutrition, and besides these and other causes there are 
 those in whom leanness seems to be constitutional or hereditary. 
 They may enjoy excellent health, but are always so thin as to be the 
 subject of comment. No diet seems to have much effect in increas- 
 ing their weight. Another class of persons are those whose weight 
 is constantly fluctuating and whose annual variation is as much as ten 
 or even twenty pounds. In winter, in town life, when overworked, 
 worried, or oppressed with mental strain, they lose weight rapidly, 
 and in summer, in a brief holiday in the country, with little to do 
 but eat and sleep, they gain at the rate of two or three pounds a 
 week. This is true more often of those whose general tendency is 
 towards obesity rather than towards leanness. 
 
 It is almost hopeless to attempt to remedy obstinate leanness by 
 diet unless other favouring conditions can be secured. First among 
 these is entire freedom from mental strain, and of almost equal im- 
 portance is abundant and regular sleep. A warm climate and inac- 
 tive life favour increase in weight. In most respects the diet for 
 leanness must be the reverse of that for obesity, as would be natu- 
 rally expected, and in prescribing starchy foods it must be remem- 
 bered that the leanness is often caused solely by an entire inabilitv 
 to digest amylaceous or saccharine material owing to " nervous dys- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 639 
 
 pepsia," gastric catarrh, etc. These conditions should receive careful 
 treatment on the lines recommended on pp. 526 and 528. By a 
 little care it will often be found possible to find some forms of 
 starches which can be digested. It is a good rule in such cases to 
 give the cereals or vegetables at one meal and meat at another, so 
 that articles involving different rates and organs of digestion do not 
 interfere with each other. All bread should be stale or toasted. 
 Crackers and zwieback may be allowed. As a rule such patients can 
 be made to digest starches before they can sugars — oatmeal will be 
 better digested without sugar, and a cup of sweetened coffee with a 
 meal of starchy foods may produce flatulency which lasts for hours. 
 
 When the digestive organs admit, the following articles may be 
 prescribed in the diet for leanness : 
 
 Abundant fat meats, butter, cream, milk, cocoa, and chocolate. 
 Bread, potatoes, legumes, well-cooked cereals, especially oatmeal 
 and cornmeal, farinaceous puddings with sugar and cream, cake, 
 sweets, sirup, honey, sweet wines, port, porter, stout, ales, and beer. 
 Malt preparations of all sorts are also useful. Sweet fruits may be 
 eaten. 
 
 To be avoided are pickles, acids, condiments, much bulk of green 
 vegetables, and strong liquors. 
 
 Diet in Acute Rheumatism 
 
 Causation. — It has not been proved that any special articles of 
 diet lead to the development of rheumatism, although indulgence 
 in sweets, starchy foods, and malt liquors is sometimes held respon- 
 sible for it. Poor living seems to favour the attacks, but the prevail- 
 ing opinion at present is that acute articular rheumatism is an infec- 
 tious disease, due to a micro-organism. 
 
 Dietetic Treatment. — While the fever lasts and other symptoms 
 are acute, such as pain and swelling of the joints, the patient should 
 be put upon a fluid diet. The majority of cases do best at this time 
 with an exclusive milk or bread-and-milk diet. Those patients who 
 cannot take milk, however, may be allowed soups and broths fla- 
 voured with vegetable extracts, chicken tea, milk toast, barley or oat- 
 meal gruel, clam broth. 
 
 Thirst is often a prominent symptom, especially if there be much 
 fever, and it is advisable for the patient to drink fluid freely to assist 
 in washing out the waste products from the body. Lemonade and 
 slightly acid drinks of various kinds, such as dilute phosphoric acid 
 or the effervescent mineral waters, are recommended. Boiled milk 
 and Seltzer or Vichy may be drunk, or oatmeal or barley water 
 flavoured with lemon. Alcohol should be avoided while the acute 
 symptoms last, unless the complication of inflammation of the endo- 
 cardium or pericardium enfeebles the heart action to such a degree 
 as to make stimulation necessary. If convalescence is prolonged 
 
64O DIET IN DISEASE 
 
 and anaemia is considerable, alcohol may be given as a tonic two or 
 three times a day in the form of a glass of claret or Burgundy (one 
 to two ounces), or diluted whisky. 
 
 During convalescence the appetite is not usually vigorous, and it 
 is not necessary to urge the taking of much food at first. The diet 
 should be principally farinaceous, but not saccharine. 
 
 Such articles may be given as rice (plain or spiced), arrowroot, 
 oatmeal, cornmeal, semolina, wheaten grits, panada, milk toast, sim- 
 ple unsweetened puddings, wine jelly, blancmange, and malted foods. 
 
 The return to solid diet should be gradual, and for a long time 
 the patient should abstain from eating meats as well as from pastry 
 and sweets. Fagge states that no meat or fish should be allowed for 
 at least a week after subsidence of the fever and acute symptoms, 
 or, better, for a fortnight, and many believe that beef tea is harmful. 
 Meat can undoubtedly induce a relapse. 
 
 When convalescence becomes established, eggs, fish, oysters, and 
 the white meat of broiled or roasted chicken may be given, and one 
 or two such vegetables as asparagus, spinach, or stewed celery, with 
 a baked apple or fresh fruit, but sweets and alcohol should long be 
 withheld. 
 
 The patient should be fed often, having one or two extra lunches 
 during the day, for anaemia is apt to prevail for some time, and 
 abundant nutriment is required. 
 
 Diet in Chronic Rheumatism 
 
 In the dietetic treatment of chronic rheumatism, especially if the 
 patient is anaemic, animal food cannot be excluded, but the basis of 
 the diet should be farinaceous food with a few fresh green vegeta- 
 bles. Fish, eggs, and fowl may be eaten, but dark meat is not de- 
 sirable. Sweets and alcoholic beverages should be omitted from the 
 menu, and all foods should be plainly cooked and eaten in moderation. 
 
 Arthritis Deformans 
 
 Causation. — Arthritis deformans is a chronic disease in which the 
 joints of the body, and particularly those of the extremities, are 
 affected. The alterations in joint structures are produced mainly 
 by impoverished nutrition, and the disease is especially one of ad- 
 vanced life, occurring in persons in whom various evidences of senil- 
 ity have begun to appear. The structural changes in the joints in- 
 volve proliferation of the cellular elements of the cartilages, with 
 thickening and erosion and with the production of osteophytes. In 
 mild cases there is not much impairment of general health. In 
 severer cases the patient is confined to the house and, on account of 
 pain or immobility of the joints, is unable to take ordinary exercise. 
 Digestion and nutrition suffer considerably in consequence. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 641 
 
 Dietetic Treatment. — Since the disease is one of debility and im- 
 poverished nutrition, it follows that a low diet is harmful and a nour- 
 ishing diet, with increased frequency of meals, is desirable. James 
 Stewart says : " The practice of limiting the amount of nitrogenous 
 food is not to be commended. Provided there is no general or local 
 contraindication, the patient should be directed to take as much 
 nitrogenous food as can be digested with facility." And Garrod 
 wrote : " I consider it of the utmost importance throughout the 
 whole course of the disease to support the system and to allow the 
 patient as nourishing a diet as he is capable of properly digesting." 
 Good roast beef, beefsteak, mutton, fowl, fish, eggs, and milk may 
 be eaten. 
 
 Alcoholic beverages taken with meals in proper moderation are 
 beneficial for their strengthening and tonic effect, and bitter tonics 
 may be combined with them to advantage. The objection which 
 exists to the use of alcohol in gout and acute rheumatism does not 
 apply with such force in this disease. Malt liquors may be given, 
 such as ale or stout, and it is often desirable to prescribe a good 
 Burgundy, port, or sherry. If it is well borne by the stomach, cod- 
 liver oil should be given in teaspoonful doses, an hour after meals, 
 three times a day. It is an excellent food in this disease, and its use 
 should be long continued. Other forms of fat may be used, such as 
 butter, cream, or bone marrow, olive oil, etc. 
 
 When acute exacerbations occur the quantity of food and stimu- 
 lants should be reduced, but otherwise it is important that the diet 
 should always be ample. 
 
 Patients do well to try the effect of a course of treatment at the 
 hot springs of Virginia, Arkansas, Mount Clemens, Michigan, or 
 Banff. 
 
 Gout 
 
 Gout is a constitutional disease which has local manifestations 
 appearing from time to time in the joints, especially the metacarpo- 
 phalangeal articulation of the great toe, but it must be remembered 
 that the gouty diathesis is a condition which once acquired may exist 
 for years, producing many other and more serious symptoms or 
 structural changes in the body than the local inflammation of one or 
 more joints. 
 
 Causation. — Gout has been defined as a condition dependent 
 upon disturbed retrograde metamorphosis of the nitrogenous in- 
 gredients of the food — a high-sounding phrase, which, it must be 
 confessed, carries with it very little genuine explanation of the nu- 
 tritive processes involved. Whatever may be the theories in regard 
 to the production of an attack of acute gout, it is universally ad- 
 mitted that careful regulation of the diet is the most important 
 factor in its treatment. Gout and the various conditions allied to it 
 are dependent upon retention in the blood or other fluids of the 
 
642 DIET IN DISEASE 
 
 body of forms of waste matter which normally should be oxidised 
 and completely converted into the soluble materials which are ex- 
 creted in the urine. For some reason the oxidation of waste matter 
 is suspended, and, as a result, a variety of intermediate products of 
 imperfect solubility may be deposited in the joints or tissues of the 
 body. The active manifestations of gout are due to an accumulation 
 of insoluble urates in the joints. In conditions which are closely 
 allied to gout, such as the uric-acid diathesis, there is a deposition 
 of crystals of uric acid in some portion of the urinary tract or, in 
 other conditions, deposits of insoluble cholesterin are formed from 
 the bile and accumulate as gallstones in the gall bladder. 
 
 The direct relation existing between uric acid and gout has been 
 most exhaustively investigated by Garrod, and this relation may be 
 briefly summarised as follows : First, the gouty diathesis is associ- 
 ated with a more or less constant excess of uric acid in the blood ; 
 secondly, the quantity of uric acid normally present in the urine is 
 diminished by at least one half during a severe attack of gout, and 
 increases beyond the normal as soon as the acute symptoms subside. 
 An acute attack of gout is therefore preceded by accumulation of 
 uric acid in the blood, which is a substance that in itself represents 
 incomplete combustion of nitrogenous waste material in the body. 
 The retention of this form of waste in considerable quantity proves 
 markedly irritating to the nervous and other organs of the body. 
 
 Sir Dyce Duckworth writes : " We perhaps come nearer a com- 
 plete understanding of this matter if we regard as present in the 
 gouty a peculiar incapacity for normal elaboration within the whole 
 body, not merely in the liver or in one or two organs, of food, 
 whereby uric acid is formed at times in excess, or is incapable of 
 being duly transformed into more soluble and less noxious prod- 
 ucts," and he agrees with Ralfe that the failure to complete the met- 
 abolism of uric acid is dependent primarily upon disturbed inner- 
 vation. 
 
 In referring to the habit of overeating Sir Henry Thompson says 
 that in early life it may cause occasional attacks of biliousness, but 
 after the first half of life has been spent the remaining half may be 
 affected in a different way, and " recurring attacks of gout perform 
 the same duty, or nearly so, at this period of life that bilious attacks 
 accomplished in youth." 
 
 On the other hand, in persons who are subject to attacks of gout 
 starvation may bring it on (Senator), and " poor man's gout " is by 
 no means a disease induced by plenty. 
 
 Sugar eaten in excess is not of itself a direct cause of gout, but 
 sweets combined with certain other foods, such as special fruits 
 and wines, will precipitate an attack in a gouty subject with certainty. 
 According to the view of Sir Dyce Duckworth, it is the combina- 
 tion of sugar with vegetable acids which is injurious. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 643 
 
 Sugar, under some conditions of fermentation in the stomach 
 and intestines, forms lactic acid, which is capable of splitting so as 
 to produce carbon dioxide, which, according to Ralfe, forms acid 
 salts of sodium and potassium from their neutral compounds. 
 
 Lack of exercise is often assigned as a cause for gout, and with 
 many persons it is true that outbreaks of gout may be intensified in 
 this way ; but it is not uncommon for the disease to affect men who 
 lead lives of considerable activity or who practise athletics, but who 
 at the same time consume large quantities of nitrogenous food. By 
 free perspiration the amount of fluid present in the blood is reduced 
 and the solids become both relatively and absolutely increased, 
 making it difficult or impossible for them all to become thoroughly 
 oxidised. 
 
 Symptoms. — The most distinctive symptoms of gout are the 
 local joint manifestations of pain, swelling, redness, and tenderness. 
 These symptoms usually occur together in an acute attack, but either 
 one may occasionally be absent. Other symptoms may appear from 
 time to time, such as disorders of the mucous membranes, especially 
 of the stomach and bowels ; a tendency to catarrhal affections of 
 the mucous membranes of the respiratory passages ; chronic end- 
 arteritis ; alterations in the composition of the urine ; and various 
 forms of irritation of the nervous system and the skin. 
 
 Children who inherit the gouty diathesis are very apt to present 
 some one or more of this group of symptoms, especially neuralgic 
 pains, digestive disturbances, and skin diseases, which appear at an 
 early age and long before the gout is fully developed with typical 
 localised joint symptoms. The symptoms connected with this diath- 
 esis are believed to arise from obscure alterations in the composi- 
 tion of the blood which are more or less remediable by dietetic treat- 
 ment. 
 
 Preventive Treatment. — The prophylactic treatment of gout in 
 those who inherit a constitutional predisposition to the disease is 
 very important. From birth onward the children of gouty parents 
 should be abstemious, have the diet carefully balanced so that neither 
 animal nor vegetable food predominates in great excess. As the 
 child grows older, confectionery and sweets in general should be 
 avoided, especially with other food or at the conclusion of meals, as 
 well as alcohol in every form. In youth all varieties of beer, ale, 
 cider, etc., are particularly injurious. Tea and coffee, if allowed at 
 all, should be taken in moderation, and some persons can often pre- 
 cipitate a violent attack of gout by a single glass of champagne or 
 sweet wine. 
 
 If they are accustomed to the use of alcoholic beverages and it is 
 impossible for them to go without them, those which are least injuri- 
 ous are a dry white wine or old Bordeaux, but all wines containing 
 sugar must be absolutely prohibited. 
 
644 DIET IN disease 
 
 Cyr says : " If a glass of beer, spirits, or wine is habitually fol- 
 lowed by pain in a joint or nerve it is gouty." 
 
 Theory of Dietetic Treatment. — An important question in re- 
 gard to the theory of gout is still under discussion — namely, whether 
 the increased quantity of uric acid is to be attributed to overproduc- 
 tion or merely to faulty elimination. It is conceivable that the fluids 
 of the body, by becoming less alkaline than normal, may fail to re- 
 tain the salts of uric acid in solution, and are consequently precipi- 
 tated in the joints and elsewhere. The matter is of vital importance 
 in the selection of the proper diet for gouty patients. If the disease 
 is caused merely by imperfect oxidation of nitrogenous food, the 
 indication is clearly to diminish the quantity of such food ingested 
 and to promote oxidation by exercise and fresh air. If, on the other 
 hand, oxidation processes are fairly normal, but the blood is in a 
 morbid state in which it becomes less alkaline than normal and loses 
 its solvent power upon the nitrogenous waste matters, it is possible 
 that other causes may be responsible for the condition produced. 
 Albumins contain both sulphur and phosphorus which are destined 
 to leave the body in the form of salts of sulphuric and phosphoric 
 acids respectively. If these acids fail to be wholly neutralised while 
 yet in the blood they will lessen its alkalinity, and in this way over- 
 indulgence in albuminous food by furnishing an excess of sulphur 
 and phosphorus may diminish the alkalinity of the blood and produce 
 uricsemia. This explains why the use of alkaline waters is so gener- 
 ally beneficial in gout and lithaemia. Such fluids assist in regulating 
 the normal alkaline reaction of the blood. This is the line of argu- 
 ment which has been advanced by many physiological chemists, and 
 it applies in equal force to the method of formation of renal calculi 
 and gravel. The acidity of the urine is increased by a meat diet and 
 reduced by a vegetable diet. With the latter it may even become 
 strongly alkaline. Whether we adopt the theory of deficient oxida- 
 tion or of diminished alkalinity of the blood, the indications for die- 
 tetic treatment of gout are the same — namely, reduction of proteid 
 food and increase of vegetable food. It does not follow that albu- 
 minates must be entirely given up in all cases of gout, but they 
 should be so restricted that the normal balance of the metabolism of 
 the blood shall be restored. It will be found necessary for those 
 who live luxurious and idle or sedentary lives to give up nitrogenous 
 food absolutely while those who are accustomed to take active mus- 
 cular exercise may be allowed animal food in very moderate quanti- 
 ties once a day. 
 
 Dietetic Treatment. — Although no one food is invariably inju- 
 rious at all times, it is almost universally agreed that for the gouty, 
 fat and nitrogenous food should be greatly restricted and saccharine 
 food should be entirely prohibited. 
 
 It may be established as a general rule that the diet of the gouty 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 645 
 
 should consist principally of easily digested fresh green vegetables 
 and sometimes certain fruits, in addition to which a moderate quan- 
 tity of lean meat (beef, lamb, and mutton) may be eaten to prevent 
 the necessity of taking an excessively bulky diet, which in order to 
 furnish sufficient nitrogen for the needs of the body would unduly 
 tax the digestive system. Fruit is less apt to disagree if taken by 
 itself, not with sugar or other food. Luff, of London, believes 
 that the mineral salts of such vegetables as spinach, turnip-tops, 
 Brussels sprouts, string beans, cabbage, and celery act chemically 
 in preventing formation of gouty deposit in the tissues by increas- 
 ing the solubility of sodium biurate and retarding the conversion 
 of quadriurates into biurates. 
 
 It is a serious mistake to prescribe any treatment for the gouty 
 which tends to lower the general vitality of the system too much. 
 The diet, therefore, must be so adjusted as to secure the right pro- 
 portion of the different classes of foods. Atonic cases require a gen- 
 erous diet with more proteids. 
 
 Gout is often combined with excessive corpulency, and when this 
 is the case no chronic disease, with the exception, perhaps, of dia- 
 betes, requires more strict regulation of the diet and hygiene of the 
 patient. While it is undesirable to allow animal food in large quan- 
 tities in gout, it is also true that vegetables are fattening, and if the 
 diet is too restricted in both these classes of foods the obese patient 
 suffers from lack of nutrition, and digestion becomes still further im- 
 paired in consequence. 
 
 The theory has been held that but little fat should be eaten by 
 the gouty, for it fixes oxygen which would otherwise complete the 
 oxidation of albuminates, and hence it favours accumulation of pro- 
 teid waste products. On the other hand, it has been show T n that the 
 accumulation of uric acid is not due to lessened oxidation, but that 
 it is increased by proteid metabolism, and its elimination by the kid- 
 neys is actually promoted by fats. Clinically, however, it is found 
 best to control the use both of albumins and fats. 
 
 Sugars and gelatinous material, like fats, all tend to retard the 
 complete combustion of proteid food, and the latter therefore remains 
 in an imperfectly oxidised condition which may give rise to uricse- 
 mia. The combination of the latter classes of foods, therefore, is 
 particularly injurious in gout. On the other hand, Ebstein favours 
 the use of fat in moderation, on the ground that it appeases the 
 appetite and makes the consumption of a large quantity of carbo- 
 hydrates unnecessary. If fat is allowed at all in the diet, it is best 
 to give it in very small amount ; otherwise it interferes with the 
 local digestion in the stomach and tends to aggravate the dys- 
 pepsia which is so common in gouty subjects. It will be better 
 borne in those cases which are not complicated by a tendency to 
 obesity. 
 
646 DIET IN DISEASE 
 
 In the dietetic management of gout in robust subjects it is of 
 quite as much importance to reduce the quantity of food consumed 
 as to restrict the variety. 
 
 Robust gouty patients must be made to restrain a too vigorous 
 appetite, and especially the eating of all sorts of foods between 
 meals, for, as Balfour says (The Senile Heart), " there is nothing 
 so destructive of gastric comfort as the continual pecking induced 
 by gouty bulimia." 
 
 They should never be allowed to eat to complete satiety at meals, 
 and all rich sauces, pastry, and strong condiments and fried food 
 should be avoided. The majority of gouty patients have been in the 
 habit for a long time of eating too much meat, and some of them 
 of partaking too freely of carbohydrates. Overeating is almost as 
 bad for patients as drinking too much. " Gout is evidence of an 
 overfed, overworked, and consequently clogged machine " (Osier). 
 As Bence Jones says : " It is best to allow a minimum of albuminous 
 food to produce the least amount of uric acid and a minimum of car- 
 bohydrates, in order to give the uric acid formed opportunity to be 
 oxidised as much as possible.'' 
 
 When an acute exacerbation of gout occurs it is necessary to 
 curtail all variety in diet, and put the patient upon light farinaceous 
 food with abundant diluents, alkaline waters, weak tea. Gruels of 
 sago, arrowroot, or barley may be given, with bread or toast. When 
 the fever subsides and the acute symptoms abate, bouillon, clam 
 juice, simple broths made of lean mutton or chicken with rice, may 
 be allowed. Later, a little whitefish or breast of chicken. Meat 
 should be given only when absolutely necessary for nourish- 
 ment, for, as Garrod says of it, " everything beyond what is 
 absolutely required for the nourishment of the body only feeds the 
 disease." 
 
 Sir Dyce Duckworth's treatment of the acute disease is briefly as 
 follows : He recommends such substances as rice, bread, arrowroot, 
 sago, tapioca pudding, and semolina. He allows milk, weak tea, and 
 infusion of cocoa nibs. Later, chicken broth may be given, fol- 
 lowed by fish and a mealy roasted potato. No meat should be given 
 until all acute symptoms are over, and then it should be allowed 
 but once a day. Elderly persons may have a little dilute whisky or 
 brandy, not to exceed two ounces per diem. He also favours the use 
 of hot water, as in the treatment of dyspepsia, but discountenances 
 the eating of fruits, especially with sugars. 
 
 When the acute attack subsides and chronic gout supervenes 
 Garrod replaces the farinaceous diet gradually by fruit, fish, fowl, 
 and finally by meat, but any dishes containing free acids or sweets 
 are liable to cause a relapse. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 647 
 
 DIET FOR THE GOUTY DIATHESIS AND CHRONIC GOUT 
 
 In the following dietary a liberal variety of foods will be found, 
 some of which may be selected and changed from time to time ac- 
 cording to need in the intervals between the exacerbations or in 
 chronic gout. Should an acute attack occur at any time in the 
 course of the disease, the diet must be at once restricted, as described 
 above. The number of dishes allowed at any one meal should be 
 few. In dealing with any case of chronic gout for the first time it 
 is injudicious to make radical changes in the diet too suddenly. 
 
 Soups. — Soup should be free from all fat, and it is better made 
 of vegetables than meat, and purees of potatoes, celery, etc., may be 
 recommended. If the taste of meat is desired, as suggested by 
 Yeo, it is best imparted to the soup by one of the meat extracts 
 which contain simply the highly flavoured extractive matter without 
 contributing to the bulk of proteid food. A teaspoonful or two of 
 Valentine's meat juice or Liebig's extract of meat in a half pint of 
 vegetable soup accomplishes this result. 
 
 Milk. — Alilk wholly disagrees with some gouty persons, but in 
 those who digest it well, if it be not too rich in fat or if it is taken 
 skimmed or diluted, it forms an excellent food. Many are, however, 
 opposed to its use in any form^ even when rendered alkaline by the 
 admixture of alkaline waters or a few grains of bicarbonate of so- 
 dium. Yeo gives a small salt-spoonful each of potassium bicarbonate 
 and common salt in a breakfast-cupful of hot milk and water. Oth- 
 ers give it with warm w r ater. The attempt has been made to place 
 gouty patients upon an exclusive milk diet. This sometimes, but not 
 often, aids those who are robust and young, but it is injurious to 
 older patients. 
 
 Cheese, being a concentrated, proteid food, should not be eaten. 
 
 Eggs. — Garrod allows eggs and bacon for breakfast, and Ralfe 
 recommends an occasional " savoury omelet." Eggs cooked with 
 milk and custard puddings (unsweetened except with saccharin) 
 may sometimes prove harmless, but Senator is opposed to them on 
 account of the fat and lecithin which they contain. 
 
 Shellfish and Crustaceans. — The soft part of oysters and clams 
 may be eaten, but crabs, lobsters, and shrimps may not be allowed, 
 least of all in salads. 
 
 Fish. — Some writers maintain that fish should constitute the 
 chief nitrogenous food, while others prescribe it very moderately, if 
 at all. 
 
 Broiled or boiled fish, such as bluefish, whitefish, bass, shad, are 
 permissible occasionally for variety, but fish having firm flesh and 
 those which contain considerable fat are not good. Salmon, mack- 
 erel, halibut, codfish, should therefore be avoided, although Garrod 
 43 
 
648 DIET IN DISEASE 
 
 allows salmon served with salt and Cayenne, but without sauce. 
 Rich sauces must not be eaten with fish or salads. In lieu of them, 
 a simple dressing of an infusion of aromatic herbs and pepper, or a 
 plain bread sauce, may be employed. 
 
 Smoked and pickled fish are forbidden. Fish roe, such as shad 
 roe and caviare, is admissible. 
 
 Meats. — Meat cannot be prohibited entirely for months at a time 
 in chronic gout, especially for a middle-aged man, although the 
 young may thrive better without it. It should be only eaten once a 
 day in any case, and roasting or broiling is the best form of cooking 
 it. Twice-cooked meats should not be eaten. Beef, lamb, and poul- 
 try may be allowed sparingly. Generally speaking, white meat is 
 better than dark meat. Veal, pork, fat bacon and ham, game, and 
 dried, smoked, pickled, or salted meats must all be forbidden. Only 
 one kind of meat should be eaten at a meal. 
 
 Fats. — Fats should be used sparingly, and all food fried or cooked 
 in grease must be forbidden. Fat meats and fat fish are to be 
 avoided. A little well-cooked bacon may occasionally be eaten, and 
 butter may be taken only in moderation. The objection to the use 
 of fats and oils is that, unless the general nutrition is very poor, they 
 interfere in gouty subjects with complete oxidation of proteid 
 elements. 
 
 Farinaceous Food. — Farinaceous food is allowable, and in the 
 acute stage of gout it should constitute the main diet. Bread (not 
 fresh), rice, sago, tapioca, oatmeal, cracked wheat, may all be eaten. 
 Pastry, cake, hot rolls, hominy, griddle cakes, preserves, and confec- 
 tionery of all kinds are forbidden. 
 
 Sugar. — Sugar has not proved to be always harmful to the gouty, 
 but eaten with a mixed diet, especially with fruits or drunk with 
 wines, it undergoes fermentation processes which are at once dis- 
 tinctly harmful. It is generally admitted that carbohydrates eaten 
 in excess with other food are more injurious than fats in excess. 
 
 Sweets, jams, and jellies of all kinds are forbidden. When sugar 
 positively disagrees, a little glycerin or, better, saccharin or diabetin 
 (levulose) may be substituted for it. 
 
 Vegetables. — Of vegetables, although a great variety are eaten, 
 there are a few which are prohibited on account of the fact that they 
 contain oxalic acid, which is closely allied to uric acid, and which 
 produces oxaluria. These are sorrel, radishes, asparagus, rhubarb, 
 tomatoes, and spinach. The two latter are allowed by some au- 
 thorities, however. Beets are forbidden. Vegetables, such as cab- 
 bage, onions, old peas, beans, and corn, if they occasion flatulence, 
 must be eschewed. The following may be eaten : French peas 
 (petit pois) and young French beans, string beans, celery, young 
 tender green corn, carrots (very moderately), turnips, parsnips, well- 
 baked and mealy potatoes (except sweet potatoes) sparingly, cu- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 649 
 
 cumbers, broccoli, beet tops, cauliflower, celery plant, eggplant, 
 okra, artichokes. Salads, provided they are not dressed with much 
 oil, are allowable. Vegetables which act injuriously on account of 
 their acids are made still more harmful by being cooked with sugar. 
 
 Fruits. — Some writers allow fruits of almost every kind, both 
 raw and cooked, but Sir Dyce Duckworth and many authorities de- 
 clare that fruits in general are harmful. Sir Andrew Clarke forbade 
 their use in toto. If they produce no dyspepsia, and are ripe and 
 fresh, a few fruits may be eaten, such as stewed pears, or apples 
 stewed, baked, or roasted ; but all those fruits which contain large 
 quantities of sugar, such as grapes, figs, bananas, prunes, etc., must 
 be forbidden, as also acid fruits, especially strawberries. No fruits 
 cooked with sugar can be allowed. Melons are forbidden. Garrod 
 expressly forbids all stone-bearing fruits, and says that subacid 
 fruits furnish alkaline salts that split up in the blood and reappear 
 in the urine, chiefly as potassium carbonate, and stimulate the kid- 
 neys. Melons are usually the least hurtful of fruits. 
 
 Fothergill wrote : " The potash in the strawberry renders its juice 
 a desirable drink for the gouty and for strumous children," but there 
 are many patients who cannot eat a half dozen strawberries without 
 an exacerbation of inflammation in a gouty joint. 
 
 If any fruit is eaten it should not be in connection with other 
 food or with sugar. Hence all candied fruits are proscribed. Nuts 
 are forbidden. 
 
 Pickles, vinegar, spices, strong condiments, salted foods, mush- 
 rooms, and truffles must all be forbidden. 
 
 Eating between meals and at irregular intervals is injurious. 
 Fresh air and exercise are often more needed than extra luncheons 
 of bouillon, broths, wines, etc. 
 
 Ralfe gives the following menu for breakfast and lunch : 
 
 Breakfast. — A poached egg, bacon, or fresh fish, tea (coffee and 
 cocoa disagree) without milk or sugar. 
 
 Light Lunch. — A clear soup, vermicelli or julienne, sandwiches, 
 cold meat with salad. 
 
 Dinner is to be eaten not too late, and fully three hours before 
 retiring. 
 
 Cantani's treatment of gout is based on the belief that all sub- 
 stances should be withheld from the diet which retard the oxidation 
 of nitrogenous food or lessen alkalinity of the blood. He there- 
 fore prohibits all fatty, farinaceous and saccharine food, including 
 bread and potatoes, sweet fruits, etc., but allows fish, eggs, broth, 
 and fresh green vegetables to be eaten. Especially to be avoided 
 are milk, cheese, all acid foods, pickles, sweets, pungent condiments, 
 bread, rice, potatoes, all farinaceous foods, and coffee. 
 
 Sir Dyce Duckworth gives the following excellent menu for 
 goutiness or chronic gout in Allbutt's System of Medicine : 
 
650 DIET IN DISEASE 
 
 " Six or eight ounces of hot or cold water may be taken half an 
 hour before breakfast. Breakfast should consist of one or two 
 ounces of well-toasted stale bread without butter, grilled whitefish, 
 grilled mutton chop or beefsteak, or cold chicken, game, beef, 
 tongue, or lean ham. One or two small cups of tea or coffee, with a 
 little skimmed milk and without sugar may be taken. Saccharin 
 may be used as a sweet flavouring agent, but is commonly disliked. 
 Six ounces of bouillon or clear soup may be taken by weakly pa- 
 tients between breakfast and luncheon, and a gluten or almond bis- 
 cuit with it. For luncheon order cold meat or a poached tgg with 
 spinach or lettuce, or other green vegetable, as watercress and mus- 
 tard and cress, or a small omelet. Crust of bread or hard biscuit 
 in small amount is allowable and a small quantity of fresh butter. A 
 glass of good Bordeaux or Moselle wine (dry) may be taken with as 
 much water. A cup of tea with a little skimmed milk and a rusk or 
 gluten biscuit may be taken in the afternoon. For dinner no soup 
 is to be taken, as a rule, but occasionally about eight ounces of a 
 thin consomme may be allowed, then a little grilled or boiled fish, 
 without starchy or fatty sauces, but flavoured sometimes with an- 
 chovy or some other sauce, oysters, or caviare, a little grilled or 
 roasted meat, mutton, game, or fowl, with a small proportion of fat, 
 green vegetables, no potatoes, and some stewed fruit flavoured 
 with saccharin or made less tart by the addition of half a teaspoon- 
 ful of Rochelle salt. Two glasses of claret or of a dry Moselle di- 
 luted with water are allowable. Later in the evening a cup of hot 
 weak tea, without milk, or as much hot water should be taken." 
 
 BEVERAGES 
 
 Water. — It has been already stated that to favour the washing 
 of waste matter from the system it is desirable to drink considerable 
 quantities of fluid, and gouty people who are corpulent usually per- 
 spire with freedom; their urine therefore becomes concentrated, 
 and there is a tendency to the precipitation of uric acid, urates, and 
 oxalate of lime. It must be observed that the presence of uric acid 
 in the urine does not always indicate an excess of that acid, and it 
 may happen that the urine is too concentrated or otherwise altered 
 to hold it in solution, and hence precipitation results. An excess of 
 acid phosphate may combine with the sodium and potassium which 
 are necessary to hold the uric acid in solution in the form of urates, 
 and it is deposited in insoluble crystals. Copious draughts of hot 
 water at bedtime or taken on rising in the morning are often pre- 
 scribed, but it is doubtful whether the temperature of the water 
 makes any difference in the desired result so long as plenty of fluic 
 is taken. 
 
 Fluid should be drunk half an hour before meals, when the stom- 
 ach is empty. Besides serving to cleanse the mucous membrane oi 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 65 1 
 
 the alimentary canal, the diuretic action of water will be greater when 
 absorbed at such times. 
 
 Sir Dyce Duckworth holds somewhat different views in regard to 
 water drinking, although he does not make clear his reasons for so 
 doing. He says : " I feel sure that Sydenham was right in condemn- 
 ing water drinking for the gouty. ' Water alone is bad and danger- 
 ous, as I know from personal experience. When taken as the regu- 
 lar drink from youth upward it is beneficial/ ,: He prefers to allow 
 a moderate quantity of wine — from four to six ounces of good sound 
 Bordeaux, and adds : " The least excess is harmful, but a little good 
 wine is better for most gouty persons than water drinking, espe- 
 cially after middle life." This, of course, was written for English- 
 men in the upper classes, whose ordinary consumption of wine is 
 greater than that of Americans in the same social position. Much 
 depends upon one's previous habits of life, and in this country ex- 
 amples of gout may not rarely be found among patients who have 
 never been in the habit of drinking alcoholic beverages daily, and 
 such persons do best to abstain from them entirely. 
 
 Tea, Coffee, etc. — Tea and coffee are admissible among bever- 
 ages for the gouty, and it will be found that they are less likely to 
 cause dyspepsia if taken quite weak without sugar. A quarter of a 
 grain of saccharin may be added instead. Senator forbids tea and 
 coffee, and prescribes " acorn coffee." Infusion of cocoa nibs is less 
 to be recommended on account of the excessive fat which it holds. 
 Esbach states that he has found oxalic acid in it also, amounting 
 sometimes to 0.4 per cent. Chocolate is forbidden. 
 
 Patients who are still able to lead active outdoor lives may 
 drink more alcohol than those of sedentary habits, without aggravat- 
 ing their symptoms. In general the quantity consumed is as im- 
 portant as the quality, and it should be definitely prescribed and 
 kept within bounds. 
 
 Alcoholic Drinks. — With regard to the use of alcoholic bever- 
 ages it is their acid and saccharine ingredients rather than the alcohol 
 itself which disagree. Strong liquors, diluted, may not be injurious, 
 but nothing is worse than rich sweet wines and malt liquors. 
 
 It is, however, true that alcohol in all forms lessens the elimina- 
 tion of tissue waste, and decreases the volume of urea and uric acid 
 excreted. According to Pfeiffer, both beer and wine may lessen this 
 volume by one half ; on the following day it is increased, and subse- 
 quently diminished again. The longer wines have been fermented, 
 or the more complete the conversion of the sugar to alcohol, the 
 less hurtful they become to the gouty. 
 
 While free perspiration exists in warm weather, and free diuresis 
 as well, alcoholic drinks of all kinds are less harmful. Whatever 
 form of alcohol is taken, it should be drunk to the exclusion of all 
 others, for mixtures are particularly bad. 
 
652 DIET IN DISEASE 
 
 Strong beer, ales, porter, stout, all malt extracts, and sweet cider 
 must be absolutely prohibited. Sir Henry Thompson and Germain 
 See regard cider as beneficial as a solvent of uric acid, but by oth- 
 ers it is looked upon as injurious on account of the malate of po- 
 tassium which it contains, and which it is claimed favours the for- 
 mation of uric acid (Yeo). Undoubtedly the alcoholic drinks which 
 are best tolerated by the gouty are good French Cognac or old 
 Scotch whisky, well diluted with water, Apollinaris, or soda water. 
 Scotch whisky is by many found to agree better than any other 
 variety. Weak brandy and soda may be substituted, or unsweet- 
 ened Plymouth gin. It is the part of wisdom to abstain entirely from 
 alcohol. Very many persons are so habituated to its use that they 
 are unwilling to abandon it, and a compromise must be effected. 
 It is easier for them to give up certain foods than drink. There are 
 some wines which should be absolutely prohibited, among them 
 all which are re-enforced by, or which contain, a large proportion 
 of saccharine material. Strong port, sherry, champagne, Madeira, 
 Canary, claret, and Burgundy are comprised in this list. 
 
 Port wine has even acquired the reputation of being a primary 
 factor in producing gout, when a hereditary diathesis does not exist. 
 It is an incompletely fermented wine to which alcohol has been 
 added for preservation, and all wines of this class are the worst 
 forms of alcohol for the gouty. Garrod says that exceptionally a 
 sound sherry, Amontillado or Manzanilla, may be prescribed. There 
 are patients, too, who maintain that they do better with port as a 
 daily beverage than with any other form of wine, but their example 
 would be a very unsafe one to follow, and their experience is due to 
 constitutional idiosyncrasy. 
 
 Duckworth says : " Rhenish wines are acid and harmful ; those of 
 the Moselle district are, however, less acid, and rather better borne. 
 Australian, Californian, Hungarian, Greek, and other Mediterranean 
 wines are too strong, and after a time generally disagree." 
 
 An absolutely dry champagne may sometimes be permitted, or 
 very dilute and weak pure claret. The stronger clarets containing 
 more tannin, and all wines with much free acid, are injurious. 
 Among the light wines, several may be permitted in moderation, 
 but they should be diluted with an alkaline water in order to com- 
 pletely neutralise any acidity. 
 
 Such wines should be either long bottled or drunk from the 
 cask, for newly bottled wines are more injurious. 
 
 The best Bordeaux and lightest Hungarian wines, light hock and 
 a still Moselle, such as Zeltinger, may be drunk, for these wines are 
 quite thoroughly fermented, and therefore contain no sugar or free 
 acid, though they have salts, such as cream of tartar. These wines 
 should only be allowed in extreme moderation, not over half a pint 
 in a day. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 653 
 
 Yeo says : " The more distinguished the diuretic effect of the 
 wine, the better, as a rule, will it agree with the gouty." 
 
 Ralfe's practice is to allow no wine of any sort with dinner, but 
 afterwards two claret-glassfuls of some light wine are permitted ; 
 and he says that a tablespoonful of brandy in half a tumblerful of 
 water before meals increases the secretion of gastric juice. If the 
 patient is weak, or suffers from insomnia, he gives brandy or whisky 
 at bedtime in some effervescing water. 
 
 He states that in his experience patients who have been long 
 habituated to the daily use of port, sherry, or ale, often become 
 worse when a sudden change is made to claret or hock. In such 
 cases he advises changing gradually by substituting at first a drier 
 port or sherry. 
 
 Usually such red wines as St. Julien and St. Estephe are prefer- 
 able to the higher class, such as Lafitte or La Rose. 
 
 Different persons show peculiar idiosyncrasies in regard to the 
 gout-producing influence of certain wines. Some will always have 
 gouty inflammation set up within a few hours in a particular joint by 
 one form of liquor or wine and not by others. 
 
 Saline Waters. — Alkaline and saline mineral waters have a well- 
 deserved reputation for benefiting gout. Many persons, especially 
 obese gouty subjects, are helped by taking one or two " courses " of 
 treatment a year for two or three successive years at Carlsbad, in 
 Bohemia, or elsewhere. Carlsbad water may be drunk at home, 
 four or five ounces being taken on rising in the morning, or an 
 equivalent of the evaporated salts — chiefly sodium sulphate. 
 
 The water of the Kreuzbrunnen at Marienbad has essentially the 
 same composition with that of Carlsbad, and contains even more 
 sodium sulphate. Elderly persons may be injured by a too vigorous 
 use of these salines, and they should take only milder alkaline waters 
 containing less sodium. 
 
 The German Fachingen water has proved very serviceable. It 
 contains 3.5 per cent of bicarbonate of sodium and 6 per cent of 
 bicarbonate of lime. 
 
 Vichy is good for strong patients, but not for the feeble or 
 anaemic. It also contains considerable sodium bicarbonate, and the 
 Vals water has more sodium carbonate than many alkaline waters. 
 These waters favour the elimination of uric acid as a salt rather than 
 in the free state. 
 
 Saratoga alkaline water is among the best in this country for 
 gouty patients. It contains carbon dioxide, sodium and alkaline 
 carbonates, and chlorides. The waters of the St. Clair Spring in 
 Michigan, and St. Catherine Spring in Ontario, are good alkaline 
 salines for gout. Many lithia waters are also recommended, but 
 they contain little lithium. Apollinaris and Johannis water are 
 good. All beverages drunk by the gouty should be well diluted, and 
 
654 DIET IN DISEASE 
 
 mildly alkaline mineral waters are especially valuable for this pur- 
 pose. 
 
 Aids to Dietetic Treatment. — The individual peculiarities of 
 digestion should be carefully studied in each case by the physician, 
 and the patient must be very thoroughly examined in regard to 
 the minutiae of all his hygienic and dietetic habits. Meals should 
 be taken at stipulated hours — the breakfast on rising, dinner not 
 later than three o'clock, when practicable, and late suppers should 
 be avoided. Between the acute attacks it is absolutely necessary to 
 maintain digestion in a normal condition. The bowels must be kept 
 open, and the condition of the skin should be actively maintained 
 by cold bathing and friction. Exercise should be taken in the open 
 air. The urine should be frequently examined, with especial refer- 
 ence to the hour of the day at which it is passed and the relation 
 which its composition bears to the food eaten. 
 
 Diabetes Mellitus 
 
 Nature of the Disease. — Diabetes mellitus is a disease charac- 
 terised by the passage of a large quantity of urine containing grape 
 sugar or glucose and usually of high specific gravity — 1.035 or 
 more — excessive thirst, and sometimes exaggerated or perverted 
 appetite ; progressive emaciation ; muscular weakness and langour. 
 The disease runs a chronic course, and the majority of cases ter- 
 minate fatally in from two to four years. Death may result from 
 inanition or from " diabetic coma " or other causes. The knowledge 
 of the disease has been very largely obtained from experimentation 
 upon the lower animals, in which diabetes can be artificially pro- 
 duced. The treatment is almost entirely dietetic and hygienic, for 
 as yet no medicinal remedy has been found which is curative, and 
 very few have been discovered which are even palliative in any num- 
 ber of cases. Diabetes is therefore essentially a dietetic disease, for 
 although not usually caused by errors in diet it may be exception- 
 ally so produced, and most cases are more or less benefited by 
 dietetic treatment, while some may undoubtedly be cured by it. 
 
 Diabetes was described more than a century ago ; and Rollo in- 
 augurated the dietetic treatment by withholding vegetable food. In 
 1838 Gmelin and Tiedemann established the existence of the relation 
 between the digestion of carbohydrates and the formation of sugar. 
 In 1848 the eminent physiologist Claude Bernard began elaborate 
 researches which first threw definite light upon the relations of the 
 liver to the consumption of sugar and the formation of glycogen, and 
 since that day a number of physiologists and clinicians in many coun- 
 tries have contributed extensively to the knowledge of the disease. 
 Notwithstanding this fact, however, the true cause of this affection is 
 still obscure, and aside from dietetic treatment but little advance can 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 655 
 
 be claimed in regard to the controlling influence of medicine. The 
 method of production and elimination of the sugar and the influ- 
 ence of the disease upon general nutrition is understood, but its real 
 exciting cause and the fundamental reason for the interesting de- 
 parture from the normal metabolism of starchy foods which is its 
 basis is still unknown. 
 
 Frequency. — Diabetes is not a very rare disease, and a few cases 
 occur from time to time in the experience of almost every general 
 practitioner. It is reputed to be of more common occurrence to- 
 day than it was fifty years ago, but this fact is possibly due to 
 the much more careful and frequent urinary analyses which are 
 made as a matter of routine by all physicians, that often reveal a 
 latent diabetic condition which might otherwise have been over- 
 looked. In regard to those cases which are of neurotic origin, the 
 general increase in the proportion of diseases of the nervous system 
 which has been observed in the United States must be taken into 
 consideration. Diabetes may occur alone or in association with a 
 variety of diseases, particularly those of the liver, pancreas, lungs, 
 and nervous system. 
 
 Causation. — The influence of heredity can be traced as a factor 
 in about one third of all cases. The disease may occur in any cli- 
 mate and in any age with either sex, but it is commonest in males 
 in the proportion of three to one. In females it occurs oftenest be- 
 tween twenty and forty years ; in males, between thirty and forty- 
 five years. It is somewhat more common among the wealthy than 
 the poor because of sedentary habits combined with overindulgence 
 in eating. The obese, particularly those who have much omental 
 fat, are more liable to diabetes than are thin persons who are more 
 active. 
 
 Cantani has observed the unusual prevalence of diabetes in south- 
 ern Italy, where carbohydrates are so extensively used, and he be- 
 lieves that the liver is exhausted by metabolising such food, while at 
 the same time it is weakened by failure to receive proteids. This 
 view will hardly withstand the criticism that in many other coun- 
 tries the natives have lived for generations upon carbohydrates with- 
 out developing diabetes. 
 
 Among the various determining causes of the disease have been 
 reported blows and shocks affecting particularly the nervous sys- 
 tem, injuries to the back of the head and blows over the liver, as 
 well as general concussion, such as that produced in railway acci- 
 dents ; exposure to cold, wet, and fatigue ; convalescence from 
 fevers; emotional strain, worry, mental fatigue, and anxiety. Tu- 
 mours and haemorrhage at the base of the brain and circumscribed 
 lesions of the floor of the fourth ventricle have been known to oc- 
 casion the disease. A number of cases have been associated with 
 disease of the pancreas, as stated below (p. 660). 
 
656 DIET IN DISEASE 
 
 Overindulgence in Food. — There is some doubt whether any one 
 article of diet can determine an attack of diabetes, although inordi- 
 nate eating of candy, preserves, raisins, fruit, confections, etc., may 
 occasionally cause temporary glycosuria. 
 
 Bernard claimed that taking excess of starch into an empty stom- 
 ach caused transient glycosuria in animals, but this observation has 
 not been uniformly confirmed in man. 
 
 Fowler wrote some time ago : " I have been in the habit of sup- 
 plying my classes with saccharine urine simply by taking about four 
 ounces of dried dates or about a tablespoonful of pulverised glucose 
 upon a fasting stomach." 
 
 According to Harley, temporary glycosuria may be induced by 
 eating asparagus. 
 
 Rich food of either an animal or vegetable nature keeps the 
 liver constantly overtaxed, and unrestrained indulgence in sweets, 
 new wines, and sweet fruits is said to excite diabetes. Sugar may 
 be present in the urine in the proportion of from five to ten parts per 
 thousand, but so long as its occurrence in this manner is of brief 
 duration, and so long as it can be immediately traced to indiscre- 
 tion in the abuse of saccharine foods, it is of little practical signifi- 
 cance. It has been claimed that continued eating of predigested 
 starchy foods containing too much glucose may result in the pro- 
 duction of diabetes. 
 
 In transient glycosuria the ingestion of excess of cane sugar 
 does not, according to Worm-Muller and others, produce glucose in 
 the urine, but saccharose, and he attributes diabetes to overfermen- 
 tation on the part of the liver. 
 
 In diabetes lactose reappears in the urine as glucose, but under 
 normal conditions if eaten in excess it causes a transient lactosuria. 
 
 RELATION TO GOUT AND OTHER DISEASES 
 
 The frequent association of gout and diabetes has long been ob- 
 served, and in " gouty glycosuria " (Brunton) comparison is made 
 between the chronic hyperemia of the diabetic liver and the acute 
 hyperemia of the gouty joints. 
 
 Occasionally persons past fifty years of age who are gouty may 
 present the symptom of glycosuria without other accompanying 
 manifestations of diabetes, such as emaciation and debility. This 
 symptom may persist for a number of years and end in recovery, or 
 the patient may die of some intercurrent disease in no way con- 
 nected with diabetes. 
 
 In a long series of cases of diabetes reported by Ord, gout oc- 
 curred in over one third, and in some there was arthritis deformans. 
 In these cases not only does the urine contain sugar in excess, but 
 the urea and uric acid are largely increased. It is interesting to 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 657 
 
 remark in this connection that similar dietetic treatment benefits 
 gouty, obese, and diabetic patients, for they live best upon a nitrog- 
 enous diet with alkalies. The occurrence of an excess of uric acid 
 in the urine (uricaemia) is often a forerunner of diabetes (Coignard, 
 Comillon). Diabetes is also often associated with neuralgia, phthisis, 
 hepatic engorgement, and congestion. There is no one form of dis- 
 ease of the liver in which diabetes is uniformly or frequently asso- 
 ciated. In about one third of the cases a history is obtainable of 
 mental strain or overwork, and in about one third there is a history 
 of alcoholism. 
 
 PHYSIOLOGICAL EXPERIMENTS 
 
 In order to understand fully the dietetic treatment of diabetes, it 
 will be necessary to discuss somewhat at length certain physiological 
 experiments and theoretical causes in relation to aetiology. These 
 topics will be found to throw some light upon the relations of diet 
 to the symptoms. The experiments of Claude Bernard above al- 
 luded to were made to determine where the sugar which has been 
 ingested by an animal is destroyed. He was the first to accurately 
 determine the amount of sugar normally present in the blood. Ac- 
 cording to his estimate, when this quantity does not exceed three 
 parts in one thousand, the limits of health are not surpassed, and 
 sugar does not appear in the urine, as it promptly does when the 
 proportion is increased. 
 
 He fed animals heavily upon sugar, killed them, and examined 
 the blood from various blood vessels. In this manner he ascertained 
 that a good deal of sugar is destroyed by the passage of the blood 
 through the lungs, but he also found it to be carried by the hepatic 
 vein, whjle the portal vein contained a trace only. He demonstrated 
 that the liver, excised from the body and washed free of all blood 
 by a stream of water injected through the portal vein, would, after 
 standing for a few minutes, still yield sugar. He thus proved that 
 the liver is capable of forming sugar by some process which is con- 
 tinued independently of its blood supply. He next searched for the 
 source of the sugar formed by the liver, and discovered the sub- 
 stance, to which he gave the name of " glycogen." Glycogen, or 
 animal starch, is a normal ingredient of the liver cells, in which it is 
 stored in the form of amorphous granules around their nuclei. When 
 treated by diastatic ferments or boiled with dilute mineral acids, it 
 is converted into a grape sugar or glucose. Hensen, of Kiel, dis- 
 covered glycogen independently of Bernard and at nearly the same 
 time. This substance, which is isomeric with starch, occurs in the 
 skeletal muscles as well. 
 
 Bernard also found that the quantity of sugar which he could 
 collect from the hepatic vein at any time did not increase when the 
 animal was fed upon a large amount of sugar ; this circumstance led 
 
658 DIET IN DISEASE 
 
 him to argue that the liver arrests the sugar ingested on its way to 
 the general circulation, and thus acts as a regulator of the amount 
 of sugar contained in the blood. 
 
 Man takes his food at comparatively infrequent intervals, and it 
 is important that the energy derived from the ingestion of a large 
 meal of carbohydrates should not be immediately expended, but 
 should be stored in some form which will enable it to be gradually 
 used in the intervals between digestion of meals, and in any emer- 
 gency when food is withheld for a longer time than usual. The liver 
 affords this means of storing a considerable amount of energy by 
 converting the sugar — brought to it in the portal system which has 
 been absorbed from the intestinal wall — into glycogen, a temporary 
 product which is stored and held back in the liver cells, but which 
 can be readily paid out in small quantities from time to time into 
 the hepatic blood as it leaves the liver. In this manner an excess 
 of sugar ingested or an excess of sugar derived from the digestion 
 of starchy food is normally kept from immediately entering the 
 circulation, and its use is economised by holding it back until it is 
 required for force production. The ultimate destination of the 
 sugar reformed from the glycogen of the liver is that it is consumed 
 either in the capillaries or intercellular spaces or in the muscular 
 and other tissues of the body by obscure ultimate processes of nutri- 
 tion, which result in its splitting up into carbonic acid and water 
 with the evolution of heat. In support of this view Claude Bernard 
 proved that there was less sugar in systemic venous blood than in 
 arterial blood. 
 
 Bernard extracted with glycerin a diastatic ferment from the 
 liver and blood, which he supposed had the function of converting 
 the glycogen into glucose ; this action he called the " glycogenic " 
 function of the liver. The sugar absorbed from the intestines and 
 arrested in the liver he supposed to be there converted into glycogen 
 by the glycogenic ferment. Glycogen is also formed from peptones. 
 Foster says that glycogen may be accumulated in the liver upon a 
 mixed diet, and that it may be in part formed by dehydration of 
 sugar derived from metabolism of proteid food. It is a fact that 
 when diabetes is once established, the elimination of sugar in the 
 urine will sometimes continue in both man and animals kept upon 
 an exclusive nitrogenous diet. 
 
 The foregoing experiments, verified by many physiologists, have 
 given rise to three principal theories regarding the origin of glyco- 
 suria, which are as follows : 
 
 1. It is due to impaired glycogenic function, and the sugar 
 taken as a food is at once passed into the general circulation 
 unaltered. 
 
 2. It is due to increased glycogenic function ; there is an over- 
 production of sugar from the glycogen, the latter being derived both 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 659 
 
 from sugar and peptones, and the newly formed sugar is swept into 
 the blood. 
 
 3. The conditions of absorption of carbohydrates and of the func- 
 tional activity of the liver may remain normal, and yet the final com- 
 bustion of sugar by the tissues or its assimilation by them may be 
 imperfect and lead to its accumulation in the blood and subsequent 
 appearance in the urine. 
 
 The three conditions mentioned above imply either diminished 
 activity of the liver, increased activity of the liver, or a normal liver, 
 the fault being in other tissues of the body. 
 
 Either one will give rise to the presence of an abnormal amount 
 of sugar in the blood (glycohaemia), which is excreted by the kid- 
 neys (glycosuria). To aid in substantiating these theories, it should 
 be proved : (a) That there is a definite relation between the quantity 
 of sugar that leaves the liver and the quantity of glycogen remain- 
 ing in the liver, (b) That the " glycogenic ferment " resembles 
 diastase, (c) That the glucose passing through the hepatic vein is 
 identical with the sugar which can be formed from starch by fer- 
 mentation, (d) That there is a definite relation between the quan- 
 tity of hydrocarbons (and peptones) entering the liver and the 
 quantities of glycogen and glucose subsequently obtained. The ex- 
 periments of Bernard have been in the main confirmed by other 
 physiologists, but there is exception taken to some of them, and his 
 theories are not universally accepted. 
 
 It is probable that in the majority of cases the primary difficulty 
 is to be found in altered metabolism in the liver. 
 
 Pavy strongly favoured the view that diabetes is due to a faulty 
 action of the liver in not preventing the sugar which is brought to it 
 by the portal vein from reaching the general circulation. 
 
 The essential difference between the theories of Bernard and 
 Pavy in regard to the glycogenic function of the liver concerns 
 merely the final destination of the glycogen. Both agree as to the 
 primary conversion of sugar from the portal vein into glycogen, but 
 while Bernard believed that the glycogen is reformed into glucose 
 and consumed in the tissues, Pavy held that the normal use of glyco- 
 gen is in the formation of fat. 
 
 Pavy believed that a small amount of sugar may be absorbed by 
 the lacteals during the digestion of sugars or starches passing 
 through the thoracic duct directly into the venous circulation with- 
 out entering the liver. This he considered a normal condition. It, 
 however, requires the use of far more delicate tests than those com- 
 monly employed in clinical work to detect the minute traces of sugar 
 in the urine which Pavy claimed are normally present. 
 
 Pavy has propounded another ingenious theory to account in 
 part for diabetes, even though other theories be not wholly aban- 
 doned. It is that the intestinal epithelium of the villi ordinarily ex- 
 
660 DIET IN DISEASE 
 
 erts a sort of glandular control over the sugar absorbed from the 
 bowel, and converts it into glycogen and fat as it reaches the blood. 
 Failure to perform this function results in the production of glyco- 
 suria. This failure, Pavy holds, is due primarily to faulty nerve 
 action affecting the calibre of the arterioles and capillaries with hy- 
 peroxidation, which favours the too rapid conversion of carbohy- 
 drates into glucose, causing glycosuria. This theory has been some- 
 what severely criticised by Paten, and is opposed to Seegen's views, 
 but it does not exclude belief in the storage of carbohydrates as gly- 
 cogen in the liver — it is merely accessory to it. 
 
 If the liver of an animal be rapidly excised and cut into small 
 fragments to prevent further fermentation, it will be found on anal- 
 ysis to contain sugar in a small proportion which varies, according 
 to different observers, between 0.2 and 0.6 of 1 per cent (Bernard and 
 Seegen) ; hence but little sugar is to be found in the liver during 
 life, or immediately after death, and it has been suggested by Flint 
 that whatever sugar may be found is immediately washed out by the 
 hepatic blood stream. If the excised liver be not boiled, but be 
 allowed to remain at the body temperature for some minutes, or if 
 the portal circulation be suddenly cut off while the liver remains in 
 the body, it is found that the formation of sugar continues for at 
 least an hour, owing to a process of fermentation which produces it 
 from glycogen. From these and other experiments it is believed 
 that the glycogen stored in the liver is constantly but gradually con- 
 verted into sugar, which is carried off in the general circulation in 
 such small quantities that it is often difficult to detect its presence 
 in the blood. 
 
 Glycogen is found in the muscles, and in some other tissues of 
 the body, and it has been suggested that sugar might be formed in 
 the blood vessels, quite independently of the liver, by a ferment car- 
 ried in the blood, but the hepatogenous origin of the glucose is the 
 view generally accepted at present. 
 
 THE PANCREAS AND DIABETES 
 
 Extirpation of the pancreas in man has been shown by William 
 T. Bull to sometimes produce diabetes, and experimental extirpation 
 of this gland in dogs has the same result. In many, but not all fatal 
 cases of diabetes, more or less pancreatic disease, usually of the 
 nature of chronic interstitial inflammation, has been observed. The 
 gland is known to produce an internal secretion — i. e., a secretion 
 passed into the circulation, which is a glycolytic ferment — and when 
 the gland is diseased this ferment is reduced in quantity, sugar fails 
 of conversion to glycogen, and diabetes results. Opie believes that 
 the islands of Langerhans are the structural portions of the pancraes 
 concerned with the production of the ferment, and degenerative 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 66l 
 
 changes have been observed in diabetes in these islands of polygonal 
 cells which are supplied with a rich capillary network. 
 
 THE NERVOUS SYSTEM AND DIABETES 
 
 It is a curious fact that the irritation or puncture of a very cir- 
 cumscribed area in the floor of the fourth ventricle in the medulla is 
 followed by the appearance of sugar in the urine. This spot is 
 called the " diabetic centre," and it is in close relation with the sym- 
 pathetic and vasomotor nerves that control the capacity of the he- 
 patic blood vessels. In animals in which fatty degeneration of the 
 liver cells has been artificially produced by metallic poisoning, punc- 
 ture of the diabetic centre produces glycosuria. Glycosuria is also 
 observed in men after the inhalation of chloroform and in animals 
 after the inhalation of irritant vapours and after stimulation of the 
 pneumogastric nerve. Schiff produced glycosuria experimentally by 
 the removal of the spleen from animals, but it does not follow this 
 operation in man. He also tied off successive portions of the liver 
 from connection with the circulation, and found the production of 
 sugar proportionately decreased. The frog is capable of surviving 
 extirpation of the liver for three weeks, and at the end of this time 
 no sugar is found in the blood (Schiff). If the vagus nerve is di- 
 vided in the neck, or if the spinal cord be divided above the origin 
 of the great sympathetic nerve, diabetes may result. Bernard sug- 
 gested that glycosuria might be cured if it were possible to galva- 
 nise the sympathetic nerves. The foregoing experiments demon- 
 strate that glycosuria may be caused by a variety of nerve lesions 
 and irritations. It is also frequently associated with modifications 
 in the activity of the hepatic circulation. 
 
 THE CIRCULATION AND DIABETES 
 
 The occurrence of diabetes in connection with acute inflamma- 
 tions of the liver and passive hepatic congestion secondary to ad- 
 vanced cardiac disease favours the hypothesis that glycosuria may be 
 developed by an increase in the amount of blood flowing through 
 the liver, which is thereby stimulated to an active conversion of its 
 glycogen into sugar, or else the blood passes so rapidly through the 
 liver that the sugar absorbed from the food by the branches of the 
 portal vein does not have time to be converted into glycogen, but 
 goes through the liver into the general circulation unaltered. Thus, 
 whether the glycogenic function be increased or diminished in gly- 
 cosuria, either condition would demand altered activity of the portal 
 circulation. 
 
 VARIOUS THEORIES OF DIABETES 
 
 Huppert, Pettenkofer, and Voit advocate the following theory: 
 Sugar, like urea, is a normal product of the decomposition of albu- 
 
662 DIET IN DISEASE 
 
 minous bodies. In health the sugar is oxidised; in diabetes less 
 oxygen than normal is absorbed, owing to the destruction of the 
 red blood-corpuscles occasioned by malnutrition ; therefore sugar 
 accumulates in the blood. Sugar is formed from the albuminous 
 constituents of the body which undergo rapid chemical change. 
 This fact they regard as proved by the increase in the quantity of 
 urea eliminated. Von Mehring found sugar in the urine of a dia- 
 betic patient after a twenty-six hours' fast. 
 
 Porter believes that the renal epithelial cells, which he claims are 
 frequently enlarged in diabetic patients, take an active part in the 
 manufacture of glucose because the blood of diabetic patients never 
 contains enough sugar at any one time to account for all which is 
 found in the urine. The epithelial cells are supposed to manufac- 
 ture the sugar out of carbon dioxide and water. This theory lacks 
 confirmation, however, and it should be observed that a very small 
 amount of sugar, which furnishes a mere trace in the blood at any 
 one time, but which is constantly eliminated from the large quantity 
 of blood continually passing through the kidneys, may amount in 
 the course of twenty-four hours to a number of grammes. In view 
 of the established facts in regard to the glycogenic function of the 
 liver, it seems unnecessary to believe that the renal epithelium exer- 
 cises any special metabolic power in diabetes ; moreover, the kid- 
 neys may appear quite normal in severe cases of diabetes. 
 
 Brunton reports several cases due to the presence of a tape- 
 worm. He thinks that the increased appetite caused by the presence 
 of the worm may have been instrumental in causing the glycosuria 
 from overeating, but it is possible that the peripheral irritation of 
 sympathetic nerve fibres may have been conveyed to the diabetic 
 centre in the medulla, and thence reflected to the vasomotor system 
 of the liver. 
 
 Some recent experiments and clinical observations justify the 
 belief that the skeletal muscles play a more important role in the 
 production of diabetes than has heretofore been supposed. 
 
 During their activity they normally consume glycogen in con- 
 siderable quantity. If they fail to perform this function properly, it 
 accumulates in the system. 
 
 Kiilz has shown that muscular activity favours the consumption 
 of sugar in the organism of the diabetic, and that much less sugar is 
 eliminated while such patients are taking vigorous exercise. 
 
 It must be admitted that there are many hepatic diseases and 
 lesions in which a large part of the secreting surface of the organ is 
 destroyed, and in which glycosuria may never be present, but in 
 these conditions it is possible that while a part of the liver is totally 
 destroyed there may be some remaining cells which are still endowed 
 w r ith normal functional activity, whereas in the disease under discus- 
 sion it is probable that none of the parenchyma of the liver main- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 663 
 
 tains its normal control over metabolic processes, and hence, what- 
 ever sugar is brought to the organ by the portal vein passes into the 
 general circulation unaltered. In the graver forms of diabetes, in 
 addition to the functional disturbances of the liver, there is believed 
 to be present also a condition of malnutrition in which sugar either 
 fails to. be consumed or, as suggested by Yeo, " we may suppose that 
 in these cases a morbid ferment is formed in the system, possibly in 
 connection with some radical fault of stomach or intestinal digestion, 
 and that this determines the rapid reconversion of glycogen into 
 sugar." 
 
 Symptoms. — The most important symptoms of a typical case of 
 diabetes which are to be combated by diet are (a) extreme thirst, 
 (b) the large quantity of urine voided and rapid emaciation and loss 
 of strength. 
 
 (a) Thirst. The Month. — Thirst becomes excessive, and is not 
 quenched by drinking, although patients will drink almost any avail- 
 able fluid — even their own urine — in their endeavour to relieve it. 
 
 The absorption by the blood vessels of fluid from the tissues is 
 held to be the main cause of this thirst (Vogel), which is most in- 
 tense one or two hours after meals, when sugar formation is most 
 active, and ten or fifteen quarts of water may be consumed daily if 
 patients are not restrained from drinking freely. 
 
 The saliva is thick, frothy, and acid, and often contains sugar. 
 
 The mouth becomes sticky or dry, even to the extent of interfer- 
 ing with articulation, and there is often a sweetish taste, which may 
 be accounted for by the sugar present in the saliva and the blood of 
 the capillaries which circulate among the taste bulbs. 
 
 The tongue is at first moist and sticky and coated with promi- 
 nent papillae ; later it may become dry, dark red, and fissured. The 
 appetite is at first excessive ; it amounts to bulimia in some cases ; at 
 other times it is capricious or intermittent, and subsequently it fails 
 completely when the digestion becomes impaired through the symp- 
 toms of gastric and intestinal catarrh. 
 
 (b) The Urine. — The average quantity of urine voided is between 
 two to three times the normal amount — that is, from 3,000 to 4,500 
 cubic centimetres. If water is being drained from the tissues the 
 quantity of urine voided may exceed the amount of fluid ingested, 
 but obviously this condition cannot last very long. Exceptionally 
 as much as 5,000 to 6,000 cubic centimetres or more may be voided 
 within twenty-four hours. 
 
 Frequent calls to micturate at night greatly interfere with the 
 patient's rest. As a rule, the more sugar present the paler is the 
 urine, and it grows turbid soon after standing, from the development 
 of yeast fungus (Tonda ccrcvisid), derived from the atmosphere. 
 The sediment, if present, is usually light, and the odour may resemble 
 whey or hay. The urine is sweetish ; the reaction is usually acid, 
 44 
 
664 DIET IN DISEASE 
 
 but may be neutral or alkaline, and the acidity is usually pro- 
 portionate to the quantity of sugar ; it is increased by development 
 of carbon dioxide and acetic acid, products of fermentation. After 
 standing it does not become alkaline from ammoniacal fermen- 
 tation, but undergoes saccharine fermentation. In a majority of 
 cases the specific gravity is considerably higher than the normal, 
 rising to between 1.035 and 1.050 or more. Bouchardat reports a 
 case with a specific gravity of 1.074, and Pavy one with a specific 
 gravity as low as 1.010, which is certainly exceptional. It should 
 be remembered that the quantity of urea present as well as sugar 
 affects the specific gravity. 
 
 The urea is proportionate to the amount of proteid food elements 
 ingested, and as patients are usually fed upon nitrogenous food, urea 
 is naturally increased beyond the normal average. Sometimes two or 
 three times the normal quantity is excreted. Urea, however, always 
 exists in small proportion in comparison with the whole quantity of 
 urine voided. There are some instances in which there is appar- 
 ently an increased waste of the albuminous tissues of the body, re- 
 sulting in the production of more urea. 
 
 The quantity of sugar present varies greatly ; an average may 
 be stated as from thirty-two to thirty-five parts per thousand 
 of urine, but the total may even exceed five hundred grammes 
 per diem. 
 
 The effect of a heavy meal of starchy food in increasing the 
 sugar is promptly shown by the urine, usually within two hours, and 
 it lasts during several hours. In some cases very little sugar is 
 eliminated, and yet the symptoms are very severe ; in others a great 
 deal is voided and the symptoms are not at all severe, but as a 
 rule applying to a majority of cases, the severity increases or dimin- 
 ishes with the quantity of sugar passed. After grape sugar has dis- 
 appeared during dietetic treatment, inosite is sometimes found in 
 the urine, as in simple polyuria. Other substances found occasionally 
 in connection with sugar are acetone, alcohol, alkapton, diacetic acid, 
 aceton, /3-oxybutyric acid, peptones, and fat (lipuria). More or 
 less albuminuria is observed. 
 
 While dietetic treatment is in progress the urine should be peri- 
 odically tested with careful relation to the ingested food, and speci- 
 mens should be examined which are passed from two to four hours 
 after eating various articles of diet in order to observe as exactly 
 as possible the influence of such diet upon the elimination of glu- 
 cose. 
 
 The Skin and Bowels. — Because so much water is eliminated in 
 the urine there is scarcely any perspiration, and the skin becomes 
 dry and wrinkled, the face looks drawn and pinched, and the eyes 
 are hollow T . In advanced cases a sweetish, sickening odour is ex- 
 haled from the skin and in the expired air. From lack of intestinal 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 665 
 
 secretion the bowels are usually constipated, although diarrhcea may 
 alternate with constipation in the later stages of the disease. 
 
 Hunger. — At first the food eaten does not supply the needs of 
 the body and there is constant craving for more. 
 
 To -obtain the requisite carbon from fats a labourer, taking his 
 ordinary allowance of proteids, would in addition have to eat about 
 three hundred and fifty grammes of fats, which would be manifestly 
 impossible. The diabetic is practically in this position when all 
 carbohydrates are denied him, and a much larger bulk of food is 
 necessary for him than if he could eat food containing more carbon 
 but less protein. This accounts in a measure for the extreme hunger 
 which is felt by many diabetics when suddenly deprived of their ac- 
 customed starchy foods. 
 
 Later Symptoms. — In the later stages of the disease dyspeptic 
 symptoms are prominent with flatus, sour eructations, and a disgust 
 for all kinds of food. The teeth decay, the gums become tender, 
 and mastication is difficult. 
 
 The alimentary canal is frequently the seat of chronic gastric 
 catarrh, with thickening of the mucous lining of the stomach and 
 small intestine. Diarrhcea may be caused by the excretion of sugar 
 from the intestinal mucous surface. Occasionally nausea and vom- 
 iting are present, and the ejecta may contain acetone. The secre- 
 tion of bile is lessened. Emaciation sooner or later becomes extreme 
 and progresses, although the appetite remains normal or may be still 
 increased. 
 
 The loss of weight, which is so pronounced a feature of most 
 advanced cases of diabetes, is attributed in part to the non-burning 
 of carbohydrates, and in part to the loss of their albumin-protecting 
 action (Graham Lusk). In health, oxygen is used to consume sugars, 
 which in diabetes, when sugars are withheld, burns the fat of the 
 body instead, so that the quantity of oxygen inhaled and carbon 
 dioxide exhaled may remain nearly identical in the two conditions, 
 while emaciation progresses. In addition to lack of nitrogen of 
 the tissues the wasting is also in part to be accounted for by the 
 drain of fluid from the system which takes place when once over- 
 action of the kidneys is established. Phthisis is often present and 
 increases the rapidity of the emaciation. Exceptionally, early in 
 the disease the patient, owing to the greater appetite and the large 
 amount of fluid drunk, may increase somewhat in weight. Muscular 
 weakness and debility rapidly supervene to a greater extent than is 
 to be accounted for by the usual loss of flesh. 
 
 In general, it may be said in the milder forms of diabetes that the 
 sugar in the urine is derived from carbohydrate foods, while in the 
 more serious forms it is also derived from the nitrogenous metab- 
 olism. The sugar which is eaten as food or which is formed by 
 starch in the alimentary canal, after absorption is mainly used under 
 
666 DIET IN DISEASE 
 
 normal conditions in the production of force, but in diabetes it is 
 eliminated unaltered from the body, and there is consequent lack of 
 heat production and muscular power. 
 
 Since a large amount of heat-producing material passes from the 
 body without complete oxidation, the body temperature is not in- 
 frequently subnormal; and it may so remain throughout the disease 
 unless there be some inflammatory complication. The axillary tem- 
 perature m#y be gy° or even 95 F. The occurrence of any acute 
 joint or visceral inflammation or of any acute fever causes a reduc- 
 tion in the quantity of sugar eliminated while the pyrexia lasts. The 
 explanation of this fact is by some observers thought to be due to 
 increased combustion of sugar in the body during the pyrexial stage, 
 but Bernard attributed it to an interference with the glycogenic 
 function of the liver. The pulse becomes rapid and feeble and the 
 temperature is subnormal. 
 
 When great feebleness compels the patient to become bedridden, 
 bedsores and excoriations from frequent passage of acid and sac- 
 charine urine add to his discomfort. 
 
 Diabetic coma is the precursor of sudden death in a certain num- 
 ber of cases, and it is also to be regarded as the worst possible symp- 
 tom which may arise. Many theories have been offered in explana- 
 tion of this symptom, and the one which is at present in vogue is 
 that it is produced by an acid intoxication produced by accumulation 
 in the system of /3-oxybutyric acid, constituting an acidosis (Nau- 
 nyn). This acid is found in the tissues and blood, and also, in com- 
 bination with bases, in the urine. The acid is derived from tissue 
 albumins, and possibly fats, and over 200 grammes may be present 
 in the tissues in a fatal case. Gangrene, asthenia, or intercurrent 
 diseases cause a number of deaths. 
 
 There are other symptoms affecting the nervous system, the eyes, 
 etc., and there are many complications which may arise in the course 
 of the disease, but a consideration of them would lead too far from 
 the object of the present discussion, which is to deal with those 
 symptoms which bear a more immediate relation to the metabolism 
 of the food. 
 
 Some of the complicating diseases with which diabetes may be 
 associated make it impossible to adhere to a rigid regimen without 
 producing more harm than good. Such, for example, are acute gout 
 and chronic nephritis, in both of which a meat diet is injurious, and 
 if carbohydrates are also cut off the patient has little or nothing 
 left to eat. In these cases the diet must be determined by whichever 
 constitutes the graver complication (see p. 496). 
 
 Course. — The course of diabetes is so protracted that there is 
 abundant opportunity and usually necessity for trying dietetic ex- 
 periments, for it will be found impossible to establish rules for die- 
 tetic treatment to which exceptions may not arise from time to time 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 667 
 
 in the course of any individual case. The disease is sometimes well 
 established long before its symptoms become sufficiently urgent to 
 attract .the attention of the patient. Persons who believe themselves 
 to be in perfect health and who apply for life-insurance examination 
 may be informed for the first time of the presence of glycosuria, 
 and many cases are now discovered through incidental examination 
 of the urine in connection with some other disease, which would have 
 been overlooked a few decades ago, when clinical urinalysis was very 
 imperfect. 
 
 If treatment is begun before the symptoms are well advanced 
 the lives of many patients may be prolonged — in some cases for more 
 than ten or twelve years — whereas, of seven hundred cases reported 
 by Prout which occurred over thirty years ago, only two patients 
 lived beyond ten years. Frerichs reported one case which extended 
 through twenty years and several more in which the disease lasted 
 between ten and eighteen years. Occasionally diabetes is extremely 
 acute, and may prove fatal within three weeks, but in such instances 
 it is probable that glycosuria has been present for a long time with- 
 out discovery. 
 
 Prognosis. — Between 50 and 60 per cent of all cases are fatal in 
 less than three years ; undoubtedly a few which are recognised 
 sufficiently early may be completely cured, but glycosuria, like al- 
 buminuria, indicates a weakness of the system in a special direc- 
 tion, and, the disease having once occurred, the patient should be 
 under reasonable supervision for many years. It has been aptly 
 said that " the only chance that a diabetic has of being cured is to 
 believe that he never is cured " — that is, to be constantly on the alert 
 to avoid all indiscretions in hygienic and dietary matters. There 
 seems to be a relation between the general bodily nutrition and the 
 chance of recovery or improvement. Usually stout, middle-aged 
 men yield best to treatment ; thin persons withstand the disease less 
 well, and rapid emaciation is always more to be dreaded than the 
 presence of sugar. The prognosis is more favourable in those cases 
 which are readily amenable to the influence of a strict dietetic regi- 
 men. The prognosis is more favourable if the sugar does not 
 speedily return if the dietetic treatment be interrupted, and also 
 if the amount of urea excreted is large and the quantity of uric acid 
 small. Cases which occur in connection with gout are relatively 
 light. In emaciated cases the malnutrition is so great that the pa- 
 tients easily acquire other diseases, especially pulmonary tubercu- 
 losis, and many die from complications rather than from the imme- 
 diate effect of the disease itself. 
 
 Diagnosis. — To determine the presence of permanent glycosuria, 
 the patient should be placed for two days upon a standard diet con- 
 taining no other carbohydrate food than 100 grammes of wheat bread 
 (von Noorden). The urine passed during twenty-four hours is then 
 
668 DIET IN DISEASE 
 
 collected and analysed by polarisation and titration or fermentation. 
 If sugar be present, the carbohydrate allowance should be varied for 
 a day or two, in order to determine its effect upon the quantity of 
 sugar eliminated, and serve as a guide for dietetic treatment. Tem- 
 porary glycosuria may be caused by a variety of conditions, such as 
 excessive indulgence in sweets, poisoning from amyl nitrite, mer- 
 cury, chloroform, alcohol, etc. It has been observed during preg- 
 nancy and after anthrax, diphtheria, scarlatina, typhoid fever, etc. 
 In the transient form of glycosuria the urine contains much less 
 sugar than in diabetes mellitus, and all the severe symptoms of ex- 
 cessive thirst, emaciation, and extensive tissue waste, leading to local 
 disease and usually death, are wanting. 
 
 In polyuria or diabetes insipidus there is no sugar in the urine, 
 and the specific gravity is very low — 1.002 to 1.005. 
 
 Primary peptonuric diabetes is described by Quinquand as a dis- 
 ease presenting the clinical features of mellituria — thirst, marked 
 cachexia, polyuria, etc. — but instead of sugar, the urine contains 
 peptones ; it polarises to the left, and is of low specific gravity. 
 
 Temporary lactosuria sometimes occurs as an accompaniment of 
 the puerperal state, and is not of special dietetic significance. 
 
 Treatment. — The treatment of diabetes to-day is much more 
 successful than it was thirty or forty years ago, when every case was 
 regarded as necessarily fatal. The treatment should be (1) prophy- 
 lactic, (2) dietetic, (3) hygienic, and (4) medicinal. 
 
 Prophylaxis. — Until more is known of the aetiology of diabetes 
 definite prophylactic rules cannot be established; but in general, 
 where there is distinct heredity to be feared, or when the lithic-acid 
 diathesis exists, all excitement of the nervous system, mental or 
 physical, as well as indulgence in alcohol and sweets, should be stren- 
 uously avoided. 
 
 Dietetic Treatment. — General Observations. — When prescribing 
 any dietetic regimen for diabetic patients, the general condition of 
 bodily nutrition must be carefully considered. Obese, naturally 
 robust, and sometimes gouty patients will be benefited by very 
 strictly limited and carefully regulated diet, but emaciated and feeble 
 patients cannot always endure the severity of a strict diabetic 
 diet without too great loss of vitality, and it becomes necessary to 
 maintain their strength even at the cost of sometimes increasing the 
 amount of sugar in the urine. Obese persons make their fat largely 
 out of carbohydrates, and hence a nitrogenous diet is particularly 
 well suited to their condition, whereas emaciated, weak patients gain 
 no flesh upon an exclusive nitrogenous diet, and it may barely sup- 
 port life for them. 
 
 Some persons with diabetes have been said to excrete more sugar 
 on a diet of animal food than on the hydrocarbons, but it will gener- 
 ally be found that such patients have eaten some farinaceous food, 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 669 
 
 bread, etc., with their meat, and the combination seems particularly 
 favourable to the maintenance of a secretion of saccharine urine once 
 established. Such patients may be temporarily given a diet in which 
 fat in great part replaces meat, the fat being eaten with those vege- 
 tables which contain a minimum of starch and sugar (see p. 135). 
 
 Regulation of the diet should be faithfully tried before any medi- 
 cation is resorted to, for the latter frequently becomes superfluous, 
 but a placebo may be given if necessary. During the siege of 
 Paris in 1871 it was observed that a number of diabetics im- 
 proved considerably owing to the enforced restriction in their diet 
 (Bouchardat). 
 
 Cantani advises a preliminary fast of twenty-four hours before 
 commencing dietetic treatment, but the value of this expedient is 
 questionable. 
 
 Phenomenal improvement follows in many cases upon a diet 
 which excludes starches and sugars almost completely, but this is a 
 difficult regimen to enforce, for the craving for carbohydrates, espe- 
 cially for bread, becomes so fierce that patients whose veracity is 
 otherwise unimpeachable will resort to lying or any form of decep- 
 tion to obtain this coveted food. 
 
 It is a matter of common experience that the most difficult of 
 all food for a man to be deprived of, when once accustomed to it, is 
 bread. This has always been found to be the case in arctic expedi- 
 tions in which men have been reduced to a starvation dietary, and it 
 is usually observed in any form of largely restricted diet, although 
 patients who are living upon an exclusive diet of milk appear to 
 have somewhat less craving for it than diabetics, who are allowed a 
 greater variety of food, especially meat. This is due in part to life- 
 long association of certain kinds of food with one another at meals 
 and the habit of eating this one article of food with more constancy 
 than any other, but it is also undoubtedly referable to a positive 
 craving of the system, which is particularly marked in diabetes, for 
 a kind of food which the tissues need but cannot assimilate. For 
 this reason it is generally advisable to allow patients from two to 
 four or even six ounces of bread a day in divided portions ; other- 
 wise the craving for it does them positive harm, and a loathing for 
 all food results, or they break all restraints and injure themselves 
 more by overeating. 
 
 It should be remembered that diabetic patients are very sus- 
 ceptible to the influence of the nervous system, and that worry and 
 anxiety about themselves, with too close an observation of their 
 own diet, will often react unfavourably. Moreover, it is undoubtedly 
 much harder for these patients to restrain themselves from eat- 
 ing varieties of food which are not wholesome for them if they sit 
 at a general table where others are indulging in various luxuries of 
 the season. It is sometimes possible for them, as has been proved 
 
670 DIET IN DISEASE 
 
 by Cantani, to maintain good health for many years upon a strictly 
 nitrogenous diet, but in attempting to enforce any rigid dietetic sys- 
 tem one is compelled to have some regard for the environment and 
 general habits of life of the patient, and it is easy to make the indi- 
 vidual so miserable by too harsh rules as to defeat the very object in 
 view, and the adoption of a too restricted system of diet may result 
 in disastrous failure. For these reasons it is now customary to allow 
 patients a more liberal dietary in diabetes than was at first permitted 
 after the discovery of the real nature of the disease and the influence 
 of carbohydrates upon it, but they should always be given carefully 
 written directions as to what articles they may eat and what must 
 be avoided. 
 
 While it is necessary to secure the intelligent co-operation of the 
 patient in regard to carrying out his treatment, it is highly undesir- 
 able that he should devote too much time and attention to it, and, 
 when possible, it is better to have some one else select and provide 
 food for him in order that his mind may not be constantly occupied 
 with questions of dietetics which tend to restrict the appetite, and 
 sometimes to materially interfere with the beneficial effects of the 
 diet. There is the more need for supervision of the diet by a second 
 person, because the craving of diabetic patients often attains an 
 ascendency over their will power and habits of truthfulness ; in fact, 
 a lack of mental force and even imbecility are quite characteristic of 
 the advanced disease. 
 
 Deception should be suspected in those cases in which there is 
 more urine passed than is to be accounted for by the quantity of 
 fluid allowed in the diet, and in those cases which apparently ought 
 to improve upon dietetic treatment, but in which after repeated 
 trials no headway is made in regard to controlling the amount of 
 sugar in the urine. I have known hospital patients to steal bread 
 and potatoes and consume them surreptitiously in spite of repeated 
 warnings, and also to acquire such a craving for fluid as induced 
 them to drink their own urine. 
 
 With regard to the suddenness with which the diabetic regimen 
 should be adopted by the patient, it is found to be the rule that it is 
 easier for most patients to begin with the fully restricted diet at 
 once than to gradually eliminate one article after another from the 
 menu. The urine should always be thoroughly examined, both quali- 
 tatively and quantitatively, for sugar, urea, and albumin, before the 
 restricted diet is commenced, and periodic examinations must be 
 made during the course of the treatment in order to determine the 
 effect upon the disease of withholding different articles of food 
 and drink. 
 
 At first it is well to make such examinations daily, and subse- 
 quently, if the patient is doing well, once or twice a week is suf- 
 ficient. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 67 1 
 
 The effect of no dietetic system is immediate, and at least two 
 days may be required for the patient to come fully under the influence 
 of treatment, because the materials already present in the body when 
 the new diet is commenced may serve as a source of sugar for some 
 little time afterwards. 
 
 The general principles for the dietetic treatment of diabetic pa- 
 tients are, first, to exclude from the diet, when possible, all those 
 articles which are most likely to result in the formation of sugar; 
 secondly, to devise means for relief of the craving for starchy and 
 saccharine foods which patients kept on a nitrogenous diet are cer- 
 tain to experience before long, and to see that while reducing the 
 amount of sugar in the food, the patient is not suffering to a danger- 
 ous extent from lack of nutrition. It is difficult to formulate rules 
 of diet which can be adhered to in all cases. There are many pa- 
 tients confined to an exclusive nitrogenous diet who lose flesh and 
 strength so rapidly that although the advantage of reducing the 
 glycosuria is attained, a new danger arises from anaemia and 
 emaciation. 
 
 For convenience of description of dietetic treatment cases of 
 diabetes may be subdivided into three classes : (a) Those patients 
 who pass a considerable quantity of urine containing a large percent- 
 age of sugar, but in whom the general health is still good, (b) Cases 
 in which, in addition to the passage of considerable sugar in the 
 urine, there is more or less dyspepsia, emaciation, and debility, (c) 
 Cases in which the constitutional symptoms become rapidly severe 
 after the first appearance of sugar in the urine. 
 
 (a) In the first class of cases the dietetic treatment is productive 
 of the greatest benefit, and not rarely the patients begin to gain 
 flesh and strength ; they sleep better ; the daily quantity of urine 
 falls perhaps from three hundred ounces to seventy, and it ap- 
 proaches the normal composition; the excessive appetite and thirst 
 diminish ; the digestion improves, and in one to three weeks the 
 sugar may entirely disappear. Such patients are not to be regarded 
 as cured, however, as soon as the sugar disappears — not, in fact, until 
 they can eat starches in ordinary quantity without exciting the ap- 
 pearance of glycosuria. According to the statement of Dujardin- 
 Beaumetz, patients of this class may be cured who have been elimi- 
 nating as much as three thousand grains of sugar per diem. When- 
 ever sugar, or amylaceous food absorbed as sugar, passes through 
 the circulation unaltered, it is of no value to the system, and, as 
 Bauer says, it serves merely as " useless ballast." 
 
 (b) The second class of cases is also amenable to dietetic treat- 
 ment, but the benefit is not so immediate and usually not so great 
 as in the first group, and it may be impossible to cause the total dis- 
 appearance of the sugar, although it may be reduced to two hundred 
 or three hundred grains a day. When the amount of urine is less- 
 
6/2 DIET IN DISEASE 
 
 ened by the changes of menu, the specific gravity remains high, and 
 sugar is abundant, the prognosis is very grave. The patient cannot 
 tolerate the diet, and drugs must be resorted to. 
 
 (c) In the third and most severe class of cases dietetic treat- 
 ment is sometimes of avail, and it should be always undertaken, for 
 it may prevent the patient from becoming worse, although it is un- 
 able to accomplish a cure. 
 
 But usually the treatment of these cases is unsatisfactory, be- 
 cause the patients, who are often young subjects, continue to form 
 sugar from nitrogenous food after starches and sugars have been 
 proscribed, and it is practically impossible to devise any special com- 
 bination of food, or to find any single food upon which they can sup- 
 port life and from which they are not able to produce sugar. Their 
 nutrition is extremely poor, and they go rapidly from bad to worse. 
 Not seldom they are thin, neurotic subjects when the disease first 
 attacks them, and therefore have very little capital to draw upon. 
 In extreme cases a careful comparison between the amount of food 
 ingested and sugar eliminated has furnished evidence that they are 
 even capable of manufacturing sugar or glycogen out of the muscu- 
 lar tissues of their own bodies. 
 
 A clinical comparison of the different varieties of diabetes above 
 described, with the theories which have been discussed in regard to 
 the possible method of the production of the disease, emphasises the 
 conclusion that cases of diabetes may not all have exactly the 
 same aetiology. 
 
 By different writers all gradations of diet have been recom- 
 mended, so long as the carbohydrates are restricted, from the ab- 
 solute meat diet of Cantani to the skim-milk diet of Donkin and the 
 more liberal menu of the majority of authorities. 
 
 Some patients who have a very good appetite when allowed a 
 mixed diet lose it altogether when put upon an exclusive nitroge- 
 nous regimen. There are those who can live contentedly on an ex- 
 clusive diet of proteid food and fats for a certain length of time — 
 say ten days or a fortnight — if the principle of the treatment be ex- 
 plained to them and they are anxious of being cured, but sooner or 
 later they almost always find it intolerable to wholly abstain from 
 starchy and saccharine foods, and many prefer to live less long, 
 but in more comfort than such restriction implies. This is prob- 
 ably attributable more to long-continued habit or heredity than 
 actual inability to support life on a purely nitrogenous diet, for, 
 as stated elsewhere (p. 316), the Eskimos thrive upon a diet ab- 
 solutely free from starches and sugars of every kind. It is be- 
 lieved by Ebstein and others that an exclusive meat diet may be 
 injurious on account of a tendency to produce acetonemia, and it 
 may favour the increase of uric-acid deposits in those having the 
 uric-acid diathesis. To obtain enough carbon from such a diet for 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 673 
 
 the needs of the system, a very large quantity of proteid food must 
 be consumed. 
 
 When chronic nephritis complicates diabetes the difficulty of 
 dieting is much enhanced, for meat is injurious for the nephritis, 
 and starches are prohibited in diabetes. This condition has 
 been aptly described as the " Scylla and Charybdis of the dia- 
 betic." As a compromise such patients must usually be put upon 
 a milk diet. 
 
 Dujardin-Beaumetz states that when the quantity of sugar elimi- 
 nated falls to ten grammes a day, less rigorous withholding of 
 starches is needed. 
 
 Mild cases of diabetes seldom occur in children, hence the diet 
 for them must be even more closely confined to proteids than for 
 adults. 
 
 Many elaborate diet tables have been prepared, and for those 
 whose means permit of indulgence in delicacies considerable variety 
 may be secured without the use of carbohydrates ; but for the poor 
 in hospitals and at home it is a difficult problem to furnish inexpen- 
 sive variety without occasional recourse to starchy foods. 
 
 Foods allowed in Diabetes 
 
 Soups and broths made of meat of any kind without vegetables, 
 ox-tail and turtle soup, gumbo, curry. 
 
 Eggs in any form. 
 
 Crustaceans, crabs, lobsters, shrimp. 
 
 Fresh fish of all kinds and fish roe. Caviare, anchovies. Salt 
 fish, cod, mackerel, and herring may be allowed, unless they increase 
 thirst too much. 
 
 Fresh meat, fowl and game of all kinds. Ham, bacon, smoked 
 beef, tongue, sweetbreads, kidneys. 
 
 Fats. — Olive oil and all animal fats and oils, such as butter, 
 cream, cod-liver oil, bone marrow. Some authorities, however, 
 exclude all fats. Senator objects to them on the ground that they 
 form glycerin. Cantani excludes butter because it may contain some 
 milk sugar. But usually such rigidity is unnecessary. In some dia- 
 betic patients the power of fat digestiota is apparently increased, so 
 that they tolerate larger quantities than in health. 
 
 Vegetables. — Spinach, cress, sorrel, chicory, romaine, dandelions, 
 beet tops, horseradish, radishes, celery, sea-kale, artichokes, vege- 
 table marrow, okra, lettuce, endives, pickles, cucumbers, gherkins, 
 cranberries. The following vegetables are allowed by some writers, 
 prohibited by others : green French string beans, asparagus, summer 
 squash, onions, leeks, carrots, cauliflower, cabbage, sauerkraut, cole- 
 slaw, kohl-rabi, parsley, parsnips, eggplant, artichokes. 
 
 Because potatoes contain somewhat less starch than is found in 
 
674 DIET IN DISEASE 
 
 bread they may sometimes be allowed in moderation when the latter 
 is found to disagree. Germain See gives five ounces of potato meal 
 daily as a substitute for bread. 
 
 The following statement made by Fagge is useful : " The general 
 rule is that all white parts of vegetables in which chlorophyll has not 
 been developed by exposure to sunlight contain no sugar, and are 
 not harmful. But by boiling in a large quantity of water, even the 
 forbidden kinds of vegetables, if they contain sugar only and not 
 starch, may be rendered much less injurious." There is a decided 
 advantage in using such green vegetables as are allowed in diabetic 
 diet on account of their adding to the bulk of waste matter in the 
 intestine and preventing constipation, which almost inevitably re- 
 sults from a meat diet. 
 
 Miscellaneous. — Kidneys, tripe, pig's feet, truffles, mushrooms, 
 sweetbreads, terrapin. 
 
 Cheese, cream cheese, milk curds. 
 
 Jellies made of gelatin, calf's foot, with wine, but unsweetened 
 except with saccharin, coffee jelly, lemon jelly. 
 
 Fruits, if acid, not sweet. In England, where gooseberries are 
 eaten much more than in this country, they, as well as apples, red 
 currants, and sour cherries, are sometimes allowed. Many of these 
 fruits contain more levulose than grape sugar. Sour oranges, 
 lemons, grape fruit, olives, sour apples, peaches in brandy (without 
 sugar), raspberries, and strawberries are allowed by some, but are 
 usually forbidden. Muskmelons and watermelons may sometimes 
 be eaten. 
 
 Nuts. — Oily nuts, such as almonds, walnuts, Brazil nuts, hazel- 
 nuts, filberts, pecan nuts, butternuts, cocoanuts. 
 
 The articles above enumerated afford considerable choice, and it 
 is to be distinctly understood that only so many of them are to be 
 allowed at a time as may serve to divert the craving of the patient 
 from his chief enemy — concentrated hydrocarbons. Some patients 
 will be found who can eat any of the above articles with impunity, 
 while others can take but very few, and others can consume certain 
 foods for a short time without increasing their sugar elimination, 
 which suddenly will be found to agree no longer, when some other 
 food must be at once substituted. 
 
 It is apparently true that there are some individuals for whom 
 one or two articles of starchy food can be found which do not pro- 
 duce sugar in the urine. Fothergill reports several cases of this kind. 
 One of his patients passed urine free from sugar while eating vermi- 
 celli pudding and arrowroot. Another one took raspberry jam with 
 impunity. When such cases are thoroughly investigated, however, 
 it is usually found that they have reached an intermittent period in 
 the activity of the disease which is not infrequent in this chronic 
 affection, and in which for the time being the patient is very much 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 675 
 
 better, and the urine remains for a little while practically normal. 
 Such instances occur in the milder types of cases. 
 The following articles are absolutely 
 
 Forbidden Foods 
 
 Sugar in any form — sirup, molasses, confectionery, jams, and 
 sweets of all kinds. Honey is forbidden, for it contains both dex- 
 trose and levulose. 
 
 Starches. — All the elementary forms of starchy and farinaceous 
 food, such as rice, sago, tapioca, arrowroot, oatmeal, cornmeal, 
 hominy, samp, buckwheat, barley, semolina, macaroni, spaghetti, 
 vermicelli. All pastry, cake, puddings, pies of every description — 
 in short, everything made of flour excepting a little bread as speci- 
 fied above. 
 
 Vegetables. — Potatoes, beets, carrots, parsnips, turnips, peas, 
 beans (except string beans), lentils, cauliflower, broccoli, Brussels 
 sprouts, rhubarb. Some writers, like Dujardin-Beaumetz, occasion- 
 ally allow a well-baked potato in mild cases. It contains only 15^ 
 per cent of starch, or one fifth as much as rice, and one half as much 
 as peas and beans. 
 
 Shellfish. — The soft parts or livers of clams, oysters, and mussels 
 contain glycogen. By some these foods are entirely forbidden, 
 but many diabetic patients can take them occasionally without 
 injury. 
 
 Liver of all animals (it contains glycogen), pate-de-foie-gras. 
 
 Fruits. — In regard to the use of fruits there is some difference of 
 opinion. Sweet fruits, such as figs, dates, plums, prunes, bananas, 
 apricots, all preserved, candied, or sugared fruits must be absolutely 
 interdicted. Pears, melons, and berries are forbidden by many, but 
 allowed by others. 
 
 Nuts. — Chestnuts, peanuts. 
 
 Substitutes for Bread 
 
 After all, the problem for selecting a suitable starchy food for 
 the diabetic is governed as much by the necessity of furnishing 
 some form of food which will satisfy the craving for farinaceous 
 material as for the actual nourishment which it may contain. 
 
 The most difficult of all starchy food for the patient to forego 
 is bread. Much ingenuity has been expended in attempts to devise 
 substitutes for it, and many preparations for making artificial breads, 
 biscuits, rusk, or cakes with eggs and butter are sold in market for 
 this purpose. Some of these are palatable for a time, but many 
 have been found to contain 60 or 80 per cent of starch — fully 
 as much as wheaten bread — while others contain no nutriment 
 at all. 
 
6j6 DIET IN DISEASE 
 
 Some authorities, as Germain See and Dujardin-Beaumetz, 
 advise giving potato meal instead of bread, five ounces per diem, 
 which may be cooked in any form without sugar. 
 
 Torrified starch may be used by some diabetics. The starch is 
 prepared by baking a large ball of flour so thoroughly that the 
 starch granules in the interior of the mass are burst open by the 
 heat. Torrified bread or toast consists of thin cut pieces of bread 
 which are toasted through and through until almost black before a 
 hot fire until both the gluten and the starch are disorganised to some 
 extent. Well-browned bread crust is of the same nature. 
 
 The breads made from flour especially prepared for diabetics 
 are : (a) Gluten bread; (b) bran bread; (c) almond bread; (d) inulin 
 bread ; (e) soya bread. 
 
 (a) Gluten Bread. — Gluten bread was first used by Bouchardat. 
 It is made by washing wheat flour in such a manner as to remove 
 the starchy granules, leaving the gluten behind. Such bread is cer- 
 tain to contain more or less starch, and not seldom it has both 
 starch and sugar. It is much more tiresome to eat than any ordi- 
 nary bread, and unless prepared by a very reliable manufacturer it 
 has little to recommend it. It is not pleasant to masticate, for it is 
 often unpleasantly tough and stringy. It is difficult to panify, but it 
 may be aerated. Gluten biscuits are more palatable than gluten 
 bread, but most of these preparations have the disadvantage of not 
 keeping fresh for more than a week or ten days. 
 
 Gluten Hour is used for thickening broths, egg puddings, etc. 
 
 The following are receipts for utilising gluten flour : 
 
 Jeffries s Gluten Biscuit for Diabetics 
 
 Gluten flour i cup. 
 
 Best bran, previously scalded I cup. 
 
 Baking powder (or the equivalent of bicarbonate of soda 
 
 and cream of tartar) I teaspoonful. 
 
 Salt to taste. 
 
 Eggs 2. 
 
 Milk or water I cup. 
 
 Mix thoroughly. 
 
 James Stewart's Diabetic Bread. — " Take one quart of sweet milk 
 or milk and water, one heaping teaspoonful of good butter, one fifth 
 of a cake of compressed yeast beaten up with a little water, and two 
 eggs well beaten. Stir in gluten flour until a soft dough is formed, 
 knead as in making ordinary bread, put in pans to raise, and when 
 light bake in a hot oven." 
 
 Liebig proposed to prepare bread for diabetics by pouring a 
 malt infusion over thinly sliced wheaten bread. The sugar which 
 is thus formed is washed away, and the gluten residue may be 
 eaten. « -■ 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 6jy 
 
 It is very difficult to obtain a reliable gluten flour. Much that 
 is sold in open market contains more starch than wheaten bread — it 
 may hold 60 or 70 per cent (Harrington). 
 
 The gluten flour obtained in the market in London or Paris con- 
 tains about 15 per cent of starch, whereas that sold in the United 
 States frequently has two or three times as much. 
 
 Tyson, who has investigated the matter thoroughly, states that 
 the gluten breads made by Theodore Metcalf, of Boston, and the 
 Sanitarium Food Company of Battle Creek, Michigan, contain less 
 starch than other American preparations. Pavy recommends a glu- 
 ten bread and biscuit made by Bouthrou. A wholly starch-free flour 
 does not exist. 
 
 James Stewart gives the following test for starch to be applied 
 to gluten flour: A little of the flour is shaken well with boiling 
 water, and cooled. A few drops are then added of an aqueous solu- 
 tion of iodine and potassium iodide (Gram's solution). If starch 
 be present, a decided blue colour develops. 
 
 Dujardin-Beaumetz declares that gluten bread contains more 
 than three times as much sugar-forming material as potatoes, and 
 hence he prescribes the latter instead. 
 
 Van Abbott recommends the use of gluten macaroni, gluten ver- 
 micelli, and gluten semolina, which can be made into puddings with- 
 out sugar. 
 
 Fromentine is another form of diabetic flour made from wheat 
 germs. They contain less starch than mature wheat, but hold an 
 oil which is purgative and which prevents proper panification, and 
 causes the bread to sour easily. 
 
 Poluboskos is another form of flour said to contain a minimum 
 of starch. 
 
 Embryonine or legumine is a substance isolated from the casein 
 of legumes, and which is sometimes given for diabetes. 
 
 (b) Bran Bread. — The use of bran bread was first suggested by 
 Prout, but, like gluten bread, it is apt to contain a good deal of 
 starch, and in addition tough cellulose, which is of little nutrient 
 value and which may prove irritating to the mucous membrane and 
 alimentary canal, causing diarrhoea. It is, moreover, somewhat 
 tasteless, and patients quickly tire of it. Bran bread cakes may be 
 purchased prepared expressly for the use of diabetics. They are 
 made according to Dr. Camplin's receipt, as follows : 
 
 Camplin's Bran Bread. — " Boil one quart of wheat bran in two 
 successive waters, wash in a sieve with hot water until the water 
 runs through clear. Squeeze in a cloth after each washing. Spread 
 thinly on a dish, and dry in a slow oven. Grind in a fine mill, and 
 sift by brushing through a very fine sieve. Grind the residue again 
 and sift. Take of the powder three ounces, three new laid eggs, 
 butter two ounces, and half a pint of milk. Mix the eggs with a 
 
678 DIET IN DISEASE 
 
 little of the milk, warm the butter with the rest. Stir the whole and 
 flavour with nutmeg or ginger. Bake in thin cakes in a quick oven 
 for half an hour." More eggs may be used, and Roberts adds 
 sodium bicarbonate. The object of drying the bran before it is 
 ground is to make it friable, otherwise it is too soft to be easily 
 powdered. These cakes or biscuits may be eaten with butter or 
 cheese, and taken with meals two or three times a day. 
 
 (c) Almond Cakes. — Pavy first suggested the use of almond cakes 
 for diabetics, which he prepared by making a meal of sweet almonds. 
 This meal when washed in acidulated water is freed from sugar, and 
 may be made into cakes or crackers. Seegen gives the following 
 receipt for almond cakes : 
 
 Seegcn's Almond-Hour Cakes. — " Take of blanched sweet almonds 
 a quarter of a pound, reduce to powder in a stone mortar, steep in 
 linen in boiling water, acidulated with vinegar, for fifteen minutes 
 to remove sugar. Mix the paste with three ounces of butter and 
 two eggs, add the yolks of three eggs, a pinch of salt, stir well. 
 Whip the whites of three eggs and stir in. Put the dough into 
 greased moulds, dry at a slow fire." Almond-flour preparations 
 contain so much fat that they often prove indigestible after a few 
 days' trial, and they are relatively expensive. 
 
 Many physicians prefer to discard the use of all substitutes for 
 bread, such as bran and almond cakes, and to allow the patients a 
 limited amount of plain bread. 
 
 A nut flour, the Chicago Sanitary Flour, is recommended by 
 N. S. Davis, Jr., of Chicago. Analysis by Prof. J. H. Long shows it 
 to contain : 
 
 Water 8.01 
 
 Fat 19.82 
 
 Albuminoids 55-65 
 
 Sugar 6.25 
 
 Mineral salts 6.32 
 
 Fibre and other non-nitrogenous matter 3-95 
 
 100.00 
 
 It is thus seen to contain no starch, and most of the 6.25 per 
 cent of sugar is lost by conversion to C0 2 in the fermentation pro- 
 cess of breadmaking. It is useful not only for diabetics but for 
 those having flatulent dyspepsia. 
 
 (d) Inulin Bread. — A form of bread has been made by Kiilz 
 from inulin and lichinin. Inulin is derived from the root of elacam- 
 pane {Inula helcnium). 
 
 Kiilz's Inulin Biscuits. — " Fifty grammes of inulin are to be put 
 in a large porcelain basin, and while standing over a water bath to 
 be rubbed up with thirty cubic centimetres of milk, and as much 
 hot water as may be necessary, into a uniform dough, with which 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 679 
 
 the yolks of four eggs and a little salt are to be mixed. To this 
 the whites of four eggs are to be added, having first beaten them 
 to a foam and carefully worked them in. The dough is finally to be 
 baked in tin moulds, previously smeared with butter. The taste of 
 the biscuits may be improved by the addition of vanilla or other 
 spices " (Dietary of the Sick. Von Ziemssen's Handbook of General 
 Therapeutics). These biscuits are not agreeable to the taste and 
 patients soon tire of them. 
 
 (e) Soya Bread. — A meal is made from the fruit of the Soya 
 hispida, a bean which is grown in China and Japan and also raised 
 in Austria. It is very rich in protein. It has a peculiar taste and 
 holds a purgative oil. 
 
 The published percentage composition of the more important in- 
 gredients of soya bread is as follows : 
 
 Water 45 . 000 
 
 Protein 20.168 
 
 Fats 9-350 
 
 Starch and sugar 2 . 794 
 
 Phosphoric acid 0.863 
 
 Soya bread is nutritious on account of the large percentage of 
 fat which it contains, but according to an analysis made by an expert 
 chemist it contains carbohydrates in considerable amount. This, 
 in fact, is true of all the breads and biscuits made of substitutes for 
 flour. Prof. Leeds says that some breads which are falsely called 
 gluten breads contain from 50 to 75 per cent of carbohydrates, and 
 hence they are unreliable and deceptive. 
 
 Substitutes for Sugar 
 
 Kulz states that certain of the sugars and allied bodies may be 
 used with the food without increasing the glycosuria, being very 
 thoroughly consumed within the body. Such, for instance, are inu- 
 lin, inosite, mannite, and levulose or sugar derived from fruits. A 
 preparation of the latter is sold under the name of " diabetin." An- 
 other sugar substitute known as " crystalose " is much prescribed at 
 Carlsbad. 
 
 Glycerin has also been used, but Senator and Frerichs are op- 
 posed to it. If given in quantity, such as one or two ounces a day, 
 it occasions intestinal disorder, and may prove too laxative. It also 
 causes a continuous sweet taste in the mouth. 
 
 Saccharin is employed with success to take the place of cane 
 sugar for sweetening foods for diabetic patients. It may be used 
 to sweeten coffee and other materials. It is a crystalline nitro- 
 genous body derived from coal tar, which is sparingly soluble in 
 cold water, more soluble in hot water, and very soluble in glycerin. 
 It is about three hundred times as sweet as cane sugar, and when 
 
 45 
 
680 DIET IN DISEASE 
 
 taken not to exceed four or five grains daily it is quite harmless.. 
 Eaten in large quantity it disorders digestion and causes gastric 
 pain. A convenient formula is given by James Stewart for sac- 
 charin pastilles : 
 
 Saccharin gr. xlv. 
 
 Sod. bicarb, sice 3 ss. 
 
 Manniti 3 xijss. 
 
 M. Make ioo pastilles ; one will sweeten a cup of tea or coffee. 
 
 Cooking. — Care should be exercised in the preparation and cook- 
 ing of the food for diabetic patients that injurious ingredients are 
 not added for the purpose of flavouring or thickening. For this 
 reason all the articles of diet should be cooked as simply as possi- 
 ble, and rich sauces containing flour should be forbidden. Melted 
 butter may be used as a substitute. Roast beef should not be 
 basted with flour, and meat soups must not be thickened. Vege- 
 tables which have been boiled for a long time in a large bulk of 
 water have most of their sugar dissolved out, and on that account 
 are less injurious. 
 
 Very acid fruits may be sweetened with saccharin or cooked 
 with a little sodium or potassium bicarbonate to neutralise their 
 acidity. 
 
 Beverages 
 
 Water. — It is an important matter to decide to what extent to 
 restrict the quantity of water and other fluids drunk by diabetics. 
 When so much urine is voided that the patient's rest at night is dis- 
 turbed by acts of frequent micturition, it is always annoying, and 
 may be even serious. The increased work thrown upon the kidneys 
 is less harmful than might be at first supposed, for the water of the 
 urine is excreted chiefly by a simple process analogous to filtration, 
 which no doubt taxes the renal epithelium less than the excretion of 
 some of the solids of the urine. At all events, protracted cases of 
 diabetes do not necessarily exhibit serious renal degeneration. 
 
 For these reasons, if the water drunk is restricted, it should be so 
 more on account of relieving the patient of an uncomfortable con- 
 dition than from fear that the act of passing so much urine may be 
 injurious per sc, and the restriction should never be enforced too 
 suddenly. As a rule, when dietetic regulation reduces the glycosuria 
 and improves the patient's condition there is, pari passu, a reduction 
 in the quantity of urine voided. In other words, this symptom takes 
 care of itself. A reasonable restriction of the fluids allowed is to be 
 recommended, but when thirst is extreme it becomes unendurable 
 torture to withhold them rigidly, and, moreover, the water is ap- 
 parently needed to wash out the sugar which would otherwise accu- 
 mulate in the blood and tissues. In fact, the occurrence of impend- 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 68 1 
 
 ing coma has been postponed by flushing the circulation by means 
 of large draughts of water or enemata of salt water. 
 
 When the thirst leads to excessive drinking, salt foods and condi- 
 ments should be withheld, and some relief may be obtained by suck- 
 ing a slice of lemon or by using a little potassium bitartrate and 
 lemon juice, or dilute phosphoric acid in water. The patient should 
 drink only from a small glass, for there is more satisfaction in drain- 
 ing it than in taking the same quantity of fluid from a large goblet 
 which one is not allowed to empty. 
 
 The meat diet, if not too salt, diminishes the desire for fluids very 
 much as compared with a vegetable diet, for usually thirst in- 
 creases in direct proportion to the amount of sugar contained in 
 the blood. 
 
 It is important not to distress the patient so much by denial that 
 the nervous system suffers in consequence. 
 
 Beverages forbidden. — As a rule, patients always do better with- 
 out alcohol, and strong spirits should be absolutely interdicted as 
 well as sweet and sparkling wines of every kind, all wines with 
 " bouquet," especially Madeira, port, sweet sherry, Sauternes, and 
 champagnes. Xo punch or liqueurs, cider, beer, ginger or sweet 
 ales. Soda water with sirup is prohibited. No chocolate, unless 
 especially prepared without sugar. 
 
 Beverages allowed. — If it becomes necessary to give alcohol as a 
 tonic or stimulant, an acid claret or Burgundy, hock, or still Moselle 
 may be prescribed diluted with mineral water ; or a little much- 
 diluted brandy, whisky, or unsweetened gin may be allowed. Weak 
 brandy sometimes allays thirst better than water. Dry sherry, Cha- 
 blis, and Burton bitter ale are prescribed occasionally, and the Cali- 
 fornia Riesling or Zinfandel may be used. Bass's ale may be 
 allowed because the sugar which it originally contained has been 
 entirely converted into alcohol and carbonic acid (Flint). 
 
 Tea, alone or with lemon. Coffee, and infusion of cocoa nibs, 
 sweetened with a quarter of a grain of saccharin, are allowed. Choc- 
 olate may be manufactured especially without sugar. Buttermilk 
 may sometimes be given. Sour lemon or orange juice in Vichy with 
 a pinch of sodium bicarbonate makes an agreeable and cooling 
 draught. Saccharin may be added. In Germany acorn coffee is 
 sometimes used. 
 
 As an adjunct to the dietetic treatment, the alkaline mineral 
 waters are extremely serviceable, especially those from natural wells. 
 The baths and waters of Carlsbad and Neuenahr, Ems in Germany, 
 and Vichy and Contrexeville in France have achieved a considerable 
 reputation for the cure of diabetes, and after making all due allow- 
 ance for the improvement consequent upon proper regimen, dietetic 
 regulation, and systematic habits of life which are enforced at these 
 spas, there seems to be special benefit derived from the waters 
 
682 DIET IN DISEASE 
 
 themselves. Other waters which may be drunk are Apollinaris, 
 Johannis, Saratoga Vichy, plain soda or potash water, Seltzer, the 
 alkaline calcic Waukesha, or the different lithia waters. 
 
 SPECIAL DIABETIC DIETS 
 
 Skimmed Milk. — An exclusive diet of skimmed milk was first 
 tried by Scott Donkin. At first a gill should be given every two or 
 three hours, or from six to eight pints daily, to be increased up to 
 twelve pints. The small amount of milk sugar contained in it is 
 said to do no harm. Some authors advise the milk diet as a last 
 resort, others recommend trying it at once. Senator says that the 
 sugar of milk does not increase the glycosuria, and undoubtedly 
 some patients are much more tolerant than others of the sugar 
 of milk. 
 
 Tyson says it is harder than any other starchy food to convert 
 into glucose in the system. He recommends giving eight ounces of 
 skimmed milk every two hours between 7 a. m. and 7 p. m., or more 
 if necessary. If preferred, the curds and whey may be separately 
 taken. 
 
 After six weeks a gradual return to a mixed nitrogenous diet 
 may be permitted. But few patients, however, can be found to ac- 
 custom themselves to this diet or to endure it for more than two or 
 three days. Koumiss has been successfully substituted for the 
 skimmed milk. In it the milk sugar is already converted into 
 alcohol. 
 
 Buttermilk is sometimes given, and like koumiss it allays the 
 thirst to some extent. The milk sugar has been converted into 
 lactic acid. 
 
 By many writers, as Dujardin-Beaumetz and Flint, milk in any 
 form is prohibited, while others recommend its use in moderation 
 while a rigid diet of proteid and fat must be adhered to. 
 
 Ebstein's Diabetic Diet 
 
 Early Breakfast. — One cup of coffee or tea (black), without milk 
 and sugar. White bread toasted, thirty to fifty grammes ; or brown 
 bread well buttered — butter, twenty to thirty grammes. The yolk of 
 an egg, a little fat ham, or some German sausage, if required. If 
 any food be needed between this meal and dinner, let it be a cup of 
 broth, with the yolk of an egg. 
 
 Dinner. — Broth, with yolk of egg or marrow (the marrow bone is 
 boiled for half an hour, to solidify the marrow). Peptone may be 
 added to the broth. Meat, one hundred and eighty grammes, free 
 from bone, roasted, boiled, or stewed — beef, mutton, pork, veal, 
 fowl, or venison (fat meat preferred). Gravies, to be made with 
 cream or yolk of egg, not flour. Fish to be served with melted 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 683 
 
 butter. Vegetables prepared with much fat; purees of leguminous 
 plants ; salads, dressed with vinegar and oil. The food should be 
 well salted and spiced. After dinner, a cup of coffee or tea. 
 
 Supper. — One cup of tea or broth. Meat (roasted), or cheese, or 
 an egg, or fish, caviare. Bread, thirty to fifty grammes, with butter, 
 twenty to thirty grammes. Apples, pears, and stone-bearing fruits 
 are allowed in small quantities. 
 
 Beverages. — Ebstein forbids absolutely the use of beer, limits the 
 use of spirits, and allows about half a bottle of wine daily. If the 
 patient can digest milk well, it is allowed in moderate doses, and 
 cream is especially recommended. 
 
 In the following diet, recommended by During, it will be noticed 
 that, contrary to some other symptoms, fat is excluded as much as 
 possible. 
 
 During claims that prolonged boiling so alters the carbohydrates 
 as to prevent them from being eliminated in the urine as sugar, and 
 he gives his patients a diet consisting largely of rice and fruits 
 which have been soaked in water and boiled for several hours. The 
 details of his regimen are as follows : 
 
 During s Diet for Diabetes 
 
 Early Breakfast. — Milk, with a little coffee but no sugar (lime 
 water, to prevent milk from souring in the stomach) ; stale white 
 bread ad libitum, or, if it is not well borne, oatmeal, barley, or rice 
 gruel made with water, a little salt, but no butter. 
 
 Second Breakfast. — White bread, stale and well baked ; an egg, 
 lightly boiled ; rice or oatmeal gruel, with or without milk, a break- 
 fast-cupful ; or half a glass of good red wine (with water in certain 
 cases). 
 
 Dinner (taken between two and three o'clock). — Soup, with rice, 
 barley, or oatmeal ; meat, roasted, two hundred and fifty grammes 
 (game, ham, and smoked meats, as free from fat as possible, are 
 permissible) ; no condiments, no fatty sauces; compote of dried apples, 
 plums, cherries ; dried peas or white beans in some cases ; green 
 vegetables, asparagus, French beans, carrots, cauliflower, cabbage 
 (boiled in water with salt, not with fat or stock) ; dessert of a little 
 raw fruit, apples, cherries, and one small glass of red wine diluted 
 with water. 
 
 Supper (about 7 p. m.). — Gruel of barley, oatmeal, or rice, with 
 salt (but no butter), and strained, which in some cases may be made 
 with milk. Ice or iced water, to relieve thirst between meals. 
 
 Naunyn's Diet 
 
 Naunyn divides diabetes somewhat arbitrarily into three varieties 
 — mild, severe, and intermediate. For the most severe cases he 
 
684 DIET IN DISEASE 
 
 gives a diet of fat meat ; the intermediate cases are treated at first 
 on an exclusive diet of fat meat, then, as the sugar disappears from 
 the urine, he adds eggs, milk, and a small allowance of bread to the 
 diet. In mild forms he directs the use of a few green vegetables, 
 salads, fruits, and other articles, unless the sugar reappears in the 
 urine, when the patient is to be put back upon a rigid nitrogenous 
 diet. He claims that in mild cases of diabetes patients do not re- 
 quire more than from sixteen to eighteen ounces of meat a day, with 
 two or three ounces of bread and six or seven ounces of vegetables. 
 
 Hygienic Treatment. — Patients should guard themselves as far as 
 possible from catching cold, and when possible should live in a 
 moderately warm and temperate climate. If their surroundings 
 permit, it is important to take moderate exercise and to remain in 
 the open air. Flannels should be worn next to the skin in winter, 
 and the body should always be kept warm, for there is less heat-pro- 
 ducing power than normally. The skin should be maintained in 
 good condition by frequent warm baths or hot and cold douching, 
 dry rubbing, or massage. All muscular and nervous or mental 
 fatigue is to be avoided. It is claimed by Kiilz that muscular exer- 
 cise tends to increase the consumption of sugar or glycogen in dia- 
 betes and to lessen its elimination by the kidneys. This applies to 
 the more robust cases only, for in the severe type of the dis- 
 ease with great emaciation much exercise becomes harmful or 
 impossible. 
 
 Medicinal Treatment. — The medicinal treatment of diabetes is 
 exceedingly unsatisfactory. In a certain proportion of cases of dia- 
 betes cure may result by exclusive dietetic treatment. There are 
 others in which the use of medicines is found to be of some service, 
 but it may be stated positively that there are no cases which are 
 curable by medicines without proper dietetic treatment. 
 
 Opium and codeia are successful in some instances in reducing 
 the amount of sugar. Commencing with half-grain doses, the latter 
 is to be gradually increased until ten or fifteen grains are taken in a 
 day ; alkalies, such as the citrate and acetates, are also occasionally 
 found beneficial. Clemen's liquor arsenici bromati has attained suc- 
 cess in some hands. Digestive tonics, aromatic bitters, mineral acids, 
 and cod-liver oil are frequently indicated, and strychnine and ergot 
 are to be employed as vasomotor tonics when desired. They regu- 
 late the arterial tension, and may reduce the quantity of urine and 
 relieve the thirst. 
 
 The nitrogenous diet is apt to excite diarrhoea, which may be 
 controlled by such remedies as salol, salicylate of bismuth, or cas- 
 tor oil. 
 
 For the intense craving for food experienced by some patients, 
 with a hollow, sinking feeling at the epigastrium, Roberts recom- 
 mends a two- or three-grain asafcetida pill three times a day. 
 
diseases especially influenced by diet 685 
 
 Rhachitis (Rickets) 
 
 Causation. — Rickets is a disease of malnutrition. The fault may 
 lie in a hereditary weakness of the digestive organs, or the influence 
 of some disease, but the majority of cases are directly caused by 
 improper or insufficient food. This food may be the breast milk 
 of a mother or wet nurse, who is herself enfeebled by chronic dis- 
 ease, by oft-repeated pregnancies, or whose mammary secretion is 
 modified by dietetic errors — loss of sleep, emotional or neurotic dis- 
 orders, or the milk supply may simply be insufficient from too 
 long-continued nursing or the intervention of pregnancy, or some 
 other factor. The poor, for reasons of economy, often suckle their 
 children for too long a period — in fact, until they are two years of 
 age — but even before weaning them they allow them to go to the 
 table and share in the general diet of fried fish, pickles, potatoes, 
 pork, raw fruits, beer, etc. Children treated in this manner are 
 especially prone to develop rickets. In all doubtful cases the milk 
 of the mother or nurse should be analysed before weaning, and an 
 effort should be made to improve its quality. If the child is already 
 weaned, the cause of the rhachitic condition may be a poorly selected 
 diet, such as a patent " baby food," with insufficient fat and earthy 
 salts and excess of starch. 
 
 Rickets has been experimentally produced by Cheadle, Guerin, 
 and others in young animals by depriving them of animal fats and 
 earthy salts. It is caused by withholding all lime salts from the 
 food (Voit), but especially calcium phosphate, and young, growing 
 animals failing to receive a fresh supply absorb lime salts from 
 bones already ossified for the benefit of the newer ones, and thus 
 all the bones become soft. Baginsky found that this process is ex- 
 aggerated in young animals by the presence of lactic acid in the 
 food, and Wegner proved that phosphorus has a similar effect. 
 Forster has calculated from the lime ordinarily present in milk that 
 an infant four months of age receives a gramme each day. Indiges- 
 tion lessens hydrochloric-acid secretion and increases lactic-acid 
 formation, and lessens absorption of lime salts. 
 
 Starchy and saccharine foods not only contain little or none of 
 the necessary lime, but easily undergo lactic-acid fermentation, 
 which it has just been shown intensifies the rhachitic processes. 
 
 Bottle-fed infants are very subject to rickets, especially if the 
 milk be sterilised, and breast-fed infants may become rhachitic if the 
 milk is watery, of low specific gravity, too poor or too rich in fat 
 or in lactose. 
 
 Prophylaxis. — The best prophylactic against rickets is nursing 
 through the first year by a healthy mother or a carefully selected 
 wet nurse. It is a very common practice in this country for mothers 
 to wean their babies too early, and without a physician's advice to 
 
686 DIET IN DISEASE 
 
 resort to one of the much-advertised patent infant foods, with the 
 result above described. 
 
 Dietetic Treatment. — The dietetic treatment of rhachitis in a 
 weanling must consist, first of all, in supplying good fresh cow's 
 milk modified to resemble as closely as possible the best mother's 
 milk. It is highly important that the milk should contain sufficient 
 fat, and it must be modified accordingly by the addition of cream or 
 oil. (See Modified Milk, p. 88.) 
 
 If the child must be bottle fed, the milk should be carefully Pas- 
 teurised in order to diminish the liability of its fermentation in the 
 alimentary canal, and among the poor, who cannot afford to pur- 
 chase prepared milk in this way, the milk as soon as purchased 
 should be heated, and a few grains of bicarbonate of sodium may be 
 added to it. A plug of previously baked cotton should be used in 
 the bottle in place of a cork. When given, the milk should be 
 diluted with barley water, or, if constipation is present, with oatmeal 
 water. These waters are made by boiling a tablespoonful of pearl 
 barley or of good oatmeal in a pint of water until the meal is com- 
 pletely softened. A little salt is then added, and the mass is strained 
 through a fine cloth. It is advisable also to add milk sugar. The 
 proportion of milk for the diluent should be half and half for the 
 first six weeks of infancy ; after this the proportion is to be gradu- 
 ally increased, and when six months of age it should be given three 
 parts milk and one part diluent. The quantity of milk is to be 
 continuously increased, and at the ninth month it may be in the pro- 
 portion of four to one, and at the end of the year dilution is no longer 
 required. 
 
 Very young infants who are fed by artificial means should not 
 be given any farinaceous food. In the first two or three months of 
 infant life the saliva — from deficiency in ptyalin — is incapable of 
 digesting starch, and starch is also poorly digested by the pancreatic 
 juice in the intestine. Starch, therefore, acts as a foreign body and 
 a gastro-intestinal irritant, and passes through the alimentary canal 
 unaltered. 
 
 It is advisable in all rickety children to restrict the giving of 
 farinaceous foods until some time after the period when they are 
 often allowed, and, as a rule, children having rickets should not be 
 fed any starchy food until after the twelfth or fourteenth month. 
 They need fats much more than starches or sugars. 
 
 There are some apparent exceptions to this where infants be- 
 come seemingly robust while fed upon amylaceous foods at a very 
 early period, but they are less healthy as they grow older or exhibit 
 malnutrition or some constitutional weakness. Such exceptions by 
 no means controvert the value of the rule in general, as above stated. 
 When starchy food is given to young infants it should always be 
 predigested with diastase or " malted." 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 687 
 
 Preparations of condensed milk which contain large quantities 
 of sugar are sometimes given to infants by mothers, and they pro- 
 duce a prompt increase in weight, but the appearance in these cases 
 is deceptive, and the muscles and other tissues are less firm and 
 strong than they should be. This is proved by the fact that chil- 
 dren erroneously fed in this way succumb far more easily to various 
 diseases of infancy, especially to diarrhoeal troubles, which they may 
 acquire later on. After the first year a little of some malted or pre- 
 digested form of starchy food may be added to the milk. 
 
 Whenever amylaceous food is mixed with the milk it should be 
 previously converted, as far as possible, into dextrin or glucose, and 
 it should be added rather with the object of mechanically preventing 
 the formation of coagulae of casein than with the idea of feeding the 
 infant upon a substance which its digestive organs are not yet fitted 
 to act upon. J. Lewis Smith says : " If a heaping teaspoonful of 
 barley flour be boiled in twenty-five teaspoonfuls of water, and when 
 it is lukewarm ten or fifteen drops of diastase be added to it, the 
 gruel in a few minutes becomes much thinner from the digestion of 
 starch, and it is a useful adjuvant to the milk employed in the 
 nursery, especially for infants over the age of six months." At this 
 time or later a little albuminous food in the form of mutton or 
 chicken broth or the expressed juice of rare roast beef or beef- 
 steak. 
 
 After a year or fourteen months the diet should consist of cow's 
 milk, cream, beef juice squeezed from a fresh steak, and broths, and 
 stale bread crumbs in milk may be added. Later still, the child may 
 take scraped beef or a raw beef sandwich made with thin layers or 
 bread and butter with meat pulp between them. Beef tea, mutton, 
 and chicken broths are good. Fresh fruit juice, especially orange 
 juice, is excellent. A little sweet currant jelly added to the meat 
 will improve its flavour for older children who object to taking 
 it. When a year and a half old the child may be given eggs, either 
 beaten with milk and sweetened or soft-cooked. If attacks of diar- 
 rhoea supervene, it will be well to stop the meat broths temporarily 
 and put the child for a few days on a diet of koumiss, zoolak, or 
 pancreatinised milk. In some cases maltine is found to agree well 
 with rhachitic children, and if diarrhoea does not exist they should 
 be given pure Norwegian cod-liver oil three times a day in doses of 
 a few drops for a young infant, up to a teaspoonful for a child a 
 year or two old. Older children should have abundant fat, in the 
 form of fresh butter on bread, or cream upon stewed fruit or baked 
 apples. Fothergill wrote : " The liquid fat of fried bacon is most 
 digestible, and the child should be allowed to dip its bread in it or 
 have it crumbed into the fluid fat." Or it may occasionally be given 
 a piece of bacon to suck. 
 
 The fat of bone marrow might be used for the same purpose. 
 
688 DIET IN DISEASE 
 
 Inunctions of two or three teaspoonfuls of olive oil may be given 
 daily over the legs and abdomen. 
 
 Rhachitic children, on account of their poor nutrition, usually 
 have a deficient number of teeth or their teeth are imperfect or 
 quickly decay. It is therefore important that when they have passed 
 the first dentition food should always be given them in a state of 
 fine subdivision, otherwise it will be bolted without mastication 
 and gastro-intestinal disorder will result. Meat should be thoroughly 
 hashed or pounded in a mortar, and solid meat should never be given 
 the child to masticate until it is over two years of age. Potatoes 
 should only be given baked in a soft and mealy form. 
 
 Some breast-fed infants may become rickety, while others badly 
 fed by artificial means may not, and the extraordinary instances of 
 toleration of improper food which one constantly finds among the 
 children of the ignorant poor, at times severely test one's faith in 
 dietetic rules, but much allowance must be made for the constitution 
 of individuals and for race characteristics. The subsequent history 
 of wrongly fed children often points directly to original faults in 
 diet which have affected the general nutrition of the body, although 
 the immediate effect of such errors may not have been apparent. 
 
 AIDS TO DIETETIC TREATMENT 
 
 Rhachitic babies, as well as older children, should be weighed at 
 regular intervals as an important guide for their correct feeding. 
 
 In rickets more or less gastric catarrh is commonly present, 
 which interferes with normal digestion and absorption, and appro- 
 priate medicinal remedies should be employed to regulate this condi- 
 tion when necessary. There is often excessive acidity in the stom- 
 ach which must be neutralised by sodium bicarbonate. The hygienic 
 treatment of the children in conjunction with dietetic measures is of 
 the utmost importance. Rickety children must practically live out- 
 doors in all seasonable weather, and it is better for them to remain 
 out in fresh, cold air than to be kept at home in a damp, dark, over- 
 heated, and badly ventilated tenement. They should be frequently 
 bathed in order to keep the skin in as good condition as possible, 
 and prevent the occurrence of skin diseases, which are a common 
 accompaniment of malnutrition. They should be kept quiet and 
 not worried, and if they are weak and feeble, great care should be 
 exercised in handling them and in placing them in proper positions 
 upon beds which are firm but not hard, in order to prevent the 
 weakened bones from becoming deformed by pressure. 
 
 Scurvy 
 
 Causation. — Scurvy is a disease dependent upon malnutrition, 
 which is customarily attributed to lack of fresh vegetables in the 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 689 
 
 dietary ; but this statement is somewhat vague, in that it is not ex- 
 actly known which articles of diet are most liable to produce the 
 disease by their absence, although many believe that the cause is 
 due to deficiency of salts whose acids — citric, malic, lactic, acetic, 
 and tartaric — form carbonates, but no preventive food has been 
 found which is absolutely successful in all cases. At all events, it is 
 a disease due to omission and not to consumption of certain foods, 
 and it depends rather upon the quality than quantity of food. In 
 opposition to the theory that the want of fresh vegetables acts as a 
 cause of scurvy in man, the fact is stated by Lieutenant Greely 
 that among the Danish Eskimos, who have a population of ten thou- 
 sand, not a pound of vegetables nor a dozen pounds of bread per 
 man are eaten annually, and yet they are practically free from the 
 disease, and the same statement is made in regard to the most 
 northern tribes of Eskimos of pure blood who were studied by Lieu- 
 tenant Peary, and also in regard to the natives of the Alaskan archi- 
 pelago and some tribes of North American Indians who do not 
 include either vegetables or cereals in their food. It is an undoubted 
 fact that the disease is much oftener present among people who 
 have lived for some time in bad hygienic surroundings and in damp, 
 dirty quarters, and who have been subjected to mental depression, 
 monotony of occupation and diet, or excessive work and fatigue, as 
 well as the abuse of alcohol. It has often been known in prisons. 
 It is therefore possible for scurvy to occur in any part of the world 
 among men affected by these conditions, but it is much less common 
 at the present time than formerly. 
 
 In the British arctic expedition of i^>y^-y6 over 48 per cent of 
 the men suffered from scurvy, and a still larger percentage existed 
 among those who were exempt from field service and outdoor life. 
 
 When the potato crop failed in Great Britain and Ireland in 1846 
 scurvy became very prevalent. In the war of the Crimea twenty- 
 three thousand cases occurred among the French troops alone. 
 
 Woodruff, referring to scurvy in the United States Army, writes : 
 " If transportation is so deficient that only bacon, hard-tack, and 
 coffee can be carried, actual scurvy is the result. The company 
 commander must secure something else for his men. The lack of 
 fresh vegetables and fresh meat is the chief fault. Why fresh things 
 are needed is not known, but it is believed to be due to the fact that 
 the body thus received certain salts and unknown substances neces- 
 sary as stimulants or tonics to the tissues, which salts and substances 
 are destroyed by the usual methods of preservation. It is not to be 
 denied that men may live for many years without tasting such arti- 
 cles of diet, though it is rare for a man to be denied all three — meats, 
 fresh vegetables, and fresh fruits. If they are so denied they are not 
 possessed of that health which permits of the highest mental and 
 physical development." 
 
69O DIET IN DISEASE 
 
 Scurvy contributed 15 per cent to the death rate from diseases 
 in the late civil war, and it was formerly prevalent among seafaring 
 men when upon long voyages, who lived upon salt pork or pickled 
 meats ; but the disease is encountered much less often at the present 
 time, owing to the better means of preserving foods, securing variety 
 in diet, and better hygiene. The regulations of boards of trade 
 usually require that antiscorbutic foods and remedies should be 
 carried upon vessels, and the development of scurvy on board ship, 
 unless in exceptional cases of shipwreck or in voyages prolonged 
 beyond the expected limit, subjects the captains or owners to indict- 
 ment for criminal negligence. The English law early required that 
 lime juice should be carried on long voyages, and this formerly 
 earned the nickname of " lime juicers " for British sailors. Many 
 almshouses have similar regulations. 
 
 Scurvy has been known to occur from failure of intestinal ab- 
 sorption, in which case it is less easily preventable. 
 
 Garrod holds that scurvy is caused by absence of potash, for in 
 this disease the blood is deficient in potassium salts. He regards 
 this fact also as an explanation of the muscular weakness which is 
 a prominent feature, and observes that all good antiscorbutics — 
 fresh milk, meat, lemons, and fresh vegetables — contain abundant 
 potash. 
 
 Garrod's theory is modified by Immermann, who believes that a 
 temporary lack of these salts may cause trophic disorders, which may 
 continue for some time after the deficiency in salts has been made 
 good, and Duchek has even found that in exacerbations of symp- 
 toms occurring in scurvy there may be an increased elimination 
 of potash salts in the urine. The body is capable of retaining 
 and reusing its various salts for a considerable time, so that with- 
 drawal of the potash does not necessarily induce scurvy at once 
 (Bauer). 
 
 Northrup and Crandall investigated the causes of scurvy in a 
 number of infants, and report that they find the employment of pro- 
 prietary foods which for various reasons are substituted by the 
 mother for fresh food is the most important cause of scurvy, and 
 " even fresh milk in small proportions is not sufficient to insure per- 
 fection." Their report continues : 
 
 " The exact diet is known in thirty-three cases. We find that 
 twelve of these children (36 per cent) were fed on a proprietary food 
 exclusively, six (18 per cent) had received an exclusive diet of con- 
 densed milk or evaporated cream, while three received a combination 
 of these two foods. Over 63 per cent, therefore, were fed upon a 
 diet of proprietary foods and condensed milk. Two children re- 
 ceived sterilised milk exclusively, and three a weak mixture of milk 
 and water. One was fed on condensed milk, one on boiled and pep- 
 tonised milk, and one on barlev water. 
 
DISEASES ESPECIALLY INFLUENCED BY DIET 69 1 
 
 " It is a significant fact that the country which furnishes most 
 of the literature of scorbutus in children is the same which is posted 
 from end to end with advertisements of proprietary foods." 
 
 Prophylaxis. — So long as the hygienic conditions are good and 
 the food is of the best quality and variety, and if proper discipline 
 and regular habits of eating and sleeping are insured, scurvy may be 
 prevented among soldiers and sailors, although fresh vegetables may 
 not be obtainable. On American ships potatoes are always used. 
 Cranberries keep well and are excellent antiscorbutic food. 
 
 The introduction of canned and compressed vegetables in sea- 
 men's rations has done much to prevent scurvy, but fresh food is 
 always to be preferred to preserved food of any kind. Dried legumes 
 are quite useless. For travellers in the far North, Nordenskiold 
 advised the use of cloud berries (Rubus chamcemoriis) . 
 
 Dietetic Treatment. — In mild cases of scurvy of comparatively 
 short duration patients rapidly improve under proper dietetic treat- 
 ment if it can be obtained. The juice of two or three limes or 
 lemons, or a few fresh vegetables eaten daily, may be all that is 
 necessary, and the former is one of the best preventives as well as 
 curative agents. 
 
 A. E. Wright dissents from this view, at least in regard to such 
 cases as may suffer from bleeding from the gums. He claims that 
 the acids, tartaric and citric, have a decided inhibitory action upon 
 intravascular coagulation when given per os, and maintains, contrary 
 to general experience, that in scurvy with persistent haemorrhage 
 the use of fresh lemon juice tends to keep up the oozing of the 
 blood. He says that the neutral citrates and tartrates do not act 
 in this manner, and they should therefore be prescribed instead of 
 fresh lemon juice. 
 
 Stomatitis is often the most prominent symptom, and if the 
 mouth is very tender, the gums are swollen and bleed readily, and 
 the stomach is irritable, the diet must be limited to fluid or some 
 solid food which requires no mastication. Beef tea, broths and 
 meat soups thickened with vegetables, fresh vegetable pwces, eggs, 
 and milk are recommended. To these substances the juice of two 
 or three fresh oranges, limes, or lemons should be added. If the pa- 
 tient is able to masticate food thoroughly and the stomach is not 
 too feeble, fresh meat, baked or mashed potatoes, cabbage, sauer- 
 kraut, pickles, salad, and " greens," such as water cress, fresh mus- 
 tard, or radishes, may be given. The citrate of iron, vinegar, acetic 
 acid, and potassium chlorate and bitartrate have all proved benefi- 
 cial. During the civil war the expressed juice of sorghum was tried 
 with some success. 
 
 The treatment of scurvy in children consists first in throwing 
 away all proprietary foods, and then if the disease has not pro- 
 gressed too far, improvement and cure rapidly follow change to a 
 
6g2 DIET IN DISEASE 
 
 normal diet of mother's milk or fresh cow's milk, expressed beef 
 juice, and a little fresh orange or peach juice. 
 
 HEMORRHAGIC PURPURA 
 
 With regard to idiopathic purpura, which sometimes appears in 
 well-nourished subjects, it has been stated that a non-stimulating 
 diet, by reducing the activity of the heart, may prevent the recur- 
 rence of haemorrhages. Bauer says : " Such patients should take all 
 foods and drinks cool, and never in large quantities at a time ; they 
 should abstain altogether from alcohol, and milk is to be recom- 
 mended for its easv toleration in these cases." 
 
 MISCELLANEOUS DISEASES 
 
 Addison's Disease 
 
 The aetiology of this affection is somewhat obscure, but in the 
 majority of instances it results from tuberculosis or other disease 
 of the adrenal bodies, perhaps associated with functional or organic 
 change in the neighbouring sympathetic ganglia. 
 
 At first no dietetic treatment is required, but in advanced cases 
 there is always weakness of the digestive system, and vomiting may 
 be a common symptom. There is also progressive inanition, which 
 becomes extreme. The diet, therefore, must be of a light and easily 
 digestible character. In some of the advanced cases the best re- 
 sults are obtained from an exclusive milk diet. For others, when 
 milk is not well borne, the diet should consist of beef or mutton 
 broth, with eggs beaten with milk or sherry, gruels with added 
 milk extracts or peptonoids, custard, rennet, milk toast. 
 
 Nourishment should be given at short intervals, at least once 
 in three hours, and the patient should be encouraged to take all 
 that he can possibly digest. The intermittent vomiting may neces- 
 sitate the use of nutrient enemata. Wine or spirits are usually 
 required for tonic and stimulant effect ; the special variety is im- 
 material. 
 
 Osteomalacia 
 
 The dietetic treatment of the condition of osteomalacia is sug- 
 gested by what is known of its aetiology, but the results are seldom 
 encouraging. It is characterised by progressive softening of the 
 bones, a disease in which the salts, especially the carbonate and 
 phosphate of lime, are reduced to about 30 per cent of the normal 
 quantity. 
 
 It is not definitely known in what manner these salts are dis- 
 solved out of the bony structures, and excess of both lactic and 
 carbonic acid have been regarded as probable solvents. It is not 
 
MISCELLANEOUS DISEASES 693 
 
 proved that a deficiency of salts in the diet causes the disease, which 
 has been observed in well-fed subjects. It is, however, customary 
 to arrange the diet with regard to furnishing an abundance of salts 
 together with such articles as milk, eggs, and meat. 
 
 It is advisable also to prescribe cod-liver oil, either alone or in 
 combination with various phosphates or hypophosphites, and this 
 food proves on the whole the most serviceable. Trousseau thought 
 that it cured one or two of his cases. 
 
 It is a rare affection in its worse type, although cases of moderate 
 severity are less uncommon. 
 
 Exophthalmic Goitre 
 
 It is only very advanced cases of exophthalmic goitre with con- 
 siderable cardiac palpitation that require careful dieting. The 
 indications for treatment are to support the strength and avoid 
 flatulency and constipation, and any substances liable to increase 
 palpitation or excite the nervous system must be withheld. Hence, 
 stimulants of all kinds should be avoided. Tea, coffee, alcohol, 
 condiments, and tobacco are all forbidden, as are also sugar, sweets, 
 pastry, fried food, and " made dishes." 
 
 The food should be plainly cooked, and should consist of abun- 
 dant meats, milk, fats (such as cream, butter, and cod-liver oil), care- 
 fully prepared cereals, fresh fruits, and green vegetables. 
 
 Chronic Lead Poisoning 
 
 Causation. — Chronic lead poisoning is common among all arti- 
 sans or mechanics who work much with lead in any form, but espe- 
 cially fyhite lead. Plumbers and house painters are therefore par- 
 ticularly subject to it. It may also be acquired by eating improperly 
 tinned or badly soldered canned food, although such cases are usu- 
 ally acute. It is sometimes caused by using drinking water which 
 has passed through new lead pipes. When present in the strength 
 of only one one-hundredth of a grain to the gallon it may cause palsy. 
 
 The cheap ale, or " four ale," as it is called, sold in London to 
 the lowest classes, is sometimes kept in contact with pewter pipes 
 until it contains toxic quantities of lead. 
 
 Lead is sometimes contained in poisonous amount in beer or 
 wine which has been contaminated by the metal during its careless 
 manufacture. Some persons are exceedingly susceptible to lead, 
 and cases are recorded of poisoning from the medical use of a few 
 doses of lead and opium pills, and also from that of cosmetics con- 
 taining white lead. 
 
 Dietetic Treatment. — Chronic lead poisoning is nearly always 
 accompanied by constipation, and it is highly important to over- 
 
694 DIET IN DISEASE 
 
 come this difficulty by such foods as will keep the bowels actively 
 open. Fresh fruits and coarse cereals (such as oatmeal, cornmeal, 
 wheaten grits, Graham bread), and molasses are recommended, with 
 such other foods and regulations as are given under the heading of 
 the Treatment of Constipation (p. 571). 
 
 Water should be drunk in large quantity, not only to increase 
 the digestive secretions and keep the faeces moist, but to act as a 
 diluent and aid in washing out the poison. 
 
 Lemonade, acidulated with dilute sulphuric acid, fifteen drops to 
 the tumblerful, or with a similar dose of aromatic sulphuric acid, is 
 much in vogue as a prophylactic beverage, for it forms an insoluble 
 lead sulphate from the more soluble carbonate or other salts of 
 lead which may have reached the stomach by being taken with food 
 or drink. This insoluble salt is not absorbed, and hence poisoning 
 may be averted. 
 
 Men employed in the manufacture of white lead or other prep- 
 arations of lead believe that drinking milk freely as a beverage is 
 prophylactic against poisoning, but it is doubtful whether it acts 
 otherwise than as a good diuretic. 
 
 Lead colic is sometimes benefited by lavage. 
 
 Dietetic Complications arising from Associated 
 
 Diseases 
 
 There are certain diseases and conditions which are not infre- 
 quently associated in the same individual, the dietetic treatment of 
 each of which may be directly opposed to that of the other. Such, 
 for example, are : Diabetes and chronic Bright's disease, the former 
 requiring chiefly meat, the latter none ; extreme leanness and chronic 
 gastric catarrh, the former condition requiring fats, starches, and 
 sugars, the latter prohibiting them ; obesity and chronic albuminuria, 
 the former requiring animal food, the latter none (unless it be milk) ; 
 acute rheumatism and extreme anaemia, the former requiring no 
 solid animal food, the latter demanding it ; intestinal dyspepsia and 
 gallstones, the former benefited by a meat diet and no starches or 
 vegetables, the latter doing better with opposite diet; ascites and 
 chronic albuminuria, where the quantity of fluid ingested as well as 
 the diet may present very opposite requirements. 
 
 When such complications arise it is possible to compromise for a 
 time upon a milk diet, this being the most natural food, and one 
 which, on the whole, is capable of more universal adaptation than 
 any other. In other cases, as, for example, in the first instance men- 
 tioned above — of diabetes accompanied by severe Bright's disease — 
 one must be governed by the patient's general condition, the gain or 
 loss of body weight, the strength of pulse and muscle tone being the 
 important guides for one or other system of dieting. The lesser 
 
SURGICAL PATIENTS AND AFTER OPERATIONS 695 
 
 evil, whichever it may be, must naturally give way to the greater, 
 and a generous mixed diet may sometimes be found to serve the 
 patient better than one too much restricted by theoretical consid- 
 erations. 
 
 No subject taxes the skill and ingenuity of the dietist more se- 
 verely than the treatment of such complications, when ordinary rules 
 appear most contradictory. 
 
 DIET FOR SURGICAL PATIENTS AND AFTER 
 OPERATIONS, ETC. 
 
 Food and Anaesthetics 
 
 Preparation for the Administration of Anaesthetics. — When an 
 anaesthetic, such as ether or chloroform, is to be given, care should 
 be exercised that the stomach is empty, otherwise vomiting is apt to 
 occur at a critical moment when the patient is weak, and, being un- 
 conscious, the natural reflexes of the process, including the closure 
 of the epiglottis, are not well carried out, and food is very easily 
 drawn into the trachea and excites serious, if not fatal, choking. 
 For this reason the patient is usually prepared for the anaesthetic by 
 giving a light and easily digested breakfast, consisting solely of milk 
 with, perhaps, a little farinaceous food, or a cup of coffee and a roll, 
 and three or four hours later the anaesthetic may be administered 
 with safety. 
 
 Feeble patients sometimes require an ounce of brandy or whisky 
 half an hour before the operation — long enough before for it to 
 become absorbed. 
 
 It is never desirable to give an anaesthetic within three hours 
 after the ingestion of a full meal. It impedes anaesthetisation, be- 
 sides causing the danger of vomiting and choking. In many cases 
 it is better to allow five or six hours to intervene. In an emergency 
 where an accident occurring shortly after a heavy meal requires the 
 immediate use of anaesthesia, it may be well to give an emetic first 
 for the purpose of completely unloading the stomach while the pa- 
 tient is conscious. 
 
 The instances of fatal choking from vomiting and aspirating food 
 into the larynx are fortunately rare, as they are preventable, but 
 they are by no means unknown. Since their occurrence is almost 
 always due to negligence on the part of the anaesthetiser for not 
 observing proper precautions, they are inexcusable. Ether, by some 
 specific action, is more likelv than chloroform to prove irritating 
 and excite vomiting while being inhaled. When retching is violent 
 it may be sometimes overcome by " crowding " the anaesthetic — that 
 is, by causing it to be inhaled more energetically for a moment, until 
 reflex irritation is overcome. 
 46 
 
696 DIET IN DISEASE 
 
 Diet after Anaesthesia. — Ether, much more than chloroform, is 
 apt to occasion prolonged nausea and vomiting after its adminis- 
 tration has ceased, and this may last in very susceptible persons for 
 a day or two. In all cases where ether is employed to produce pro- 
 found narcosis, even when only used to assist physical examinations 
 for diagnostic purposes, it is well that caution should be observed for 
 some hours afterwards in giving food, and a light fluid diet of milk, 
 beef tea, or a cup of cocoa, tea, or coffee only should be allowed 
 when any tendency to nausea or vomiting exists. Under ordinary 
 circumstances no food is required until the effects of the anaesthetic 
 have mainly passed off, and with continued gastric irritation it is 
 necessary to confine the patient to a fluid diet for twenty-four hours 
 or more, and give but little of that. If the patient has been much 
 exhausted by haemorrhage during the operation or by prolonged 
 anaesthesia, nourishment may be sometimes given sooner, but in 
 concentrated predigested form. Brandy and soda is useful under 
 these conditions, and often allays gastric irritation. Very hot water 
 is to be recommended for the same purpose. In cases of laparotomy 
 for operations upon any part of the alimentary canal, such as ap- 
 pendicitis, it may prove best to give the digestive organs entire 
 physiological rest for twenty-four hours at least, but if the pa- 
 tient is in need of nourishment one or two food enemata may be 
 given. 
 
 The following schedule of diet for the day may be taken as an 
 example for an ordinary operation under anaesthesia : 
 
 7 a. m. — A cup of beef tea, coffee, or cocoa, or a cup of bread 
 and milk. 
 
 11 a. m. — Anaesthesia and operation. 
 
 3 p. :\r. — Iced milk and Vichy, beef essence, or peptonoids. If 
 vomiting occurs, give hot water, or half an ounce of brandy with 
 soda. 
 
 7 p. m. — Bread and milk, or beef jelly, or cocoa and a biscuit. 
 Nothing more until the next day, when, if there are no special rea- 
 sons to the contrary from existing disease or complications arising 
 from the operation, the patient's previous customary diet may be 
 gradually resumed. 
 
 Diet after Surgical Operations and Injuries 
 
 Fractures, wounds, bruises, ulcers, and all surgical injuries natu- 
 rally heal the sooner the better the condition of the blood. Abun- 
 dant nourishing diet, properly selected in regard to its ready digesti- 
 bility, is therefore indicated. Starvation promptly impoverishes the 
 blood and retards all healing processes. 
 
 Mild Cases. — In feeding surgical patients who are confined to 
 bed, or who, from the nature of their injuries, are unable to exercise, 
 
SURGICAL PATIENTS AND AFTER OPERATIONS 697 
 
 care should be taken that the channels for removal of waste from 
 the body do not become choked and inert. In the zeal to promote 
 rapid healing by a liberal diet it is quite possible to overcharge the 
 blood with products of nutrition and defeat the object in view by 
 burdening the liver and other organs, and inducing " biliousness." 
 
 The patient's appetite should not be the only guide, but the con- 
 dition of the tongue, the stools, and the urine should be examined to 
 insure the proper assimilation of all the food taken. In the absence 
 of sepsis, fever, and all affections of the alimentary canal there is 
 usually no harm in allowing the full diet of animal and vegetable 
 food to which the patient is normally accustomed, or, if the appetite 
 flags, considerable variety in the dietary may be advantageously per- 
 mitted. 
 
 If there has been no loss of blood and no severe shock, as soon 
 as an ordinary antiseptic operation is over the patient is practically 
 as well as he was before it was performed. 
 
 Cheyne says : " After operations performed aseptically there is 
 no reduction of diet even for a few days. A hospital patient remains 
 on full diet, and a private patient may have anything he fancies, pro- 
 vided it is wholesome, and the more nutritious the food the better." 
 In fact, after opening a psoas abscess or a carious joint the appetite 
 soon returns and " hunger becomes the chief trouble." 
 
 As a rule, stimulants are unnecessary if the appetite is keen, but 
 otherwise beer or Burgundy or dilute whisky may be prescribed in 
 moderation as an aliment, to be taken with the meals only. Hard 
 drinkers who receive bad injuries, such as severe fractures, fre- 
 quently develop delirium tremens in the course of a few days, and 
 this may occur even when they have not been indulging in stimu- 
 lants for some weeks previously. In such cases it may become 
 necessary to allow a certain quantity of alcoholic stimulation at 
 stated intervals between meals, in order to tide them over an emer- 
 gency which threatens an immediately fatal result, trusting to reduce 
 the quantity as the delirium subsides. 
 
 Severe Cases. — If severe pain has preceded an operation, if the 
 operation has been prolonged, or if there has been much shock, 
 even under anaesthesia, the diet must be supervised with great care. 
 Pain is a strong depressant, and after severe shock rest and stimula- 
 tion is usually more desirable than food. Positive harm results from 
 overfeeding. Black coffee is very serviceable for such cases or 
 whenever there is lack of nerve energy, and it may be appropriate to 
 keep the patient for three or four days upon a diet of milk or pan- 
 creatinised milk. Broths, meat extracts, and beaten eggs may be 
 added when the stomach regains its tone. If nausea, anorexia, or 
 disgust for food exists, or if there is much distention of the stomach, 
 it is unwise to urge food upon the patient. It is better to utilise the 
 rectum in such cases, and coffee, pancreatinised milk, egg albumin, 
 
698 DIET IN DISEASE 
 
 and alcohol are to be given in enemata. Opium or other necessary 
 medication may be added. 
 
 If extensive loss of blood has occurred, the volume of fluid should 
 be replaced in the body as soon as possible, and liquid food is 
 needed, such as milk, beef broths, peptonoids, and brandy or whisky, 
 if the stomach retains them. Salt-water injections, or in severe 
 cases hypodermic injections of saline solutions, help restore the lost 
 fluid to the blood and improve vascular tone. 
 
 Diet after Laparotomy, Ovariotomy, etc. 
 
 After all operations involving opening the peritoneal cavity com- 
 plete rest of the stomach is necessary for at least four or six hours, 
 and not infrequently for two or three days. Food and stimulants 
 may be given by enemata (p. 408). If fed per os for the first three 
 days not over a tablespoonful of pancreatinised milk or milk with 
 lime water or barley water should be allowed once in two or three 
 hours. Later the quantity may be increased and the intervals dimin- 
 ished, and beef tea, beef peptonoids, and egg albumin may be added. 
 
 In these cases the duration of anaesthesia has usually been pro- 
 longed, and the shock is considerable. The danger from the occur- 
 rence of vomiting, malfermentation of food, and flatulent distention 
 of the abdomen is far worse than that of inanition from abstinence. 
 It is well also to precede the operation by a day or two of dieting 
 in order to lessen the bulk of intestinal waste matter. To this end 
 the diet should, when possible, consist chiefly of lean meat and dry 
 toast, vegetables and especially sweets being avoided. 
 
 After wounds and operations affecting the stomach or intestines 
 no food at all should be given by the mouth. Nothing but a little 
 cracked ice should be so administered, and all nourishment must be 
 supplied for several days by the rectum. The return to mouth feed- 
 ing must be made very slowly and cautiously by at first giving not 
 over one or two tablespoonfuls of pancreatinised milk or beef juice 
 at a time. 
 
 There is often much thirst following operations involving the 
 peritonaeum, which is relieved more by hot fluids than by ice, which 
 sometimes irritates the throat and increases the desire for drink. If 
 there is danger of all fluids exciting emesis, a salt-water enema once 
 in three or four hours will alleviate thirst (p. 404). 
 
 Diet in Surgical Inflammations, Sepsis, etc. 
 
 The diet in surgical inflammatory conditions was formerly re- 
 duced to a minimum, with the idea that the healing process would 
 be more sure if the stimulating influence of food was removed, and 
 that the inflammation, like an infectious fever, should be " starved 
 out." The diet absoluc, as the French surgeons of the first half of 
 
SURGICAL PATIENTS AND AFTER OPERATIONS 699 
 
 this century termed it, meant virtual starvation, barley water, arrow- 
 root water, or toast water being all that was allowed. With im- 
 provement in feeding fevers came a change in the diet of inflamma- 
 tory conditions, and it was recognised that the waste of tissue mate- 
 rial and the expenditure of force in the evolution of heat must be 
 replenished by nutritious food. No one to-day starves pneumonia, 
 nor yet does an intense local inflammation of a joint demand that 
 the patient should have solid meat meals, but there is an appropriate 
 mean to be observed between overfeeding and starvation. After 
 operations inflammation will not be avoided by starving, and the 
 patient's strength must rather be supported by easily assimilable 
 food. In acute inflammatory conditions tissue waste is rapid and 
 appetite and digestive power are lessened. 
 
 In severe cases a diet of milk, diluted by one third or one half 
 with Vichy or Seltzer water, may be given, four ounces every hour 
 and a half or six ounces every two hours. Other articles should be 
 added, such as expressed beef juice or beef peptonoids. These sub- 
 stances may at first be given alone, and then added to strong beef, 
 mutton, or chicken broth. Gruels of arrowroot or oatmeal, raw 
 eggs alone, or beaten and added to sherry or brandy, custard, milk 
 puddings, and beef jelly are all recommended. 
 
 When improvement occurs, a light convalescent diet may be pre- 
 scribed, such as that found on p. 435. Acidulated drinks, sour 
 lemonade, oatmeal or barley water, and effervescing waters may be 
 used to relieve thirst. 
 
 In mild cases, and in the early stages of many inflammations, 
 alcohol is not required, but if at any time the pulse becomes feeble, 
 the tongue grows dry, or delirium supervenes, stimulants, such as 
 whisky or brandy, should be freely given. Elderly people and those 
 who have been previously reduced by wasting diseases require 
 earlier stimulation in the form both of meat extracts or meat juice 
 and alcohol. From four to six ounces or half a pint of liquor may 
 be prescribed in twenty-four hours, according to its effect on the 
 pulse. In the milder inflammations, especially those of tubercular 
 joints, malt liquors may be of service. A good strong toddy at 
 night may be made to take the place of opium. 
 
 Burns, when severe or extensive, require prompt and energetic 
 stimulation. In bad cases a pint and a half of brandy must be given 
 in twenty-four hours. 
 
 In chronic surgical diseases, attended by the formation of pus, 
 fresh green vegetables and fresh fruits are often serviceable, both 
 for their antiscorbutic and laxative effect. Lemonade, oranges, 
 baked apples, or stewed prunes are recommended. Fats are also 
 especially needed, and butter, cream, olive oil, or cod-liver oil should 
 be added liberally to the diet when the patient is able to digest foods 
 of this class. 
 
PART IX 
 RATIONS, DIETARIES 
 
 ARMY AND NAVY DIETS 
 
 The food furnished to soldiers and sailors, both in time of peace 
 and war, is more accurately weighed and measured, and its effects 
 are more accurately studied, for economic reasons than is the diet of 
 any other class of men, even including hospital patients. While 
 seeking to furnish wholesome variety it is necessary to keep the 
 quantity of food as uniform as possible, and this may be done by 
 substitution of articles the nutrient power of which is closely re- 
 lated ; thus eggs may be occasionally substituted for milk, or peas 
 or beans may be served for a change instead of cereals. 
 
 The United States Army Rations 
 
 A " ration " is technically the total quantity of food issued for 
 one man for twenty-four hours in accordance with law, and not, as 
 often supposed, the allowance for one meal. The original princi- 
 ples upon which military rations have been selected are thus sum- 
 marised by Major Charles E. Woodruff, Surgeon, U. S. A. : 
 
 " i. Economy is essential. 
 
 " 2. The food must be the product of the country at large, neither 
 a specially prepared article nor the output of a few manufacturers. 
 
 " 3. The articles must be easily preserved in all climates by the 
 most ignorant men. 
 
 " 4. The articles must be easily transported and capable of the 
 roughest handling during transit. 
 
 " 5. The ration is intended for the strongest and most robust 
 men in the nation. 
 
 " 6. It must be approximate to the food used by the nation at 
 large, so that there will be no rapid change of diet on enlistment 
 that would impair the health. 
 
 " For these reasons the soldier's ration has always been simple 
 and dry." 
 
 Some of these principles, as the author quoted points out, are 
 radically wrong. It is false economy to furnish too cheap or mo- 
 notonous diet, which only courts disease and swells the pension roll. 
 
 After the Revolutionary War, in 1785, the army ration consisted 
 of one pound of beef, one pound of bread, and one gill of rum. This 
 700 
 
ARMY AND NAVY DIETS 
 
 70I 
 
 was quite insufficient, and was subsequently increased (Woodruff). 
 During that war, in addition to the above ration, the soldier received 
 one pint of milk, a little molasses, and a few dried vegetables, with a 
 quart of beer in place of rum. 
 
 The present United States army ration costs less than fifteen 
 cents. The German soldier is expected to eke out his peace ration 
 by supplies contributed from his home, and the French and English 
 soldier by contributions from his pay, but in the United States the 
 men usually serve so far from home that this system is neither eco- 
 nomical nor desirable. Moreover, with the improvements in can- 
 ning and other methods of food preservation and condensation, it is 
 no longer necessary for the ration to be the product of the surround- 
 ing country. The importance of an adjustable army ration is appre- 
 ciated when it is considered that within the limits of service in the 
 territory owned by the United States may be found a temperature 
 range of 150 F. Diet suitable for Alaska is wholly unfit for Manila. 
 
 UNITED STATES ARMY RATIONS 
 1. For Troops in Garrison {Garrison Ration, igoi) 
 
 Meat components, 
 
 Bread components 
 
 Vegetable compo- 
 nents 
 
 Dried (or evapo- 
 rated) fruit com- 
 ponents 
 
 Coffee and sugar 
 components. . . . 
 
 Seasoning compo- 
 nents 
 
 STANDARD ARTICLES. 
 
 Kinds. 
 
 Fresh beef. 
 
 Flour 
 
 C Beans. 
 
 ^Potatoes, 
 
 Prunes 
 
 Coffee, green, 
 Sugar , 
 
 Soap and candle 
 components. . . . [ 
 
 ( Vinegar 
 
 ]salt 
 
 Pepper, black 
 
 Soap 
 
 Candles 
 
 Quantities. 
 
 20 ounces. 
 
 ounces. . . 
 
 2f ounces. . 
 
 16 ounces. -{ 
 
 if ounce.. 
 
 if ounce. . 
 375- ounces. 
 
 tfr 
 
 rill 
 
 If ounce. 
 Yji ounce. 
 £f ounce. 
 - 2 *V ounce. 
 
 SUBSTITUTIVE ARTICLES. 
 
 Kinds. 
 
 Fresh mutton 
 
 Bacon 
 
 Canned meat 
 
 Dried fish 
 
 Pickled fish 
 
 Canned fish 
 
 Soft bread 
 
 Hard bread 
 
 Cornmeal 
 
 Peas 
 
 Rice 
 
 Hominy 
 
 Potatoes 
 
 Onions 
 
 Potatoes 
 
 Canned tomatoes. . . 
 
 Potatoes 
 
 Fresh vegetables, 
 
 not canned 
 
 Desiccated vegetables 
 
 1 Apples 
 
 1 Peaches 
 
 Roasted and ground 
 Tea, black or green. 
 
 Vinegar 
 
 Cucumber pickles, 
 
 Quantities. 
 
 20 ounces. 
 12 ounces. 
 16 ounces. 
 14 ounces. 
 18 ounces. 
 16 ounces. 
 18 ounces. 
 16 ounces. 
 20 ounces. 
 2§ ounces, 
 if ounce, 
 if ounce. 
 I2f ounces. 
 3^ ounces. 
 I2f ounces. 
 2,5 ounces, 
 ill ounces. 
 
 4f ounces. 
 25- ounces. 
 
 if ounce, 
 if ounce. 
 
 i-is- ounce. 
 ^ ounce. 
 
 A gill. 
 A gill- 
 
yo2 
 
 RATIONS, DIETARIES 
 
 2. For Troops in the Field in Active Campaign {Field Ration) 
 
 Meat components 
 Bread components 
 
 Vegetable compo- 
 nents 
 
 Fruit component. 
 
 Coffee and sugar 
 components. . . . 
 
 Seasoning compo- 
 nents 
 
 Soap and candle 
 components. . . . 
 
 STANDARD ARTICLES. 
 
 Kinds. 
 
 Fresh beef. 
 c Flour 
 
 Baking powder 
 Beans 
 
 Potatoes. 
 
 Jam 
 
 ( Coffee, roasted 
 ■< and ground. 
 ( Sugar 
 
 ( Vinegar 
 
 ISalt 
 
 ( Pepper, black. 
 
 j Soap 
 
 ( Candles 
 
 Quantities. 
 
 20 ounces. . 
 
 18 ounces. . , 
 
 •gf ounce.. . . 
 2f ounces. . . 
 
 r 
 
 16 ounces. •{ 
 
 I 
 if ounce. 
 
 1^5- ounce. . . 
 33- ounces. 
 
 £f ounce. 
 2^5 ounce. 
 £§ ounce. 
 -£g ounce. 
 
 SUBSTITUTIVE ARTICLES. 
 
 Kinds 
 
 Fresh mutton 
 
 Canned meat 
 
 Bacon 
 
 Soft bread 
 
 Hard bread 
 
 Hops 
 
 Dried or compressed 
 yeast 
 
 Rice 
 
 ( Potatoes 
 
 \ Onions 
 
 Desiccated potatoes. 
 
 Desiccated potatoes. 
 
 Desiccated onions. . 
 \ Desiccated potatoes. 
 1 Canned tomatoes. . . 
 
 Tea, black or green, 
 
 Vinegar 
 
 Cucumber pickles. . 
 
 Quantities. 
 
 20 ounces. 
 16 ounces. 
 12 ounces. 
 18 ounces. 
 16 ounces. 
 t^t ounce. 
 
 sV ounce, 
 if ounce. 
 I2|- ounces. 
 3^- ounces. 
 2j ounces, 
 iff ounce. 
 y§- ounce, 
 iff ounce. 
 3-5- ounces. 
 
 2% ounce 
 
 A gill. 
 A gill. 
 
 j. For Troops when Traveling otherwise than by Marching or when for 
 Short Periods they are separated from Cooking Facilities ( Travel Ration) 
 
 STANDARD ARTICLES. 
 
 SUBSTITUTIVE ARTICLES. 
 
 Kinds. 
 
 Quantities per 
 100 rations. 
 
 Kinds. 
 
 Quantities per 
 100 rations. 
 
 Soft bread 
 
 112^ pounds. . 
 75 pounds.. 
 25 pounds. 
 50 pounds. 
 8 pounds. 
 15 pounds. 
 
 
 100 pounds. 
 75 pounds. 
 
 Canned corned beef. 
 
 Corned beef hash. . . . 
 
 Baked beans 
 
 Canned tomatoes 
 
 
 Coffee, roasted and ground. . . 
 Sugar 
 
 
 
 
 The above (3) has the following composition (approximately) 
 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Calories. 
 
 /-. ( Maximum 
 
 I50 
 I20 
 
 I70 
 94 
 
 417 
 380 
 
 3,900 
 2,900 
 
 Grammes. K,. . 
 
 1 Minimum 
 
 
 Mean 
 
 135 
 
 132 
 
 400 
 
 3.400 
 
 
 " This ration is insufficient for active men, being equivalent to 
 the food of men of sedentary habits. The protein is the only ingre- 
 
ARMY AND NAVY DIETS 703 
 
 dient in nearly the proper amount, and this arises from the meats 
 and beans " (Woodruff). 
 
 Although considerable latitude is allowed in the use of substitute 
 foods or variants in the diet, in actual practice army officials and 
 cooks commonly follow routine methods. In commenting upon the 
 importance of adapting our army ration to the needs of the tropics, 
 Major Kean says : 
 
 " Fish is largely eaten by all tropical races near the source of 
 supply, and is undoubtedly less stimulating and more easily digested 
 than butcher's meats. For this cause, and to secure variety, fresh 
 fish, where obtainable, should be used twice a week, no savings 
 being permitted. 
 
 " The issue of the meat components at Columbia Barracks, 
 Cuba, for 185 consecutive days in 1900 was as follows : 
 
 Fresh beef 124 days. 
 
 Mutton none. 
 
 Bacon 47 days. 
 
 Fresh fish 1 day. 
 
 Other issues 13 days. 
 
 " Which shows well the monotony of the issue, the only impor- 
 tant variant being the undesirable bacon. A certainly more desir- 
 able issue, and one apparently permissible according to the paper 
 ration, would have been, for example, somewhat as follows : 
 
 Fresh beef 100 days. 
 
 Fresh mutton 37 days. 
 
 Fresh fish 38 days. 
 
 Other issues 10 days. 
 
 " A saving of two fifths of the fresh meat being authorised. As 
 fresh fish is quite cheap at Havana, the difference in cost would 
 have been immaterial." 
 
 For the tropics this ration contains twice too much salt pork 
 and fresh meat and too few fresh vegetables. The white beans 
 especially cause diarrhoea, and the canned tomatoes are liable to fer- 
 ment. The tropical red beans are less irritating than the domestic 
 white beans. Red beans and hominy are the staple of the Mexican 
 army diet (Seaman). 
 
 Major Kean states (U. S. Surgeon General's Report for 1900) 
 that : " A tropical dietary, as compared with one suited to a colder 
 climate, should have less fat and more carbohydrates, less stimulating 
 proteids in the form of meat, a greater variety of diet both of meats 
 and of carbohydrates in the form of fresh vegetables and fruits, and, 
 lastly, a fairly liberal supply of ice. His argument for the substitu- 
 tion of carbohydrates for fats is that the digestion is weakened in 
 hot climates and the liver is inclined to torpidity, while ingested fats 
 
704 RATIONS, DIETARIES 
 
 are prone to split up into butyric, caproic, and other irritating acids, 
 which the diminished secretion of the liver is unable to neutralise. 
 As intestinal digestion cannot proceed in the presence of acidity, the 
 condition known as biliousness is established, with putrefaction of 
 the intestinal contents and the production of various harmful alka- 
 loidal substances. A catarrhal inflammation of the bowel results, 
 with diarrhoea, which is at first of advantage in eliminating the 
 harmful substances, but which under the continued irritation of un- 
 suitable diet is liable to continue and become aggravated. As to a 
 lessened use of meat, he cites the dietary customs of the inhabitants 
 of hot climates, who get their proteids less from meat than from the 
 leguminosse. The appetite is lessened by long and continued heat 
 and becomes capricious. It craves variety, especially in vegetables 
 and fruits, and these he claims cannot be had on the basis of our 
 present ration. The need of ice to furnish a cool drinking water and 
 to preserve the perishable constituents of the ration is regarded as 
 obvious." 
 
 Munson, in an essay which was awarded the prize of the Military 
 Service Institute for 1900, says : " It is true that the sugars and 
 starches should be slightly augmented, but their increase is small 
 when compared with the considerable reduction of nitrogenous and 
 fatty matter which is proposed." 
 
 It is poor economy to make the change too radical between the 
 garrison and field ration, for in the latter service men are exposed to 
 conditions of hardship and fatigue which demand a more nutritious 
 and varied diet than they obtain in barracks. It is well known 
 that the history of all prolonged wars presents a far greater death 
 rate from disease than from the wounds of battle, and much of the 
 former is caused by improper or insufficient food. The active soldier 
 should have meat three times a day. 
 
 When leading a comparatively inactive post life the ration 
 may prove too large — i. e., the food furnishes more energy than 
 the body needs, but there is not always enough variety. Any 
 excess of food is then sold to a co-operative store, and the money 
 thus acquired is expended for a few luxuries to stimulate the 
 appetite. 
 
 The most concentrated ration which it is practical for soldiers to 
 carry in the field consists of bacon, hard-tack, and coffee. This is a 
 scorbutic diet, and always produces constipation. To obviate this it 
 is now customary to carry desiccated fruits, concentrated by drying, 
 and which are not spoiled by extremes of temperature. Chocolate 
 has been added to the new U. S. army emergency ration, as it has 
 been in Austria and Russia. 
 
ARMY AND NAVY DIETS 
 
 705 
 
 Uncooked Food of Garrison Ration for Ten Days. Weights in Pounds. 
 Daily Average, 440.4 Men (Woodruff) 
 
 Bacon 
 
 Beans 
 
 Pork 
 
 Sugar, brown . . . 
 
 Flour 
 
 Beef 
 
 Potatoes 
 
 Onions 
 
 Oatmeal 
 
 Cornmeal 
 
 Apples, canned . 
 Apples, dried . . . 
 Tapioca (26) and 
 Cornstarch ( 13) 
 
 Butter 
 
 Sirup 
 
 Lard 
 
 Rice 
 
 Corn, canned. . . 
 Tomatoes, can'd. 
 Macaroni (51) 
 
 and vermicelli 
 
 (ii) 
 
 Milk, fresh, lbs. . 
 Milk, condensed, 
 
 lbs 
 
 Cheese 
 
 Prunes 
 
 Cabbage and 
 
 sauerkraut 
 
 Ham 
 
 Apricots 
 
 Barley 
 
 Peas 
 
 Raisins 
 
 Chocolate 
 
 Gross 
 weight. 
 
 Waste 
 
 273* 
 428*1 
 
 343* 
 
 73i 
 
 4,379 
 
 5,025 
 
 5,n6 
 
 700 
 
 44 
 
 85 
 
 10 
 
 183 
 
 39 
 
 58 
 165 
 107! 
 
 26 
 
 63 
 332 
 
 52* 
 3i 
 
 3i 
 ioi 
 
 35 
 
 250 
 
 32 
 
 20 
 5 
 4* 
 
 H I 
 3 
 
 3i 
 
 I26i 
 
 1,131 
 
 1,386 
 
 150 
 
 Net 
 ,-eisrht 
 
 270 
 428* 
 3I2t 
 731 
 
 4 ,2 5 2t 
 3,894 
 3,730 
 550 
 
 44 
 85 
 10 
 
 183 
 
 39 
 
 58 
 
 165 
 
 107* 
 
 26 
 
 63 
 
 332 
 
 52i 
 3i 
 
 3i 
 
 10 
 
 15 
 
 200 
 
 28 
 
 20 
 
 5 
 
 4i 
 10 
 
 Water. 
 
 54.00 
 
 54-05 
 
 37.85 
 
 21.93 
 
 53I-56 
 
 2, 196 . 70 
 
 2,943.00 
 
 481.80 
 
 3-34 
 12.75 
 
 8.32 
 46.85 
 
 0.78 
 
 6.09 
 
 70.60 
 
 12.90 
 
 3-22 
 
 51.22 
 
 318.72 
 
 6.88 
 25.61 
 
 7-75 
 3-50 
 10.00 
 
 182.00 
 11.63 
 i3-5o 
 
 o.55 
 6.45 
 0.48 
 
 Totals 18,598 2,908!- 15,689? 7,120.50 1,413.21 1,657.175,343.66154.8219,446,960 
 
 Protein. 
 
 21.60 
 
 99.10 
 
 2. 
 
 467.78 
 682.97 
 
 78.33 
 7.70 
 6.65 
 
 7- 
 
 0.02 
 
 1.65 
 
 0.58 
 
 0.65 
 1.92 
 1.77 
 2.66 
 
 4-73 
 1.58 
 
 5-27 
 3.30 
 o.75 
 
 4.20 
 4.68 
 0.40 
 0.65 
 1.20 
 0.05 
 0.60 
 
 Fats. 
 
 187.65 
 
 8-57 
 
 259.00 
 
 46.78 
 978.38 
 3-73 
 1.65 
 3.13 
 3-23 
 0.04 
 3.30 
 
 49.30 
 
 89.66 
 0.14 
 0.70 
 i-33 
 
 0.15 
 1.50 
 
 3-4i 
 2.20 
 
 0.60 
 11.00 
 
 0.14 
 0.08 
 
 1.50 
 
 Carbo- 
 hydrates, 
 
 253-8o 
 
 705.42 
 3,185.12 
 
 667.67 
 
 55-55 
 30.01 
 60.01 
 
 i-59 
 130.85 
 
 38.14 
 
 0.29 
 
 90.60 
 
 20.65 
 8.32 
 8.30 
 
 40.32 
 2.00 
 
 13.64 
 0.50 
 4.00. 
 
 11.00 
 
 6.00 
 3.80 
 2-54 
 3-50 
 0.30 
 
 Salts. 
 
 6.75 
 13.29 
 
 13 14 
 
 3-66 
 
 21.26 
 
 35-95 
 
 37-30 
 
 3-30 
 
 o. 
 
 1. 19 
 
 0.03 
 
 2.57 
 
 0.08 
 1.74 
 3.80 
 4-30 
 0.14 
 0.38 
 1. 00 
 
 0.42 
 0.31 
 
 o.93 
 0.50 
 
 0.25 
 
 2.20 
 0.76 
 0.12 
 0.15 
 0.12 
 0.08 
 0.12 
 
 Calories. 
 
 831,600 
 691,228 
 
 J ,097,753 
 1,312,081 
 6,991,110 
 5,409,392 
 1,398,750 
 
 123,750 
 81,400 
 
 139,825 
 3,150 
 
 259,494 
 
 70,980 
 209,670 
 168,795 
 
 383,775 
 42,380 
 
 2i,735 
 26,560 
 
 73,8i5 
 12,552 
 
 49,442 
 
 16,000 
 
 3,500 
 
 31,000 
 
 54,880 
 
 9,200 
 9,000 
 
 7,043 
 6,153 
 7,950 
 
 
 Pounds. 
 
 Grammes. 
 
 Daily average 
 per man .... 
 
 Counting flour as 
 bread, amount 
 eaten is 4 lbs. 
 per man. Per 
 cent of amount 
 eaten 
 
 4.22 
 
 3.56 
 
 85^ 
 
 0.66 
 15** 
 
 733 
 45 
 
 145 
 
 9 
 
 171 
 11 
 
 550 
 34 
 
 16 
 
 4,416 
 
 
 
 
 The usual army-ration tables are misleading in that they omit to 
 account for the consumption of considerable accessory food, which 
 is purchased by the soldier in addition to the portion he receives as 
 fixed by law. Major Woodruff has taken pains to carefully com- 
 pute the nutrient value of the entire food eaten by the men of his 
 garrison at Fort Assinniboine, Montana, during a period of ten days. 
 His table, taken from the Journal of the American Medical Associa- 
 tion, December 3, 1892, p. 651, is above. 
 
706 
 
 RATIONS, DIETARIES 
 
 Additional Articles consumed 
 
 
 Daily per 
 man. 
 
 Allowance. 
 
 
 338 lb. green coffee 
 
 8 lb. tea 
 
 1.23 oz. 1 .60 oz. or 
 0.03 oz. 0.32 oz. 
 
 0. 14 gill 0.32 gill 
 0.46 oz. 0.64 oz. 
 
 0.036 oz. O.04 oz. 
 
 f Though containing m 
 ■i composition is unkr 
 [ man is very small. 
 
 
 20 gall, vinegar } 
 
 128 lb. salt ) 
 
 f Allowance is large, to allow of 
 J making a saving to be used 
 ] in making sauerkraut and 
 (_ pickles in the fall. 
 
 11 bottles flavouring ext'ts. 
 
 3 lb. mustard. 
 
 24 lb. baking powder. 
 6 lb. currants. 
 5 gall, pickles. 
 
 4 kegs pickled pigs' feet . . 
 
 uch energy, it is omitted because 
 lown, and the actual amount per 
 
 EMERGENCY RATIONS 
 
 For scouting parties, troops under forced marching, or under 
 any circumstances which make the supply of the ordinary ration 
 impossible, an emergency ration for temporary service is necessary. 
 The time-honoured food for this purpose consists of bacon, hard- 
 tack, and coffee, sometimes with addition of a little ground peas 
 or beans. 
 
 In the autumn of 1900 an emergency ration was tested in Idaho 
 upon a troop of cavalry. The ration contained in an elliptical can 
 eight inches long weighed one pound and contained three cakes of 
 sweet chocolate (four ounces) and three of a meat (four ounces) and 
 grain compound (eight ounces) having a taste not unlike parched 
 corn. The latter can be eaten uncooked, or as porridge or fried 
 mush. Salt and pepper accompanies the cakes. The ration may be 
 eaten dry, as a soup or porridge, or fried. The test proved success- 
 ful. The details of preparation of this ration, furnished me by Colo- 
 nel Alfred A. Woodhull, U. S. A., are as follows: 
 
 The chocolate component consists of equal weights of pure 
 chocolate and pure sugar molded into cakes of one and one third 
 ounces each. Three of these go into the day's ration. 
 
 The bread and meat component consists of: (1) Fresh lean beef 
 free from visible fat and sinew, ground in a meat-grinder and desic- 
 cated so as to contain five per cent or less of moisture, the heat never 
 being allowed to cook it in the slightest degree. The dried product 
 is then reduced to powder and carefully sifted through a fine-meshed 
 sieve, the resulting flour being the meat component. 
 
 (2) Cooked kiln-dried wheat, the outer bran removed, is parched 
 and then ground to a coarse powder. This yields the bread com- 
 ponent. Sixteen parts of the meat, thirty-two parts of the bread, 
 and one part of common salt, all by weight are thoroughly mixed 
 
ARMY AND NAVY DIETS 
 
 707 
 
 in such small quantities as to be entirely homogeneous and com- 
 pressed into four-ounce cakes. Three of these go into the day's ra- 
 tion. The bread and meat may be eaten dry, or be stirred in cold 
 water and eaten ; or one cake may be boiled for five minutes in three 
 pints of water and seasoned to taste ; or one cake may be boiled for 
 five minutes in one pint of water to make a thick porridge and be 
 eaten hot or cold. When cold it may be sliced, and if fat is available 
 may be fried. 
 
 Three fourths of an ounce of fine salt and one gramme of black 
 pepper are in the can for seasoning. 
 
 " This ration is calculated to subsist a man for one day, maintain- 
 ing his full strength and vigour." As it amounts to a pound of 
 water-free food perhaps it will do it if not depended upon too long. 
 
 Foreign Army Rations 
 
 Soldiers Daily Peace Ration, in Ounces Avoirdupois 
 
 
 British 
 (average). 
 
 French. 
 
 Austrian. 
 
 German. 
 
 Bread 
 
 24.O 
 I2.0 
 
 35-2 
 IO.6 
 
 3I.O 
 
 9 .8 7 
 
 26.50 
 
 j 8.81 (larger ration) 
 \ 3 . 80 (smaller ration) 
 
 Meat (uncooked) 
 
 It is apparent from this table that the French, Austrian, and Ger- 
 man rations all contain more bread and less meat than the English. 
 In addition, the men have potatoes and other vegetables, green or 
 dried, besides sugar, coffee, salt, etc., which are either issued with 
 the ration or purchased with a special allowance of pay, so that the 
 above figures, which apply to only two articles, fall somewhat short 
 of the actual food consumed. For example : The British soldier re- 
 ceives a total of sixty-five ounces of solid food against the French 
 soldier's fifty-one ounces (Parkes) ; but many of them are under- 
 grown men, being several years under twenty-five, up to which 
 period the formation of the bones is not always complete. The Brit- 
 ish army ration contains from four to six ounces less meat than the 
 United States ration, and 4.2 ounces more rice. 
 
 In England the daily ration of the soldier on home service con- 
 sists of one pound of bread (twenty-four ounces is given above as 
 the average for foreign service) and three quarters of a pound of 
 meat, which is supplemented by an allowance of about fivepence a 
 day to be expended on minor articles of diet, green vegetables, milk, 
 sugar, and beverages. 
 
 In the French army legumes form an important element of the 
 ration, to some extent replacing animal food, and many experi- 
 ments have been made with the German army in regard to the intro- 
 duction of vegetable food, especially pea meal, which is rich in nitro- 
 genous material. 
 
708 
 
 RATIONS, DIETARIES 
 
 In France and Holland during active service in the field, in 
 manoeuvres, or in battle the diet is materially increased. Experi- 
 ments made in 1897 upon an Austrian regiment in garrison showed 
 an average gain in weight of 6.6 pounds per man in three months 
 upon a steady daily allowance of protein 120 grammes, fat 56 
 grammes, carbohydrates 500 grammes (J. Schorr). 
 
 The larger ration of the German army, issued during the marches 
 or manoeuvres, contains about five ounces more meat and sev- 
 eral ounces more vegetable food, and in war thirteen ounces of 
 meat are given. Bacon, salt meat, and rice are also supplied. 
 The German army ration for the tropics contains 5.33 ounces 
 of fresh meat, or 4.4 ounces of bacon and seventy-nine ounces of 
 vegetables. 
 
 All the chief armies of Continental Europe issue a wine ration in 
 war times. To the French war ration are added nine ounces of wine 
 or two and a quarter ounces of brandy per diem. 
 
 Munson advocates the use of a tropical army ration comprising 
 fresh fruit, soft bread, potatoes, rice, tomatoes, dried fruits, sugar, 
 and protein limited to one hundred grammes. 
 
 Nation. 
 
 I. England 
 
 2. Spain . . . 
 
 3. Austria. 
 
 Ration. 
 
 1. Home 
 
 2. Foreign station, or 
 
 under canvas at 
 home 
 
 3. March 
 
 Gnis. 
 
 93 
 
 in 
 120 
 
 4. War -!M aX,!l65 
 
 \ Mm., 133 
 
 Sometimes 2 oz. rum 
 
 1. Peace 
 
 j Max. I 147 
 I Min.! 120 
 
 2. War, on march ( Max, 
 or in the field { Min. 
 Sometimes 1.7 oz. 
 brandy 
 
 1. Peace 
 
 2. War.. 
 
 131 
 113 
 
 155 
 165 
 
 Gms. 
 6l 
 
 128 
 92 
 
 125 
 130 
 
 U 
 
 Gms. 
 244 
 
 244 
 
 327 
 
 425 
 425 
 
 588 
 5OO 
 
 522 
 
 485 
 
 504 
 504 
 
 1,938 
 
 2,175 
 2,550 
 
 3,634 
 3,204 
 
 175 
 
 3,729 
 3,421 
 
 3,327 
 2,550 
 
 I50 
 
 3,865 
 3,952 
 
 Remarks. 
 
 This is starvation diet, 
 and the extra food 
 needed for health is 
 purchased and charged 
 against the soldier 
 (about six cents a day), 
 increasing, perhaps 
 doubling, the food 
 value. 
 
 Can be greatly changed 
 to suit climate. 
 
 Sufficient for such a mild 
 climate and very mod- 
 erate work. 
 
 Varies enormously ac- 
 cording to class of ra- 
 tions issued. Very 
 many extra allowances 
 of money for food. 
 
 This is augmented by 
 four cents per day for 
 vegetables, etc. On 
 the march a limited 
 emergency ration is 
 used. The war ration 
 is so insufficient that 
 commanders of armies 
 or smaller forces may 
 change, supplement, or 
 even double it. 
 
ARMY AND NAVY DIETS 
 
 709 
 
 Nation. 
 
 Ration. 
 
 4. Italy.. 
 
 5. Germany 
 
 6. United 
 States, 
 
 7. France. . 
 
 Russia 
 
 1. Garrison 
 
 2. Camp 
 
 3. Marching 
 
 Usually wine added. 
 
 Gms. 
 
 Ill 
 115 
 125 
 
 I. Small rations 
 and portions 
 in garrison 
 and canton- 
 ments 
 
 Max 
 Min 
 
 2. Large rations] 
 
 and portions j , , 
 on march or ^ax. 
 in manceu- | 
 vres J 
 
 3. Field Ijjax. 
 
 3 I Min. 
 
 Commanding general 
 may add 33- oz. 
 
 whisky 
 
 Max. 
 in 
 Max 
 Min 
 Ave 
 
 Food actually eaten "] 
 in cold climate, j 
 moderate work, { 
 including all ex- 
 tras from gardens 
 and purchases . . . 
 
 , -r> , ( Ma 
 
 • B y law ]m« 
 
 2. Usually in 
 field(bylaw). 
 
 War 
 
 Max. 
 Min. 
 Add 2tV oz. brandy. 
 
 1. Peace. 
 
 j Max. 
 • ' j Min. 
 Add 3 oz. wine 
 
 2. W; 
 
 Max. 
 Min. 
 
 Add 4-3- oz. wine. 
 
 150 
 99 
 
 172 
 
 138 
 
 195 
 
 78 
 
 183 
 
 105 
 
 106 
 
 64 
 
 85 
 
 155 
 
 183 
 146 
 
 233 
 165 
 
 174 
 149 
 
 Gms, 
 
 130 
 133 
 143 
 
 260 
 103 
 320 
 240 
 
 280 
 
 180 
 
 300 
 127 
 
 114 
 
 65 
 
 Gms. 
 
 60O 
 600 
 600 
 
 703 
 502 
 
 915 
 644 
 
 703 
 
 515 
 
 621 
 500 
 540 
 460 
 500 
 
 597 
 
 690 
 520 
 
 976 
 746 
 
 805 
 640 
 
 4,129 
 
 4,163 
 
 4.307 
 
 250 
 
 3,947 
 2,827 
 
 4,961 
 3,744 
 
 4,786 
 3,413 
 
 268 
 5,368 
 3,712 
 5,166 
 4,722 
 5,ooo 
 
 4,907 
 
 5,455 
 
 4,oi5 
 
 184 
 
 5,884 
 
 4,45o 
 
 223 
 
 4,583 
 
 3,307 
 
 362 
 
 Remarks. 
 
 Allowances of one fifth 
 cent per day for condi- 
 ments ; occasional extra 
 money allowances for 
 food. Excepting the 
 protein, it is a very lib- 
 eral diet for such a mild 
 country. 
 
 "| This is what the govern- 
 ment may supply. Usu- 
 ally the soldier feeds 
 himself and is given 
 
 )- seven cents a day, or 
 more, to reimburse him- 
 self. Food eaten is 
 more than this defi- 
 cient diet. 
 
 ") Maxima due to fats if all 
 
 ; the bacon is used and 
 
 y no meat. The whole 
 
 ration is supposed to be 
 
 J supplied and eaten. 
 
 Peace ration not stated. 
 It is purchased as need- 
 ed and charged against 
 soldier. War ration is 
 subject to great aug- 
 mentation for increased 
 work or cold climate. 
 The commanding offi- 
 cer can augment ration 
 on the march. 
 ") Also allowed money to 
 buy one half to one and 
 one half ounces extra 
 meat, and one to one 
 and one half cents for 
 vegetables, salt, butter, 
 lard, and groceries. 
 
 Extra meat and spirits 
 may be ordered by the 
 commander in chief. 
 
710 
 
 RATIONS, DIETARIES 
 
 The foregoing comparative table of various national army rations 
 was published by Major Charles E. Woodruff, M. D., U. S. A., in 
 the New York Medical Record (vol. lv, No. 20, 1899). 
 
 As stated by Major Woodruff, the United States is the only 
 nation in the world that in time of peace pretends to supply the en- 
 tire ration. Soldiers living in densely populated European coun- 
 tries supplement their rations by local purchases from a mess fund 
 or, as in Germany, from supplies from his home. In Austria bread 
 alone is furnished as a peace ration, other food being purchased 
 from a money allowance. At remote frontier posts in the United 
 States a variety of local purchases is frequently unobtainable, and 
 hence the attempt to supply the whole ration in kind. 
 
 Navy Rations 
 
 From Table A, showing the Different U. S. Navy Rations and their Compo- 
 nent Parts, as established by Law, with the Substitutes legally allowed for 
 
 each Article 
 
 Allowance for General Use 
 
 Rations as composed 
 
 EITHER 
 
 OF THE FOLLOWING — 
 
 by Law. 
 
 Specified by law. 
 
 Substitutes authorised by law. 
 
 Ration No. I 
 
 I lb. salt pork. 
 
 \ pt. beans or peas. 
 
 
 i£ lb. fresh meat, or 
 £ lb. preserved meat. 
 Vegetables of equal value, or 
 \ lb. rice. 
 
 Ration No. 2 
 
 Ration No. 3 
 
 1 lb. salt beef. 
 | lb. flour. 
 
 2 oz. dried fruit. 
 
 £ lb. preserved meat. 
 \ lb. rice. 
 2 oz. butter. 
 
 1 oz. desiccated mixed 
 tables. 
 
 vege- 
 
 l£ lb. fresh meat, or 
 
 £ lb. preserved meat. 
 
 Vegetables of equal value. 
 
 No substitute. 
 
 4 pt. beans or peas. 
 
 No substitute. 
 
 6 oz. canned vegetables. 
 
 Ration No. 4 
 
 £ lb. preserved meat. 
 
 2 oz. butter. 
 
 6 oz. desiccated tomatoes 
 
 
 No substitute. 
 No substitute. 
 6 oz. canned tomatoes. 
 
 
 Weekly Allowance 
 
 
 
 \ pt. pickles. 
 \ pt. molasses. 
 \ pt. vinegar. 
 
 
 
 
 Daily Allowance 
 
 
 
 14 oz. biscuit. 
 
 
 1 lb. soft bread. 
 1 lb. flour. 
 \ lb. rice. 
 
 
 \ oz. tea. 
 
 
 2 oz. coffee. 
 2 oz. cocoa. 
 
 
 4 oz. sugar. 
 
 
 For coffee and sugar, extract 
 of coffee combined with milk 
 and sugar may be substituted 
 by the Secretary of the Navy, 
 if not more expensive. 
 
ARMY AND NAVY DIETS 711 
 
 The law allows one of the above complete rations to be used on 
 any or each day of the week, or they may each be used in turn as 
 convenient, in case it becomes necessary to vary the order prescribed 
 elsewhere. Estimated average cost per capita per diem, thirty cents. 
 
 The following statement is from the New York Medical Record 
 (1898) : 
 
 " The naval full-diet table is as follows for one day in the week, 
 the number after each article relating to ounces : Breakfast — coffee, 
 1 ; bread, 4 ; butter, 1 ; milk, 6 ; sugar, 1 ; oatmeal, 1 ; beefsteak, 6. 
 Dinner — rice soup, 8 ; bread, 4; roast beef or roast or boiled fowl, 8 ; 
 potatoes, 8 ; other vegetables, 6 ; pickles, 1 ; bread pudding with 
 sauce, 6 ; or custard frozen, 8 ; fresh fruit, 6. Supper — tea, J ; bread, 
 6 ; butter, 1 ; milk, 2 ; sugar, 1 ; cold roast mutton or cold roast beef, 
 4 ; stewxd dried fruit or baked fresh fruit or apple sauce, 4. The 
 staples — coffee, bread, butter, milk, sugar, and fresh and dried fruit — 
 are the same for each meal, but there is a daily variety in meats and 
 other articles for breakfast, dinner, and supper. The proportions 
 are about the same, however, especially in the matter of meats, as 
 in the specimen diet table given above. In addition to its use for 
 convalescents, the table is now observed for all naval-hospital em- 
 ployees, and is gradually becoming the standard aboard ship and in 
 the marine corps. Its adoption was the result of most patient and 
 thorough investigation by Surgeon I. D. Gatewood, who consulted 
 all the leading authorities on the subject." 
 
 Table showing the Quantities of the Different Articles of the U. S. Navy 
 Ration which are required for One Man for One Year 
 
 Biscuit 319! pounds. 
 
 Biscuit (with flour) 182 " 
 
 Cornrneal 52 " 
 
 Oatmeal 52 
 
 Rye flour or hominy 52 " 
 
 Wheat flour 52 
 
 Salt pork 104 " 
 
 Beans 6i gallons. 
 
 Peas 3i " 
 
 Salt beef 52 pounds. 
 
 Rice 26 
 
 Dried fruit 13 " 
 
 Butter igi 
 
 Tomatoes 19^ 
 
 Canned meal 78 " 
 
 Ham or bacon 39 " 
 
 Sausage or salt fish 39 " 
 
 Coffee 26 
 
 Tea 4l " 
 
 Cocoa 19^ 
 
 Sugar gii " 
 
 Pickles 26 " 
 
 47 
 
712 
 
 RATIONS, DIETARIES 
 
 Molasses 3 1 gallons. 
 
 Vinegar 3^ " 
 
 Canned vegetables 39 pounds. 
 
 The British Navy ration contains one pound of fresh meat, one 
 pound and a half of bread, or one pound and a quarter of sea biscuit. 
 
 In comparing navy with army rations it should be remembered 
 that on shipboard a proper cooking range, utensils, and fuel are 
 always obtainable, whereas wholly different conditions obtain with 
 an army in the field. 
 
 Table showing the Different Articles of the U. S. Navy Ration, for which 
 Practical Equivalents or Substitutes are permitted, with the Quantity 
 of each allowed for Issue 
 
 Articles named in 
 the Law. 
 
 Bread. 
 
 Flour. 
 
 Preserved meat. 
 
 Articles considered as included under names given in 
 preceding column. 
 
 Biscuit 
 
 Soft bread 
 
 Cornmeal 
 
 Corn (hominy), 
 
 Oatmeal 
 
 Rye 
 
 Dried fruit 
 
 Tea 
 
 Cocoa 
 
 Fresh meat 
 Vegetables. 
 
 Wheat 
 
 Roast beef. 
 
 Canned mutton 
 
 Chicago corned beef. 
 
 Brawn 
 
 Ham 
 
 Bacon 
 
 Sausage 
 
 j Dried 
 
 Fish -< Smoked 
 
 ( Pickled 
 
 Dried apples. ] 
 
 Peaches. 
 
 Raisins. 
 
 Currants. 
 
 Prunes. 
 
 Figs. 
 
 Dates. 
 
 May be substituted for each other 
 
 Beef. 
 
 Mutton. 
 
 Veal. 
 
 Pork. 
 
 Poultry. J 
 
 Fresh (such as can be procured). 
 
 Canned (assorted kinds) 
 
 ■ Or any other kind of dried 
 fruit 
 
 Or any other kind of fresh meat 
 
 Quantity allowed 
 per ration. 
 
 14 OZ. 
 lib. 
 
 As substitute for 
 1 lb. bread. 
 
 \ oz. 
 2 oz. 
 
 illb. 
 
 Iilb. 
 6 oz. 
 
 DIET IN PRISONS 
 
 In prisons, penitentiaries, or reformatories the diet should be 
 adapted to keep the patients in good health through periods of 
 years, while it is maintained at a minimum of expense to the com- 
 munity. A brief review of such established diets is useful in furnish- 
 
DIET IN PRISONS 713 
 
 ing an idea of quantity and quality of food required to fulfil the 
 necessary conditions. 
 
 Voit calculated that for a prisoner not engaged in hard labour 
 the following diet is sufficient to maintain health : Carbohydrates, 
 three hundred grammes ; albumin, eighty-five grammes ; fat, thirty 
 grammes, or a proportion of about 10, 3.5, and I. 
 
 In some penal institutions the inmates are placed upon a pro- 
 gressive diet — that is, a diet which is regulated according to the 
 duration of their sentence, the degree of labour exacted from them, 
 and their conduct. Such a diet has been recommended by the 
 British Commissioners of Prisons, graded for: (1) Periods of seven 
 days or less. (2) Periods between seven days and one month. (3) 
 Periods between one and four months. (4) Periods exceeding four 
 months. 
 
 A somewhat similar system is detailed below — that of the United 
 States Army Prison at Fort Leavenworth. 
 
 Diets of the United States Army Prison, Fort 
 Leavenworth, Kansas 
 
 general diet 
 
 Breakfast. — Hash, on Tuesday, Wednesday, Thursday, Saturday 
 and Sunday. Mutton or beef stew, on Monday and Friday. Coffee, 
 one quart each morning. 
 
 Dinner. — Pork, one day each week. Corned beef, one day each 
 week. Roast beef and gravy, three days each week. Boiled beef 
 and gravy, two days each week. Vegetable soup, daily except 
 Sunday. 
 
 One pint of coffee each Sunday. Pork may be substituted for 
 corned beef or boiled beef one day each week during cold weather. 
 
 To the above will be added pickled cucumbers, beets, or toma- 
 toes on alternate days, and such other vegetables as may be avail- 
 able from the prison farm. 
 
 Supper. — Tea or coffee, one quart ; bread, as much as required. 
 Stewed apples or prunes on alternate days. 
 
 No. 1. The following diet, known as " Solitary," is given prison- 
 ers confined in cells for punishment, while not performing any 
 labour : 
 
 Breakfast. — Bread, eight ounces, water ad libitum. 
 
 Dinner. — Bread, eight ounces ; water ad libitum. 
 
 This punishment is given only for short periods, varying up to 
 twenty days. 
 
 Total farinaceous foods, sixteen ounces. 
 
 No. 2. The following diet, known as " Restricted," is given pris- 
 oners confined in cells for punishment, while not performing any 
 labour : 
 
7i4 
 
 RATIONS, DIETARIES 
 
 Breakfast. — Hash or stew, eight ounces. Bread, seven and a half 
 ounces. 
 
 Dinner. — Soup, eight ounces. Bread, seven and a half ounces. 
 Salt ad libitum. 
 
 Supper. — Bread, eight ounces. 
 
 The eight ounces of bread for supper to be given after the 
 twenty days of subsistence on the previous diet. 
 
 Total proteid food, eight ounces ; total farinaceous food, twenty- 
 three ounces. 
 
 No. 3. The following diet is given to prisoners who have under- 
 gone punishment : 
 
 Breakfast. — Hash or stew, ten ounces. Bread, ten ounces. 
 Coffee and sugar in the usual amounts. 
 
 Dinner. — Soup, the usual amount. Beef, eight ounces, or pork, 
 six ounces. Peas or beans, six ounces, or hominy in the usual 
 amount, or potatoes, eight ounces. Xo other vegetables except 
 such as are contained in the soup. 
 
 Supper. — Bread, ten ounces. Tea and sugar in the usual 
 amounts. 
 
 To prisoners who have been on " Restricted Diet " for more 
 than ten days and less than twenty days, or on " Solitary Diet " for 
 ten days, the above diet (No. 3) is given for two days. 
 
 For those who have been on " Restricted Diet " for twenty days 
 or more, or on " Solitary Diet " for fifteen days, the above diet (No. 
 3) is given for three days. 
 
 The dietary of the New York State Reformatory will be found 
 on pp. 716-718 in tabular form. 
 
 The comparison of this Reformatory Diet with other standard 
 rations is presented in the following table of actual nutrient values : 
 
 Reformatory standard dietary daily ration * 
 
 Actual upper first grade ration 
 
 Actual lower first grade ration 
 
 Actual second grade ration 
 
 Playfair's standard for adults, moderate exercise. 
 Voit's standard for labouring men at moderate work 
 
 Voit's standard for prisoners in idleness 
 
 Voit's standard for prisoners at work 
 
 NUTRIENTS, IN 
 
 GRAMMES. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 556 
 
 119 
 
 61 
 
 167 
 
 75 
 
 8IO 
 
 154 
 
 69 
 
 794 
 
 154 
 
 69 
 
 776 
 
 119 
 
 5i 
 
 53i 
 
 T18 
 
 56 
 
 500 
 
 85 
 
 30 
 
 300 
 
 105 
 
 40 
 
 500 
 
 Potential 
 
 energy, 
 
 in calories. 
 
 3.334 
 4,696 
 
 4,524 
 
 4.452 
 
 3,140 
 3.050 
 
 1.857 
 2,852 
 
 * All food supplies are issued according to this standard dietary, except bread, 
 which is unlimited. The average consumption of bread per man is somewhat in excess 
 of one and one half ration per meal, thus accounting for the increase in value of the 
 actual ration over that of the standard dietary, which conforms very nearly in food 
 values to the standards of Voit and Playfair. 
 
DIET IN PRISONS 715 
 
 At a Conference of the Prison Association of New York, the 
 following bill of fare was recommended for general adoption in pris- 
 ons. The quantity of food is not specified : 
 
 Sunday 
 
 Breakfast. — Pea soup, bread and butter. 
 Dinner. — Baked beans, brown bread, pudding. 
 Slipper. — Bread or crackers, cheese, milk. 
 
 Monday 
 
 Breakfast. — Oatmeal or boiled rice, with sugar and milk. 
 Dinner. — Salt fish, vegetables, fruit. 
 Supper. — Bread and butter, milk. 
 
 Tuesday 
 
 Breakfast. — Bean porridge, bread. 
 
 Dinner. — Roast beef, two or more kinds of vegetables, bread. 
 
 Supper. — Bread and milk, molasses. 
 
 Wednesday 
 
 Breakfast. — Pea soup, bread. 
 
 Dinner. — Beef or mutton stew, with vegetables. (Rice may be 
 used in place of potatoes.) 
 
 Supper. — Cornmeal mush, molasses. 
 
 Thursday 
 
 Breakfast. — Bread and butter, milk. 
 Dinner. — Baked beans, bread, fruit. 
 Supper. — Bread and butter, cereal, coffee. 
 
 Friday 
 
 Breakfast. — Pea soup, bread. 
 
 Dinner. — Fresh fish, vegetables. (Rice may be used in place of 
 potatoes.) 
 
 Supper. — Bread and milk, cheese. 
 
 Saturday 
 
 Breakfast. — Oatmeal mush, milk, bread. 
 Dinner. — Corned beef, vegetables. 
 Supper. — Bread and milk, molasses. 
 
716 
 
 RATIONS, DIETARIES 
 
 OV3 
 
 § J 
 
 'jo co -r u-i 
 u-> o en o 
 
 COO CO M 
 
 O l> a 
 
 T H CO 
 
 en m" 
 
 co a oj -too r^ 
 m o h m 
 
 en en 
 en en 
 
 Min. 
 
 ! *■ 
 
 1 
 
 co r^co O O 
 
 co 
 
 O O vO O <3- 
 
 
 
 mat'r 
 
 O O O w o 
 
 O 
 
 O m en <n O 
 
 
 
 
 
 
 
 
 
 
 t^. 
 
 co r^ oi r^ o O 
 
 t^ m o w en o 
 
 04 o 
 
 04 vO 
 
 O 
 
 x m 
 rt-O 
 
 o 
 
 
 
 
 
 O en m 
 
 O M 
 
 M 
 
 en o O O m co 
 
 en m 
 
 in 
 in 
 
 
 
 
 
 
 O IT) M 
 
 O 
 
 O M Tf O rf O 
 
 
 
 vs. 
 
 
 
 
 
 O m O 
 
 -t in H 
 
 o 
 
 moo r^ t^ c> en 
 
 i>.o uio r^o 
 
 
 
 
 N 
 
 h <tO vo rj- O <N 
 in c>co x^ en m m 
 
 <* 
 
 o 
 
 in 04 <N M H • 
 
 O O « O O • 
 
 ££> 
 
 
 u5 
 
 u 
 
 O t-» H O 
 
 O en O 
 
 o 
 
 o o o o o • 
 
 in 04 
 
 O 
 
 
 O l> w in O O M 
 
 01 
 
 h h m m-t • 
 
 
 
 
 &K. 
 
 co m eno nh o 
 
 o 
 
 h r^ oi 04 o • 
 
 
 
 
 N 
 
 
 <N mcO 
 
 en 
 
 m rj- Tt en en • 
 m o "* O h • 
 
 en w 
 
 a 
 
 1 
 
 
 
 M Tf M O 
 
 O *t-H 
 
 O 
 
 O O c-i O O • 
 
 04 
 
 H 
 
 
 O co m co 
 
 O Oco 
 
 O 
 
 m i-h m in ^- • 
 
 
 
 fc< 
 
 O 
 en 
 
 en r^ 
 
 h en 
 
 CJ 
 
 M CO M 
 
 M 
 
 m vn en O r^ • 
 
 M l-l 04 H 
 
 
 
 vO r-» r- o *3- 
 
 rf t^ enco 04 
 
 c> o 6 
 
 I 
 
 
 4) O 
 
 Is 
 
 
 OOOO OOOOOOOOOOmOmmO i 
 ^OOO oOOinOOOmLr, OWinNr^O 
 
 
 Omoom na)ONin*<tMNir)000 H H j 
 
 en O O m en j 
 
 
 aj 
 
 in 
 
 ml CO 
 
 
 T) 
 
 | 
 
 CO CO -T^N+HS-lN r^M 
 
 
 J3 
 
 
 CO vO ^ 
 
 
 >> 
 
 ' 
 
 
 CO 
 
 
 - 
 
 
 O co «kmHn . i-i 
 CJ l-l 
 
 
 J3 
 
 
 °. CO O 
 
 
 ed 
 
 -a 
 
 3 
 
 -C 
 
 H 
 
 -| 
 
 
 T3 
 
 1 
 
 l-l CO o 
 
 < 
 
 W 
 
 Q 
 
 XI 
 
 
 M- ^^ 
 
 c 
 
 U! 
 
 
 CO 
 
 > 
 
 T3 
 
 
 CO CO -^--^N 04 ^m^m^ ^^ 
 
 < 
 
 A 
 
 XI 
 
 
 CO O F*fl 
 
 Q 
 
 < 
 P 
 
 Z 
 < 
 H 
 
 m 
 
 T3 
 
 1) 
 
 3 
 
 H 
 
 «l 
 
 •o 
 
 
 O CO "t+H _, i_ H« -ttrHe''*i<xH l 
 
 X 
 
 
 M °° 
 
 
 -a 
 
 c 
 o 
 
 tn 
 
 
 co 
 
 
 T) 
 
 
 <N CO <N Hm 
 
 
 X 
 
 
 co rf 
 
 
 S 
 3 
 
 m 
 
 . 
 
 
 co 
 
 
 -3 
 
 
 <N CO 
 
 
 X 
 
 ^ COO 
 
 
 
 * 
 
 T3 
 <U 
 
 u 
 
 o 
 o 
 
 U 
 
 
 • • cS 
 
 
 
 v ■— 
 
 o a, 
 
 "" a. 
 
 PC 
 
 ■ ^ p. (/•-.•• 
 
 its ■'cn'':^' <1 J'^-''' 
 
 2Ph!^ « Ph O H U Oh cq H to O M PQ P< 
 
 'X 
 
 (U 
 in 
 en 
 
 Q 
 
 s 1 
 
 u a 
 
 V <u 
 
 j- a 
 
 o o 
 
DIET IN PRISONS 
 
 717 
 
 l-» 
 
 <* <N 
 
 
 <N 
 
 O ""> 
 
 
 CO 
 
 1-1 ^f 
 
 
 
 
 
 ^ 
 
 CO 
 
 
 CO 
 
 O CO 
 
 O 
 
 in 
 
 CO 
 
 
 
 
 rt 
 
 in 
 
 h r-N 
 
 c^ 
 
 
 rt- 
 
 in r^ 
 
 
 
 
 
 
 
 
 
 N I OO ^~ 
 
 
 O <U 51 
 
 U H en 
 
 o o 
 
 ^ CO I H O 
 
 moo 1 l> O 
 M in 00 O 
 
 1 CO 
 
 in in 
 
 CO rt 
 
 6 6 
 
 O 00 
 
 O co 
 
 ino 
 
 O O 
 O co 
 
 O co 
 
 O M 
 
 o 3 * a a -g 
 
 UcflQUWU 
 
 -3 
 
 £ -6 
 
 o o 
 
RATIONS, DIETARIES 
 
 From the New York State Reformatory Annual Report for i8gj 
 Calculations based on Prof. Atwater's tables, with Reformatory standard diet added. 
 
 COMPARISON OF DAILY DIETARIES 
 
 Carbohydrates 
 
 Fats 
 
 Protein 
 
 Potential energy 
 
 Nutrients, Grammes 
 
 Potential Energy, Calories 
 
 200 400 600 800 1000 1200 1400 1600 
 
 I 1 1 r- 
 
 Subsistence diet (Playfair) 
 Under-fed labourers, Lombardy, Italy 
 
 Students, Japan 
 
 Lawyers, Munich, Germany 
 
 Well-paid mechanic, Munich, Germany 
 
 Well-fed blacksmith, England 
 
 German soldiers, peace footing 
 
 German soldiers, war footing 
 
 French-Canadian families, Canada 
 
 Mechanics and factory operatives, Massachusetts 
 
 Well-to-do family, Connecticut 
 
 College students, Northern and Eastern States 
 
 Machinists, Boston, Mass 
 
 Hard-worked teamsters, etc., Boston, Mass 
 
 U. S. Army ration 
 
 U. S. Navy ration 
 
 N. Y. State Reformatory standard 
 
 Reformatory standard daily ration 
 
 Actual upper first grade dietary 
 
 Actual lower first grade dietary 
 
 Actual second grade dietary 
 
 Playfair's standard for adults, moderate exercise 
 Voit's standard for labouring men at moderate work. 
 Voit's standard for prisoners in idlene 
 Voit's standard for prisoners at work 
 
THE MILK CURE 719 
 
 THE MILK CURE 
 
 An exclusive diet of milk as a cure for certain chronic diseases is 
 advocated by some physicians, and in whose hands it has met with 
 considerable success. Karell, of St. Petersburg, and Weir Mitchell 
 are to be mentioned among those who have extensively used this 
 form of treatment. The treatment as a " cure " does not apply to 
 the temporary exclusive milk diet of typhoid fever and similar acute 
 febrile conditions, but it is believed by the advocates of the milk 
 diet that this form of food not only counteracts certain abnormal 
 conditions and meets definite requirements of the body, but that the 
 milk diet itself possesses a special curative value in some cases. 
 Bauer says emphatically : " It is an indisputable fact that in certain 
 diseases a methodical use of the milk cure gives results such as can 
 be attained by no other treatment." 
 
 It is recommended in obstinate cases of chronic intestinal dis- 
 orders, especially neuralgia, intestinal dyspepsia, and colitis ; in 
 chronic congestion, hypertrophy, and fatty degeneration of the liver ; 
 in asthma, pulmonary catarrh, and emphysema ; in dropsies of renal, 
 cardiac, and hepatic origin; in hysteria and hypochondriasis, in 
 which the predominant symptoms are dyspepsia and malnutrition ; 
 and in chronic catarrhal conditions of the whole alimentary canal. 
 
 The milk cure is also recommended in cases of neurasthenia, 
 obesity, rheumatism, gout, chronic valvular cardiac diseases, chronic 
 Bright's disease, and endarteritis. 
 
 Dosage and Method of giving the Milk. — The milk used is 
 skimmed, and it is important to have it obtained as fresh from the 
 country as possible. It is customary to begin with comparatively 
 small doses — about four ounces, once in two hours throughout the 
 day, with one or two doses at night. Karell gives the milk luke- 
 warm. At the end of a few days the dosage may be increased to six 
 or eight ounces, and the intervals made three-hourly, and finally 
 four-hourly, when twelve tumblerfuls are given daily. Pecholier 
 gave three litres per diem, in two-hourly doses. When the treat- 
 ment is undertaken it must be carried out with absolute regularity 
 and system, both as regards the quantity of milk consumed and the 
 intervals at which it is given ; otherwise, if too large an amount is 
 drunk at one time, or the intervals are too frequent, undigested milk 
 remains in the stomach to mingle with the fresh doses, and abnormal 
 fermentation and dyspeptic symptoms result. It is much better that 
 the milk should be given alone whenever large quantities are to be 
 taken for a long time. If diarrhoea exists, the milk may be boiled 
 or taken hot at any time, if the patient so prefers it, but this is not 
 necessary. If the passages from the bowels are normal in appearance 
 — small and solid — the milk is being well digested and absorbed, 
 
J20 RATIONS, DIETARIES 
 
 and the quantity may be increased. Usually the greatest difficulty 
 with indigestion in this form of treatment occurs during the first 
 week ; afterward, as a rule, the alimentary canal becomes accustomed 
 to the diet and digestion proceeds actively and nutrition improves. 
 
 Many patients — either from imagination or from past experience 
 with milk drinking — insist that they are unable to take it in any 
 form, but it is rare, indeed, to find any one who cannot digest milk if 
 it is made palatable and properly prepared. For this purpose, sug- 
 gestions will be found under the heading of the article on the Adap- 
 tation of Milk for the Sick (p. 73), to which the reader is referred. 
 Not a few learn to prefer the milk to more highly seasoned food. If 
 the patient chooses — and it is wholly a matter of taste — the milk can 
 be flavoured with very weak tea, weak coffee, or caramel, and a 
 pinch of salt should be added in most cases to each tumblerful. Ex- 
 ceptionally the flavour of a little spice of some sort may be preferred. 
 Some patients do better if the milk is diluted by one third or one 
 half with some alkaline table water, lime water, or Vichy, or it may 
 be scalded with a little boiled water to which five grains of sodium 
 bicarbonate and three or four grains of common salt are added. 
 Milk from first-class thoroughbred cows, such as Alderneys, is often 
 too rich, and it is undesirable to give any milk in this cure which 
 contains much cream. Skimming the milk is therefore necessary in 
 most instances, and in some cases, even after the milk is skimmed, 
 it is better digested if considerably diluted. 
 
 In carrying out this treatment much depends upon previously 
 gaining the confidence of the patient and having him thoroughly 
 understand the theory of the cure, so that his willing co-operation 
 may be obtained in a method which is monotonous and wearisome at 
 best. By a little tact and persuasion with care in framing the origi- 
 nal rules and supervision over their execution the cure may often 
 be conducted with great benefit in seemingly difficult cases. The 
 one object of the treatment is to enable the digestive organs to rest 
 and recuperate when they are in an exhausted or irritable condition 
 by giving only small quantities of the simplest form of food at first. 
 Later, as digestion improves, larger amounts will be tolerated and 
 the strength and nutrition of the patient will be promoted by in- 
 creasing the dosage of milk to whatever maximum can be reached 
 without taxing the stomach. 
 
 Symptoms accompanying 1 the Treatment. — The frequent occur- 
 rence of constipation is a not unfavourable indication that the milk 
 is lacing well digested and very completely absorbed, leaving but 
 small residue. Diarrhoea or obstinate vomiting, on the other hand, 
 indicate indigestion and malnutrition, and the difficulty should be 
 corrected by temporarily reducing the quantity of milk and pro- 
 longing the intervals between the doses to four or even six hours. 
 The constipation is met by the use of a pill of two grains of inspis- 
 
THE WHEY CURE 721 
 
 sated oxgall, or by the compound licorice powder (pulvis glycyr- 
 rhizae compositus), or a dose of rhubarb, or half an ounce of castor 
 oil, or thirty to sixty minims of fluid extract of cascara. The addi- 
 tion of coffee to the milk drunk in the earlier hours of the day some- 
 times renders it more laxative, and, if necessary, prunes or stewed 
 or baked apples may be taken once daily, in the middle of the 
 afternoon. 
 
 In addition to the milk, patients should be allowed a reasonable 
 quantity of water or of aerated waters. It is well that some water 
 should be given even though thirst be not complained of. After a 
 fortnight or three weeks some patients complain very much of the 
 absence of solid food, and in such cases — if the digestion is favour- 
 able — stale bread, crackers, dry toast, or a little salted Dutch herring 
 may be allowed, or a milk soup thickened with barley or groats. 
 Some patients do well to take one of the prepared starchy foods, 
 such as are in familiar use for infant feeding. As a usual result of 
 the treatment, patients lose weight somewhat during the first ten 
 days or two weeks, but after the quantity of milk begins to be in- 
 creased they may gain considerable flesh and strength, excepting in 
 the case of very obese persons, who may continue to lose fat after 
 the maximum dosage of milk has been attained. Drowsiness is also 
 a common symptom in the first few days. The urine is increased, 
 and is pale in colour and of low specific gravity. The tongue is 
 covered with a thick white or yellowish coating, and there is usually 
 a disagreeable, mawkish taste in the mouth. The latter condition 
 may be relieved very largely by proper care (compare Treatment of 
 Typhoid Fever, p. 426). The increased quantity of urine is possibly 
 clue to the large amount of lactose, which is somewhat diuretic in 
 action ; but when given alone I have not found it to possess excep- 
 tional power in this direction. According to Weir Mitchell, the 
 uric acid is greatly reduced in the urine and the colour is of a some- 
 what greenish hue, and indol and skatol also disappear. Weir 
 Mitchell calls attention to the extensive changes in assimilation in 
 the body which these various alterations in excretions indicate. 
 
 After about six weeks of this milk diet the substitution of solid 
 food is to be gradually made, reducing the number of milk meals by 
 at first one a day for a day or two, then by two, and so on until all 
 food is taken solid, and Karell suggests that lean, raw scraped beef 
 with stale bread is the best to begin with. The diet should be so 
 graded as to consist largely of milk for several months. 
 
 THE WHEY CURE 
 
 The whey cure has been extensively practised in the mountain- 
 ous regions of Germany and Switzerland and at various springs or 
 baths, especially those of the alkaline waters, which latter are fre- 
 
722 RATIONS, DIETARIES 
 
 quently mingled with the whey and drunk either warm or cold. The 
 treatment is rigorous, and consists in confining the patient's diet 
 largely to the use of about twenty ounces per diem of fresh milk 
 whey. The principles of the treatment are essentially similar to 
 those of the milk cure, but in whey the casein of the milk has been 
 artificially removed to make cheese by the addition of rennet, the 
 milk-curdling ferment. 
 
 Whey is made from the milk of several animals, such as the 
 sheep, goat, mare, and ass, as well as the cow. It consists of milk 
 sugar, albumin, substances resembling peptone, and a smaller quan- 
 tity of fat with most of the lactic acid. It is whitish, translucent, 
 and opalescent. 
 
 When milk has been standing for some time in the air it becomes 
 contaminated with bacteria, which cause spontaneous coagulation, 
 and whey is squeezed out of the contracting clot ; but this is sour 
 and not so good as that made by rennet. The percentage composi- 
 tion of whey is as follows : 
 
 Water 93-31 
 
 Lactose 4-65 
 
 Fat 0.24 
 
 Proteid o. 82 
 
 Lactic acid o . 33 
 
 Salt 0.65 
 
 The whey cure is used for the treatment of Bright's disease and 
 chronic catarrhal conditions of the alimentary canal. It is partic- 
 ularly recommended for chronic dyspepsia and chronic irritable 
 cough accompanying catarrh of the respiratory mucous membranes. 
 
 It is said to improve the secretion in chronic bronchitis, and it in- 
 creases the strength of the pulse, which is attributed to its potassium 
 salts (May). If more than twenty ounces are ingested daily there 
 is an increased peristaltic movement, with watery evacuations, colic, 
 and dyspepsia. 
 
 Whey, like skimmed milk, is diuretic and sudorific. It therefore 
 constitutes a useful beverage in fevers. The class of patients, many 
 of them phthisical, for whom the cure is recommended at Ems, 
 Ischl, Reichenhall, etc., are not fit subjects for a reducing diet, as 
 they have little or no spare strength ; they require rather abundant 
 nourishment, owing to the catarrhal processes which affect the re- 
 spiratory and alimentary passages. However, in such cases diges- 
 tion and absorption are often greatly impaired, and this condition is 
 found to be benefited by the use for a short period of the alkaline 
 waters and whey. It is not safe to limit the diet exclusively to these 
 fluids, and some nitrogenous food must be given, together with 
 fresh fruit and green vegetables. In Switzerland and Germany the 
 whey cure is often combined with the grape cure. 
 
FRUIT CURES 723 
 
 VARIOUS "CURES" 
 
 There are other diet systems or " cures," which deserve passing 
 mention rather as matter of general interest and as illustrations of 
 the effects of strong mental impressions or " mind cure " combined 
 with moderation in previous habits of overeating or gluttony, than 
 because any specific importance is to be attached to the value of 
 one such " cure " more than another. 
 
 Many diet " cures " have been devised purely for notoriety, to 
 advertise an otherwise unsuccessful practitioner or a charlatan, and 
 others again are exploited by well-meaning fanatics who have ac- 
 quired a firm belief in some dietetic system which has first helped 
 themselves, and which they feel that they owe to the world to pro- 
 mulgate for the guidance of others. But they are not always even 
 pretended followers of iEsculapius. Mr. Banting (p. 626), whose 
 name has given rise to a verb meaning to reduce corpulency, was a 
 layman, and so was Mr. Graham, whose name is a household ad- 
 jective applied to the flour which he introduced, and many famous 
 men, like Shelley and Goldsmith, have sung the praises of vege- 
 tarianism. 
 
 Not infrequently an element of religious fervour is added to the 
 belief in the efficacy of some new system, and long pilgrimages are 
 made to seek its chief apostle. Such, for example, is the 
 
 Kneipp System. — Monseigneur Kneipp was a Bavarian priest 
 whose patients lived chiefly upon a diet of milk, coarse bread of bran 
 and flour, soup, and cooked fruits, with a minimum of meat, eggs, 
 and vegetables. Water was principally drunk, with a little wine or 
 beer, but no spirits or coffee. This is undoubtedly a common-sense 
 regimen for many persons who have long abused their gastronomic 
 powers by eating too much and too rich food, but the ascetic ele- 
 ments were added of wearing very light, loose apparel and walking 
 about barefooted in the grass before the morning dew vanished. 
 
 FRUIT CURES 
 
 The " fruit cure " has appeared in many forms. At one time it 
 is confined to oranges, English walnuts, and cold water, and, strange 
 to say, some dyspeptics are able to digest it for a short time; or it 
 consists of sweet fruits and meat alone — dates, figs, prunes, bananas, 
 and apples — upon the theory that fruits were the first food of prime- 
 val man, and ergo they are the natural food of all men — an extreme 
 of atavism, surely ! There is also a " lemon cure." 
 
 Another fruit cure extends through six weeks. It begins grad- 
 ually by eating an apple or orange upon rising and again upon retir- 
 ing. In three or four days the breakfast consists of several baked 
 apples, a small quantity of bread and butter, and a little coffee. 
 
724 RATIONS, DIETARIES 
 
 During the forenoon several ripe apples or oranges may be eaten. 
 At dinner fresh animal food is furnished with a potato and roasted 
 apples or apple sauce. Green vegetables are allowed, but no bread 
 or pastry of any kind. Pickles may be eaten. During the after- 
 noon, more fruit, oranges, apples, grapes. Supper, like breakfast, 
 with a little sago in milk, with currants, raisins, or apples. This 
 diet is adapted to obstinate chronic constipation, some cases of 
 obesity, and lithsemia. 
 
 THE GRAPE CURE 
 
 The grape cure has been advocated for many years as beneficial 
 in certain forms of disease, but, like the majority of vaunted dietetic 
 " cures," it is almost certain that the chief benefit experienced is 
 from the change of scene and the favourable climatic and hygienic 
 surroundings of the patient, and possibly the influence of a stimu- 
 lated imagination. The " cure " is in vogue during the grape-bear- 
 ing season of the vineyards in various parts of southern Europe, 
 especially at Meran and Montreux. Grapes, being very largely 
 composed of water, do not possess a very high degree of nutritive 
 power, and it is impossible to maintain life upon their exclusive use ; 
 but the grape sugar which they contain, as well as a large amount of 
 potassium and other salts, may have some slight alterative effect 
 and benefit nutrition. Grapes are also laxative. Almost every one 
 is fond of the fruit, and the cure is therefore an agreeable one to 
 take, especially as the diet is not too exclusive, for the eating of 
 large quantities of grapes is made an adjunct to the employment of 
 highly nutritious food. 
 
 Vineyard labourers who eat little else but grapes quickly lose 
 weight, and other food must be taken with the grapes if the strength 
 is to be maintained, for a pound of grapes contains a little less than 
 three grammes of proteid. 
 
 It is recommended by Lebert that the grapes should be eaten 
 systematically and in quantities commencing with half a pound, and 
 seldom exceeding four pounds per diem, although six or eight 
 pounds are sometimes eaten, a quantity which may excite diarrhoea. 
 Owing to the mildly laxative effect of the fruit, this cure is bene- 
 ficial in cases of chronic constipation, and especially in engorgement 
 and hyperemia of the liver accompanied by extensive venous con- 
 gestion, hemorrhoids, and the formation of various forms of calculi. 
 In gastric catarrh patients are sometimes allowed to eat six pounds 
 of grapes a day. The laxative effect is always greater if the fruit is 
 taken in the intervals between meals, and especially if taken fasting 
 on rising in the morning. At first only half a pound of grapes is to 
 be taken two or three times a day, from half an hour to an hour 
 before meals, the quantity being gradually increased to a pound or 
 
THE GRAPE CURE 725 
 
 more at each dose. Some patients digest the grapes better, however, 
 if they are eaten in the form of dessert than if taken into an empty 
 stomach. The laxative effect gradually increases, and is usually 
 more pronounced after several days. The uric acid and acidity of 
 the urine is lessened. 
 
 When patients become tired of the monotony of this single fruit 
 they may be allowed to substitute pears or figs. It is stated that the 
 gums may become somewhat swollen and tender from the acid con- 
 tained in so much fruit, and to obviate this difficulty the mouth may 
 be cleansed thoroughly after eating with listerine or a solution of 
 sodium bicarbonate, or the mastication of a small quantity of bread 
 will serve to cleanse the teeth. 
 
 Abundant other food is allowed with the grapes, but it is impor- 
 tant that it should be of an easily digestible character, and certain 
 articles must therefore be forbidden, such as fats, rich sauces, gra- 
 vies, pickles, condiments, the heavier vegetables, such as potatoes 
 and the legumes, cheese, pastry, cakes, sweets, and beer. 
 
 The usual duration of the cure is from a month to six weeks. 
 The average chemical percentage composition of grapes is given by 
 Konig as : 
 
 Water 78.17 
 
 Sugar « 14 . 36 
 
 Free acid. o. 79 
 
 Nitrogenous material o. 59 
 
 Extractives 1 . 96 
 
 Stones and woody fiber 3 . 60 
 
 Ash 0.53 
 
 The latter is chiefly composed of potash salts, some lime and 
 magnesia. 
 
 Patients who have undertaken the grape cure without proper 
 supervision easily disorder their digestion and cause gastric catarrh 
 and even jaundice. Knauthe says that the eating of several pounds 
 of grapes daily may at first cause symptoms of flatulent dyspepsia, 
 more or less vertigo, and increased frequency of the pulse, palpita- 
 tion, diuresis, and malaise. The stools become more frequent and 
 semisolid. 
 
 The grape cure is reputed to be useful in chronic bronchitis, the 
 first stage of phthisis, emphysema, in obesity when combined with a 
 restricted diet, in gastro-intestinal catarrh, anaemia, vesical catarrh, 
 gout, hepatic engorgement, malarial cachexia, and chronic cutane- 
 ous affections. 
 
 In phthisis the grapes should not be given in quantities sufficient 
 to occasion diarrhoea. 
 
726 RATIONS, DIETARIES 
 
 MEAT AND HOT-WATER CURE 
 
 The meat and hot-water cure, often called in this country by the 
 name of Salisbury, one of its chief advocates, is given to many 
 classes of patients — consumptives, rheumatic subjects, and others. 
 Lean raw beef is ground to a pulp in a machine which is made for 
 the purpose and sold in hardware shops. It is freed from all fibre, 
 seasoned with salt and pepper, rolled into little balls, and cooked 
 just enough to turn the outside from a red to a drab colour. From 
 two to four ounces are eaten at a meal at first ; later as much as 
 seven ounces may be taken. In addition, from two to four raw eggs 
 are given with dry toast. Xo fluid is allowed with meals, but from 
 a half pint to a pint of hot water is given before each meal, and 
 again at bedtime. 
 
 This diet reduces corpulency rapidly, and is beneficial in cases of 
 chronic gastric catarrh and dilatation, but it is too rigid for many 
 patients. It is somewhat similar to, but much more strict than, the 
 diets of Carlsbad and Wiesbaden, which consist chiefly of lean meat, 
 eggs, and milk with a minimum of bread, and sometimes fruit. 
 
 THE DRY CURE 
 
 The " dry cure " is the name given to the treatment which con- 
 sists in withholding fluid from the diet in increasing degree until the 
 patient takes just as little as is necessary to sustain life. If carried 
 to this extreme, however, thirst becomes intolerable, and patients 
 usually rebel against the rigour of such treatment. 
 
 Practically it is found that the minimum of water aside from that 
 contained in food which patients can tolerate is about fifteen ounces 
 per diem, which should be taken between meals. For the relief of 
 thirst in these cases various measures are employed, such as are 
 described on p. 43. 
 
 In Germany the dry diet has been tried extensively in some cases, 
 especially those of gastric dilatation and cases of chronic effusion 
 into the joints and in the peritoneal cavity. There are many forms 
 of disease in which it is well to temporarily restrict very much the 
 quantity of fluid consumed, but it is hardly ever justifiable to do so 
 to the degree recommended by enthusiastic advocates of the "dry 
 cure," among whose patients fatal cases of scurvy have occurred as 
 well as cases of fever with a temperature sometimes amounting to 
 104 F. The conditions in which the quantity of fluid drunk should 
 be especially restricted are gastric dilatation, chronic serous effu- 
 sions, flatulent dyspepsia due to indulgence in sweets, coffee, tea, 
 etc., some few cases of obesity, and aneurism of the aorta (compare 
 Tufnell's treatment, p. 482). 
 
diet for athletic training 727 
 
 Schroth's Method 
 
 The dry cure of the yeoman John Schroth has achieved some 
 notoriety in Europe, where several " institutes " have been estab- 
 lished for its practice. It is a rigorous method which many patients 
 find difficult to endure. The diet is gradually reduced in quantity 
 and variety at first for a few days, and then the actual " cure " is 
 begun, which consists in giving no fluid at all, excepting a small 
 glass of hot wine twice a day for as many days as the patient will 
 endure it. Boiled vegetables are allowed for dinner, and otherwise 
 nothing is given but dry bread. Thirst becomes so extreme that in 
 three or four days the patient is allowed to drink hot wine freely to 
 quench it, after which the quantity of fluid is again cut down to two 
 small glasses a day until the patient is again obliged to receive more. 
 
 This treatment has in some cases been carried to the verge of 
 starvation with extreme prostration and fever, and it has little or 
 nothing to recommend it. Even fatal scurvy has followed its use at 
 Kiel. It is based upon the theory that the blood becomes more 
 dense, which favours osmosis between the serum and the surround- 
 ing lymph and tissues. As an adjunct to the treatment hot moist 
 packing is employed. 
 
 Jurgensen modified the treatment by giving from one third to 
 two thirds of a pound of lean beef with bread as desired, and light red 
 wine. It has been found by this writer and by Bartels that proteid 
 metabolism is undoubtedly increased by the dry diet, for the urine 
 contains nitrogenous waste in as large a proportion as when the 
 patient is upon a full diet — in some cases there is even more than 
 the normal. 
 
 Upon slowly resuming the accustomed diet a considerable gain 
 in weight compensates for previous loss, which is attributed in part 
 to restoration of water to the tissues. Bartels noted an increase in 
 urea which was greatest immediately after the treatment. The con- 
 siderable rise of temperature (104 F.) which accompanies this treat- 
 ment is explained by the facts that but little water is evaporated 
 from the lungs and skin, and that the body heat is retained by the 
 hot packs. 
 
 The treatment has been applied with some success in obstinate 
 cases of syphilis, gastric dilatation, chronic rheumatism, and chronic 
 peritonitis. 
 
 DIET FOR ATHLETIC TRAINING 
 
 The object of dietetic " training " in athletics is to fit men either 
 for feats of great muscular endurance and strength or for exhibitions 
 of dexterity requiring accurate and quick muscular movements and 
 nerve control. The method of training naturally differs consider- 
 ably according to the object to be attained. Professional athletes, 
 48 
 
728 RATIONS, DIETARIES 
 
 who are more or less constantly employed in exhibitions of 'strength 
 or muscular skill, are obliged to adopt very regular habits of life in 
 regard to sleep, bathing, and diet, and abstinence from the excessive 
 use of tobacco and strong drink. In addition, when they enter spe- 
 cial contests requiring continued feats of endurance, as in prolonged 
 bicycle races or walking matches, for example, they have to undergo 
 a period of special training for several weeks before the contest. 
 Young men who devote themselves to athletic sports in college 
 usually do so for a comparatively limited period, and are not sub- 
 jected to such special strain or feats of endurance excepting, per- 
 haps, in boat races, which are of short duration. As a general rule, 
 from six to ten weeks is ample time to cover their course of special 
 dietetic training, although they usually exercise ordinary care in 
 such matters for a longer period before their contests. 
 
 The physiological objects to be attained by any system of dietetic 
 training are to reduce the fat and water contained in the tissues of 
 the body, to increase the functional activity of the muscles, to train 
 both muscles and nerves, improve the breathing power or " wind," 
 the heart action and the condition of the skin. This is accomplished 
 by carefully regulated diet, systematic exercises directed to the in- 
 crease of oxidation processes, and the more perfect elimination of 
 waste matter from the system. Dietetic training prevents the with- 
 drawal of protein from other tissues than the muscles and supplies 
 an excess of protein to make good any loss of this material. The 
 protein is needed to build up muscle protoplasm and repair it. 
 
 Rigorous dietetic training should be conducted with great care 
 and supervised only by those who are experienced in such matters,, 
 for any system carried to excess may cause too great a reduction in 
 weight, and its object will be defeated by breaking down the indi- 
 vidual at the moment of critical contest or laying the foundation for 
 future organic weakness and disease. The heart may become hyper- 
 trophied and subsequently fail in accommodation. 
 
 It may be observed, however, that much of the ill effect of ath- 
 letic training may be due not so much to any particular form of 
 exertion or to being trained " too fine " in diet, but to the fact that 
 the system brings to light constitutional weaknesses which were 
 unsuspected until revealed by unwonted effort — in short, the system 
 involves survival of the fittest. 
 
 The transition from ordinary diet to that of any training system 
 should be made gradually, and the return to the usual diet after a 
 period of rigid training should be similarly slow. For the first two 
 or three weeks of training athletes usually lose in weight an amount 
 proportionate to their previous condition of robustness, but after 
 several weeks an equilibrium should be reached in which, upon an 
 established diet, the body weight remains practically the same while 
 the muscular strength and vigour and power of endurance increase ; 
 
DIET FOR ATHLETIC TRAINING 729 
 
 the complexion improves in appearance, the skin becomes clear, the 
 muscles become firmer, and all superfluous fat disappears. 
 
 While individual dietaries differ in training for the various forms 
 of contest, most of them include lean meat, chiefly rare or " under- 
 done," either roasted or broiled ; the bread should be dry or toasted; 
 a moderate quantity of potatoes and green fresh vegetables and fruits 
 are usually allowed. The class of foods to be especially forbidden 
 are sweets, pastry, entrees, rich puddings, sour pickles, and condi- 
 ments. For beverages, weak tea or coffee may be allowed, although 
 sometimes, where the object of training is the attainment of special 
 skill in feats of delicate balancing, all forms of nerve stimulants, 
 including tea, coffee, and tobacco should be prohibited. Chocolate 
 and cocoa, if not too sweet, may be sometimes allowed, and in some 
 training systems the use of light beer and light wine in moderation 
 is included, but strong alcoholic spirits are absolutely forbidden. As 
 a rule, three meals a day at intervals of about six hours are recom- 
 mended. 
 
 The ancient Greek and Roman athletes used to train very largely 
 upon a dry diet, which at first consisted of fresh cheese, dried figs, 
 and preparations of wheat. Later they ate such meats as pork, beef, 
 and goat flesh. 
 
 Parkes gives the amount of fluid which may be allowed as about 
 five pints in winter and six in summer, a little over one fourth of 
 which is contained in the food. Drink should not be taken either 
 shortly before exercise or during meals. If the mouth be well rinsed 
 before drinking, less fluid will be required, and what is taken should 
 be drunk slowly. 
 
 The use of tobacco, particularly in the form of cigarette smoking, 
 must be forbidden, and as alcohol in excess lessens the power of 
 sustained muscular exertion, not over two ounces per diem can be 
 allowed. 
 
 The following dietaries of training have been kindly furnished me 
 by Dr. Hartwell, who has had much personal experience in such 
 matters : 
 
 DIETARY OF THE BOAT CREW AT YALE UNIVERSITY 
 
 From March 1st till June 10th (ten weeks and a half), the hours 
 of work are from 4 to 7 p. m., with exercise for an extra half hour or 
 more at such odd times as recitations may permit. During this pe- 
 riod the following regulations of the training table are observed : 
 
 Breakfast, 7.30 a. m. 
 
 Fruit. — Oranges, tamarinds, figs, and dates. 
 
 Cereals. — Oatmeal or one of the many preparations of wheat ; a 
 rich milk (not cream) and sugar are allowed with this. Toast. No 
 hot breads are allowed. 
 
730 RATIONS, DIETARIES 
 
 Meats. — Beefsteak (usually rare), chops, stews, hash. Once or 
 twice a week some salt meat, as bacon or ham, is allowed, and with 
 it usually liver. 
 
 Potatoes. — Stewed, browned, and baked. 
 
 Eggs. — Served in all styles, except fried (unless with the ham). 
 Eggs appear in some form about four mornings a week. 
 
 The meats are varied, steaks or chops alternating with one of the 
 others. 
 
 Fluids. — Water, milk, tea on special occasions for some indi- 
 vidual man. The water is boiled and poured while hot on the oat- 
 meal. On cooling it has about the consistence of rich milk and a 
 strong flavour of the oatmeal. 
 
 Dinner 
 
 Soups. — All varieties, including oyster stews and clam broths. 
 
 Meats. — Roast beef, mutton, turkey, chicken. Gravies are but 
 little used. Two kinds of meat are always served. 
 
 Fish, broiled or boiled, is served twice a week. 
 
 Vegetables. — Potatoes (mashed or boiled). Tomatoes, stewed or 
 sometimes raw. Beans, peas, corn (occasionally). Two vegetables 
 besides potatoes are usually served. 
 
 Bread. — Toast. 
 
 Dessert. — Puddings — rice, bread, tapioca ; but little butter is al- 
 lowed in their preparation. 
 
 Fruit. — Same as breakfast, with berries and cantaloupe in season. 
 Baked apples. 
 
 Fluid. — Same as breakfast. 
 
 Supper (one hour after rowing — i. e., from y to 8.15 p. m.) 
 
 Cereals. — Same as breakfast. 
 
 Meats. — Chops, stews, cold meats from dinner. Rarely, beef- 
 steak. 
 
 Potatoes. — Stewed or baked. 
 
 Eggs. — All styles, about three times a week, usually not on same 
 day as for breakfast. 
 
 Fluids. — Same as breakfast. Bass's ale for men who are getting 
 " fine " and for whole crew after especially hard day's work. 
 
 Ale and milk are never taken at same meal. 
 
 For three weeks following June 10th the crew is at New London 
 in final preparation for their race. The programme is then some- 
 what changed. 
 
 Breakfast is served at the same hour and consists of the same 
 variety of food as before. 
 
 The morning work is from 9.30 or 10 to 11.30 or 12. 
 
 Dinner, with same menu as before, is served at 12.30 or 1 p. m. 
 
DIET FOR ATHLETIC TRAINING 731 
 
 Luncheon. — The afternoon till 4.30 is spent in loafing — often in 
 the water in the steam launch. At that hour a lunch of cold meat, 
 stewed or baked potatoes, milk, and toast is served. The afternoon 
 work — which is the hard work of the day — begins from forty-five to 
 sixty minutes after the lunch and continues for about two hours, 
 more or less, depending on its severity. Forty-five minutes after 
 this work cold oatmeal or other cereal, with toast and milk, is 
 served. 
 
 Many of the men are allowed ale every night during the final 
 three weeks, either with the late supper or an hour later — 9.30, on 
 retiring. 
 
 Quantity of Food and Fluid. — There is no limit set to the quantity 
 of food. The fluids, however, are limited to three glasses at a meal, 
 with but little drink between meals. Of late years this is becoming 
 changed, and in hot weather, when the men are perspiring freely, 
 more fluid is allowed. To counteract the constipating effect which 
 training has upon some men, stewed prunes are served for either 
 breakfast or supper. 
 
 The training table of the present day, as given above, is far more 
 liberal than it was five or ten years earlier, and it is aimed to regulate 
 it on a rational basis. What few statistics are at command seem to 
 show that the new is an improvement on the old system, and cases 
 of overtraining are less frequent and less serious now than formerly. 
 
 It is the opinion of J. W. White that " an ordinary farmhouse 
 table with its midday dinner and early tea will rarely (with the ex- 
 ception of coffee, hot cakes, pastry, and fried meats) offer anything 
 which should be excluded from a rational training diet as it is at 
 present understood." 
 
 DIET OF HARVARD UNIVERSITY CREW 
 
 The Harvard University Boat Crew diet while in active training 
 in 1898 was studied for six days by W. O. Atwater and A. P. Bry- 
 ant. The average weight per man was 162 pounds. A daily loss 
 of from 2 to 3f pounds per man was produced by rowing and re- 
 stored before the next day. As much as 4J pounds is sometimes 
 lost by a man during a four-mile race, and i-| pound may be lost 
 through worry and excitement immediately preceding the race. 
 
 " The diet was simple. Roast and broiled beef and lamb, fric- 
 asseed chicken, roast turkey, and broiled fish, made up the meats. 
 Eggs were used plentifully either raw, poached, or boiled in the shell. 
 Large amounts of milk and cream were also consumed. Oatmeal, 
 hominy, and shredded wheat were eaten largely, and corn cakes 
 were occasionally served. Bread was almost always taken in the 
 form of dry toast. Potatoes were served twice a day. These were 
 sometimes baked, sometimes boiled and mashed with a little milk 
 
732 RATIONS, DIETARIES 
 
 and butter added, and at other times ' creamed.' Boiled rice, pre- 
 pared with a little cream and sugar, was served instead of potatoes at 
 some meals. Beets, parsnips, green peas, and tomatoes were used 
 to furnish a variety of vegetables. Macaroni was occasionally 
 served. For dessert, apple tapioca pudding, custard pudding, or 
 other pudding containing a large proportion of milk and eggs was 
 used. The members of the crew were allowed beer once a day. 
 Xo pastry was allowed, and the puddings were, as above stated, com- 
 posed largely of eggs and milk. A small amount of coffee jelly was 
 served, and at one meal during the study ice cream. No fresh fruit 
 was served, with the exception of oranges for breakfast. Stewed 
 prunes, rhubarb, or apples were also eaten, prunes most abundantly. 
 Xo beverages were allowed other than water, milk, and beer. 
 Breakfast was served at 8, lunch at i, and dinner at 6 o'clock." 
 
 These experimenters found that the average nutrients consumed 
 per man per diem amounted to 145 grammes protein, 170 grammes 
 fat. and 375 grammes carbohydrates, aggregating 3,705 calories. 
 Just before racing each man received one ounce of beef extract 
 with eight ounces of dry toast. 
 
 A subsequent study of the Harvard University Boat Crew was 
 made in 1899 by E. A. Darling, who reports as follows: 
 
 " Diet. — The diet allowed was a very generous one, consisting 
 of a hearty breakfast at 7.30, lunch at 1, and dinner after the even- 
 ing row. For breakfast the fare consisted of fruit, oatmeal, or shred- 
 ded wheat, eggs, some form of meat, bread and butter, potato, and 
 milk. At noon there was cold meat, potato, bread and butter, 
 marmalade, preserved fruit, and milk. Dinner comprised soup, 
 occasionally fish, roast beef or some other hot meat, several vege- 
 tables, bread and butter, and a simple dessert. No tea or coffee 
 was allowed, but ale or claret was permitted at dinner, also water 
 in small amounts, as desired. During the last week before the race 
 each man received a dish of calf's-foot jelly with sherry wine after 
 the morning row, and a light lunch of oatmeal, milk, and bread was 
 served at 4 o'clock in the afternoon." 
 
 Another study of the Harvard Freshman Crew during training 
 was made in 1898 by Atwater and Bryant : 
 
 " The men arose at about 7 o'clock. Before this time no noise 
 was allowed in the kitchen or elsewhere. After a short run, break- 
 fast was served at 7.30 o'clock and was quite a hearty meal, consist- 
 ing principally of oranges, a breakfast cereal, hot meat or fish, and 
 potatoes. During the morning there was usually a practice row 
 on the river, followed by a light lunch at about 11.30 to 12 o'clock. 
 The principal meal of the day was taken early in the afternoon. In 
 the late afternoon the crew had another season of hard work on the 
 river, after which another hearty meal was served. Leisure time 
 was spent in study or recreation." 
 
DIET FOR ATHLETIC TRAINING 
 
 733 
 
 Sugar in large quantity may be added with advantage to the diet 
 of athletes and soldiers on the march. It may be given with other 
 food, such as cereals, tea and coffee, etc., as is customary with the 
 Cornell University Crew ; or it may be given separately either as 
 plain confectionery or in the form of cakes of chocolate. In a re- 
 cent study of the training diet of boat clubs in Holland as much as 
 one third of a pound of sugar per man per diem was found to be 
 consumed with very marked benefit. 
 
 Summary of Results of Dietary Studies of University Boat Crews and 
 other Dietary Studies, by W. O. Atwater and A. P. Bryant, igoo 
 
 (Nutrients in food actually eaten per man per day) 
 
 DIETARY STUDIES OF UNIVERSITY BOAT CREWS 
 
 Harvard University crew at Cambridge 
 
 Harvard Freshman crew at Cambridge 
 
 Yale University crew at New Haven 
 
 Harvard University crew at Gales Ferry 
 
 Harvard Freshman crew at Gales Ferry 
 
 Yale University crew at Gales Ferry 
 
 Captain of Harvard Freshman crew 
 
 Average. 
 
 SUMMARISED RESULTS OF OTHER DIETARY STUDIES 
 
 Football team, college students, Connecticut. . . 
 
 Football team, college students, California 
 
 Professional athlete, Sandow 
 
 Prize fighter, England 
 
 Average of 15 college clubs 
 
 Average of 14 mechanics' families 
 
 Average of 10 farmers' families 
 
 Average of 24 mechanics' and farmers' families. 
 Average of 14 professional men's families 
 
 Man 
 
 Man 
 Man 
 Man 
 Man 
 Man 
 Man 
 Man 
 
 DIETARY STANDARDS 
 
 with moderate muscular work, Voit 
 with moderate muscular work, Playfair. 
 with moderate muscular work, Atwater. 
 
 with hard muscular work, Yoit 
 
 with hard muscular work, Playfair 
 
 with hard muscular work, Atwater 
 
 with severe muscular work, Playfair. . . . 
 with severe muscular work, Atwater. . . . 
 
 Protein. 
 
 Fats. 
 
 Grms. 
 
 Grms. 
 
 162 
 
 175 
 
 153 
 
 223 
 
 145 
 
 I70 
 
 160 
 
 170 
 
 135 
 
 152 
 
 171 
 
 I 7 I 
 
 155 
 
 l8l 
 
 155 
 
 177 
 
 1S1 
 
 292 
 
 270 
 
 416 
 
 244 
 
 151 
 
 27S 
 
 73 
 
 107 
 
 I4S 
 
 103 
 
 T50 
 
 97 
 
 I30 
 
 100 
 
 141 
 
 104 
 
 125 
 
 11S 
 
 56 
 
 119 
 
 51 
 
 125 
 
 
 U5 
 
 IOO 
 
 156 
 
 71 
 
 150 
 
 
 185 
 
 71 
 
 175 
 
 
 Carbo- 
 hydrates. 
 
 Fuel 
 
 value. 
 
 Grms. , Calories. 
 
 449 
 463 
 
 375 
 448 
 416 
 
 434 
 
 487 
 
 440 
 
 557 
 710 
 502 
 S3 
 459 
 402 
 
 467 
 429 
 
 423 
 
 5 CO 
 
 53i 
 
 450 
 568 
 
 568 
 
 4,130 
 4,620 
 3,705 
 4,075 
 3,°75 
 4,070 
 
 4,315 
 
 4,cS5 
 
 5,740 
 7,885 
 4,460 
 2,205 
 3,690 
 3,465 
 3,515 
 3,48o 
 
 3o25 
 
 3,055 
 3,140 
 3,5oo 
 3,370 
 3,630 
 4,5oo 
 3,750 
 5.700 
 
 DIET OF YALE FOOTBALL TEAM 
 
 " The diet of the football team is practically the same as for the 
 crew except for lunch, which is eaten at 1 p. m., the practice taking- 
 place from 2.30 to 3.45 or 4 p. m. This one-o'clock meal consists of 
 cold meat, one chop or eggs, hot broth or bouillon, and toast. Milk 
 and oatmeal-water are drunk. Apple sauce is sometimes allowed " 
 (Hartwell). 
 
734 RATIONS, DIETARIES 
 
 DIET OF PUGILISTS, JOCKEYS, AND BICYCLE RACERS 
 
 Chambers gives the following example of a diet used by 
 pugilists : 
 
 7 a. m. Light breakfast : oatmeal with little or no milk and 
 sugar ; one to three eggs, poached or raw ; a cup of tea with little or 
 no milk or sugar; a slice or two of toast. The eggs may be varied 
 by a rare or well-broiled chop. 
 
 12 noon. Dinner (following a half hour of rest) : roast beef or 
 mutton and vegetables; cup custard and plum pudding. A heavy 
 dinner may be eaten, unless it is desired to reduce the weight. Old, 
 mixed, or Bass's ale is allowed, but only a little water should be 
 drunk, for it favours obesity. If thirst is annoying, a pebble may be 
 carried in the mouth to increase the flow of saliva. 
 
 An hour or two of rest should be taken after dining. 
 
 6 p. m. Light supper : toast, a mutton chop or an egg, a vege- 
 table, and a cup of tea. 
 
 Percy studied the diet of a prize fighter twenty-two years of age, 
 5 feet 6 inches in height and weighing 119. pounds. " He break- 
 fasted at 9 a. m., and ate one pound of mutton, weighed before cook- 
 ing. He dined at 1 p. m., and ate the same quantity of mutton, with 
 the addition of about two ounces of bread. And again at supper, at 
 8 p. m., he had the same quantity of mutton. At each meal he drank 
 half a pint of ale, but no other liquid at any other time of the day. 
 Nor did he eat any other vegetable matter whatever besides the small 
 quantity of bread mentioned. He walked seventeen miles per day." 
 
 Such a diet would not be indorsed by most trainers, nor would 
 it fit a man for sustained effort. 
 
 A noted New York prize fighter says that in training he is accus- 
 tomed: to eat almost any plain substantial food that he likes, relying 
 largely upon beef, mutton, bread, and potatoes, but avoiding pastry 
 and sweets. He drinks fluid freely until within a week of the con- 
 test, when he reduces the water ingested to a minimum. 
 
 Bicycle racers entering six days' contests undergo the severest 
 kind of muscular strain and require a diet rich in protein and energy. 
 They work from eighteen and a half to twenty-one hours out of the 
 twenty-four, and have a minimum of sleep. They take most of 
 their food in fluid or semisolid form, in part to save time and in part 
 because it is easily digestible. Water is not drunk during the race. 
 A dietetic study of bicycle racers was made in 1898 in New York 
 by W. O. Atwater and H. C. Sherman. The most remarkable con- 
 testants were C. W. Miller, who rode 2007.4 miles in six days, and 
 F. Albert, who rode 1822.6 miles. Miller lost four pounds the first 
 day, but subsequently maintained his average weight. His average 
 daily food consumption in grammes was: Protein, 169; carbohy- 
 
DIET AND OCCUPATION 735 
 
 drates, 585 ; fat, 181 ; having a total fuel value of 4,770 calories. His 
 food was of very simple character, and pastry and pork, as well as 
 alcohol and tobacco, were excluded during a month of training. 
 
 Albert, on the other hand, limited his diet chiefly by the exclu- 
 sion of veal and fat meats. He smoked tobacco in moderation but 
 did not use alcohol. He lost three pounds and a half in weight on 
 the first two days of the contest, but subsequently regained them. 
 His average daily food consumption in grammes was: Protein, 179; 
 carbohydrates, 859; fat, 198; having a total fuel value of 6,079 calo- 
 ries. The protein metabolised by these two contestants was found 
 to be about twice as much as that metabolised by the average 
 mechanic, and they did more than two days' work in one. Each 
 contestant lost " body protein equivalent to two or three pounds 
 of lean flesh, and that no injury resulted therefrom would seem 
 to indicate that these men had stores of protein which could be 
 metabolised to aid in meeting the demands put upon the body by 
 the severe exertion, without robbing any of the working parts, and 
 at the same time relieving the system of a part of the labor of diges- 
 tion. Possibly the ability to carry such a store of available protein 
 is one of the factors which make for physical endurance " (Atwater 
 and Sherman). 
 
 The dietetic training of jockeys is merely for the purpose of re- 
 ducing weight, and more depends on their eating a small quantity of 
 food than upon its restriction in variety. They should make their 
 fare chiefly bread and meat, and abstain from much fluid. 
 
 Chambers points out that men who have brief holidays in the 
 country often fail to get the maximum good of their outdoor life, 
 because they are not in proper condition for it. If a shooting or 
 walking trip is to be undertaken for a week or two, it is well to ab- 
 stain for a fortnight beforehand from eating elaborate dinners, and 
 to leave off sweets and pastry and live on a drier diet than usual. 
 
 In general the athlete in training, when not trying to reduce his 
 weight, develops more energy from food and consumes more pro- 
 tein than the ordinary working man. In the case of the crews 
 studied by Atwater this excess of energy equalled 400 calories, or 
 10 per cent, and the protein consumption was increased by 45 per 
 cent. This excess of protein is demanded by the increased nervous 
 tension which is lacking in the slow, methodical, muscular exertion 
 of the day labourer (Zuntz). 
 
 DIET AND OCCUPATION 
 
 There are some occupations which are more or less closely con- 
 nected with dietetics. Workers in lead, plumbers, painters, polish- 
 ers, pottery glaziers, et ah, should be taught to be very careful to 
 cleanse the clothing, hands, and especially their finger nails, before 
 
73^ 
 
 RATIONS, DIETARIES 
 
 The following Table, compiled by A. P. Bryant for the Yearbook of the 
 U. S. Department of Agriculture for 1898, presents a Comparison of 
 the Average Food Consumption of People of Different Occupations or 
 in Different Conditions of Life 
 
 (Per man per day) 
 
 Families Studied. 
 
 Average of 10 farmers' families in ) Yood 
 Vermont. Connecticut, and New >- -^ , 
 York.... \ Fo ° d 
 
 Average of 14 mechanics' families ) p j 
 in Connecticut, New Jersey, y y , 
 Tennessee, and Indiana ) 
 
 Average of 14 professional men's ) y , 
 families in Connecticut, Penn- [-p 00 J 
 sylvania, Indiana, and Illinois.. ) 
 
 Average of 15 college clubs in ) -p j 
 Maine, Connecticut, Tennessee, >• -p j 
 and Missouri ) 
 
 Average of above 53 studies < y , 
 
 Average of 12 labourers' families [ Food 
 
 in New York city \ Food 
 
 Average of 11 poor families in ) Food 
 
 New York city ) Food 
 
 Average of 2 labourers' families, } Food 
 
 very poor, in Pittsburg, Pa ) Food 
 
 Average of 2 labourers' families, ) y _, 
 
 more comfortable circumstances, y y _, 
 
 in Pittsburg, Pa ) 
 
 Average of 12 negro families in ) y , 
 
 Alabama ) 
 
 Average of 4 Italian families in ) y j 
 
 Chicago, 111 ) 
 
 Average of 5 French Canadian ) p OQ j 
 
 families in Chicago, 111 ) 
 
 Average of 4 families of Russian ) p OQ j 
 
 Jews in Chicago, 111 ) 
 
 Average of 8 -Bohemian families ) y , 
 
 in Chicago, 111 ) 
 
 purchased 
 eaten .... 
 
 purchased 
 eaten 
 
 purchased 
 eaten. . . . 
 
 purchased 
 eaten. . . . 
 
 purchased 
 eaten .... 
 purchased 
 eaten .... 
 purchased 
 eaten .... 
 purchased 
 eaten .... 
 
 purchased 
 eaten .... 
 
 purchased 
 
 purchased 
 
 purchased 
 
 purchased 
 
 purchased 
 
 Cost. 
 
 Pro- 
 tein. 
 
 Fats. 
 
 Carbo- 
 
 hy- 
 drates. 
 
 Cents. 
 
 Grms. 
 
 Gr?ns. 
 
 Grms. 
 
 
 IOI 
 
 I36 
 
 483 
 
 
 97 
 
 I30 
 
 467 
 
 
 no 
 
 l6l 
 
 425 
 
 19 
 
 103 
 
 I50 
 
 402 
 
 
 108 
 
 132 
 
 429 
 
 28 
 
 104 
 
 125 
 
 423 
 
 
 130 
 
 187 
 
 519 
 
 
 107 
 
 I48 
 
 459 
 
 
 113 
 
 I 5 6 
 
 463 
 
 
 103 
 
 138 
 
 436 
 
 
 103 
 
 IIQ 
 
 356 
 
 iq 
 
 IOI 
 
 Il6 
 
 344 
 
 
 96 
 
 98 
 
 414 
 
 15 
 
 93 
 
 95 
 
 407 
 
 
 81 
 
 98 
 
 3ii 
 
 11 
 
 80 
 
 95 
 
 308 
 
 
 121 
 
 148 
 
 534 
 
 19 
 
 120 
 
 147 
 
 534 
 
 9 
 
 67 
 
 134 
 
 453 
 
 16 
 
 103 
 
 in 
 
 391 
 
 22 
 
 118 
 
 158 
 
 345 
 
 19 
 
 120 
 
 IOI 
 
 406 
 
 12 
 
 115 
 
 IOI 
 
 360 
 
 Fuel 
 value. 
 
 Cats. 
 3,655 
 3,515 
 
 3,690 
 3,465 
 
 3,435 
 3,325 
 
 4,390 
 3,690 
 
 3,810 
 3,5oo 
 2,95o 
 2,905 
 3,005 
 2,915 
 2,525 
 2,485 
 
 4,055 
 4,045 
 
 3,375 
 3,060 
 
 3,365 
 3,095 
 
 2,885 
 
 eating. The soft crumb of bread getting under the nails easily be- 
 comes contaminated with lead salts, which by this means are con- 
 veyed to the stomach, where the white-lead carbonate, which is in- 
 soluble in water, is dissolved by the gastric juice into a more dan- 
 gerous chloride. Workers in dyestuffs, artificial flowers, green wall 
 papers, and other materials in which arsenic is used, should be simi- 
 larly careful, and should never be permitted to bring their food into 
 the workrooms. 
 
 Some occupations — those of foundrymen, stokers, and porcelain 
 manufacturers — necessitate exposure to extremely high tempera- 
 tures. Profuse sweating results, and thirst. The thirst is quenched 
 by subsequently drinking enormous quantities of fluid, which should 
 be water or oatmeal water, not too cold, rather than beer or other 
 
DIET FOR BRAIN WORKERS 737 
 
 alcoholic beverages. Their lives at best are apt to be shortened by 
 the suddenness and severity of the changes to which their kidneys 
 and circulation are subjected, and a resort to alcohol is soon fatal. 
 
 Tea tasters acquire more or less poisoning, although they do not 
 swallow the beverage, for a good deal is absorbed by the mucous 
 membrane of the mouth. The symptoms are insomnia, nightmare, 
 headache, " nervousness," tremors, dyspepsia, and constipation. 
 Even smelling the tea infusions constantly is poisonous to some 
 sensitive persons (Chambers). To mitigate the danger they should 
 eat abundantly before exposing themselves to the noxious effects of 
 their occupation. 
 
 Among other diseases occasioned by the handling of food prod- 
 ucts may be mentioned the grocer's itch, from handling low grades 
 of sugar (now much less common than formerly, owing to better 
 methods of refining), and the bronchial diseases produced by 
 the inhalation of flour and grain dust in grist mills and grain 
 elevators. 
 
 There are, in addition, many occupations which directly interfere 
 with the proper digestion of food, such as those of tailors and shoe- 
 makers, whose cramped positions compress the abdominal viscera 
 and impede full respiratory action. Their discomfort from dys- 
 pepsia and flatulency teaches them to avoid eating vegetables and 
 sweets. 
 
 All occupations conducted in close, ill-ventilated apartments are 
 injurious by depriving the individual of sufficient oxygen to con- 
 sume the food products in the system. 
 
 DIET FOR BRAIN WORKERS 
 
 Persons who are constantly employed in mental labour, and con- 
 sequently lead sedentary lives, usually find from experience, sooner 
 or later, that they must pay attention to their diet in order to main- 
 tain the best condition of health. Energy diverted for mental work 
 is apt to be at the expense of digestive activity, consequently it is 
 important that the meals should be of such a character as not to 
 unduly tax the stomach and intestines. As a rule, meat should be 
 eaten but once a day, and then only in moderation, and persons who 
 are not of strong physique do well to replace meat for a time by 
 other varieties of animal food which require less time and energy 
 for their digestion. Milk, eggs, fish, and abundant fresh fruit, 
 with light, porous, and dry bread, should constitute their staple 
 dietary. 
 
 Brain workers may suffer from lithsemia, which is undoubtedly 
 often due to other causes than dietetic errors, such as anxiety, worry, 
 and overwork. Patients of this class do better with a good, full, 
 nourishing diet than by any attempt at restriction, provided their 
 
738 RATIONS, DIETARIES 
 
 food is thoroughly well cooked and is light and digestible. They 
 should avoid saccharine, fatty, and purely starchy dishes, but they 
 need meat, and may have a moderate variety of fruits and fresh 
 green vegetables. 
 
 The brain contains nearly three times as much fat as may be 
 found in the muscles, and in nerves an even larger percentage is 
 present. For this reason carbohydrates and fats are of value for 
 brain workers who are not lithaemic, and the latter food may be 
 supplied in the form of cream, butter, or fat well-cooked bacon. 
 
 It is believed by some writers that the fact that fat is good food 
 for brain workers depends upon the ease with which it develops 
 energy with less complex metabolism than starches, and the nervous 
 energy of many Americans is sometimes attributed to the greater 
 consumption of fat in this country as compared with Continental 
 Europe and England. 
 
 The popular idea that fish has some specific action as a brain 
 food on account of the phosphorus which is present in some species 
 in considerable amount, and which is also an ingredient of nerve 
 tissue, is not founded upon fact. Fresh fish is very wholesome, and 
 by replacing meat in the menu less labour is required of the digestive 
 organs, and some forms of fish contain abundant fat or oil, but aside 
 from this, fish cannot be said to be especially a brain food. It has 
 been pointed out elsewhere (p. 124) that the tribes of man who live 
 very largely upon fish are by no means noted for their intellectual 
 development. 
 
 For brain workers who desire to keep in good health the alterna- 
 tive is either to take at least two hours of rest after a noon dinner 
 or else to eat a light meal at noon and dine later in the day. This 
 fact should be recognised in the arrangement of meals for college 
 students. It is far better during the active hours of brain work 
 to supply only such food as is necessary for prompt force produc- 
 tion without calling upon the digestive organs for the expendi- 
 ture of much energy in elaborating food which is only needed for 
 storage. 
 
 Breakfast should consist of fresh fruit, a cereal with cream, a 
 poached Qgg, a bit of broiled (not fried) fish, or a rasher of bacon, 
 with tea or coffee. 
 
 Luncheon may comprise such articles as a roast potato with butter 
 and cream, or beans and bacon, one or two light sandwiches made 
 with a slice of game or a relish of some sort, cheese, lettuce or salad, 
 and a baked apple and cream. 
 
 Dinner should be a hearty meal with soup, a roast or joint, vege- 
 tables, and a light farinaceous pudding. If evening w T ork must be 
 done, there should be an interval of at least an hour for rest and 
 recreation. A generous meal is easier digested after work is done, 
 and makes the best preparation for the next day's toil. 
 
DIET FOR BRAIN WORKERS 
 
 739 
 
 A Work Ration for a Professional or Literary Man 
 (Mrs. E. H. Richards) 
 
 Ounces. ! Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Calories. 
 
 Bread.. 
 
 Meat 
 
 Butter 
 
 Sugar 
 
 Milk 
 
 Oysters . , 
 
 Soup 
 
 Potatoes 
 
 Eggs... 
 
 Oatmeal 
 
 Cream 
 
 Fruit 
 
 Additional liquid — tea, coffee, or water 
 
 Total. 
 
 16 
 16 
 
 i 
 
 4 
 
 S 
 
 4 
 4 
 6 
 
 3 
 
 2 
 
 I 
 
 8 
 
 3o 
 
 Grammes. 
 32.O 
 50.0 
 
 I8.0 
 7.0 
 4.O 
 3.0 
 
 IO. O 
 I .O 
 1-5 
 0.5 
 
 Grammes, 
 
 3-o 
 30.0 
 25.0 
 
 18.0 
 1.0 
 3-o 
 
 9.0 
 
 0.5 
 6.5 
 
 127.0 
 
 96.0 
 
 Gram?nes. 
 258.O 
 
 IIO.O 
 22.0 
 
 38.0 
 4.O 
 
 1.0 
 50.0 
 
 483.0 
 
 1,216.6 
 481.0 
 230.0 
 
 451.0 
 ^29.6 
 
 37.8 
 
 44.0 
 168. 1 
 
 123.8 
 25.1 
 70.1 
 
 207.1 
 
 3,384.2 
 
 Overeating should be studiously avoided. Loading the system 
 with incompletely assimilated food products impairs intellectual 
 activity and exhausts the nervous system. If some special task 
 requires long hours of work and absorbing concentration, it may 
 be better to eat but little at a time, and take one or two extra lunches 
 during the day. When such labour proves fatiguing, alcohol may 
 be temporarily employed, but only with the meals, and not as a 
 stimulant between. The quantity may be regulated somewhat by 
 the appetite, but it should never be large. If a glass or two of claret 
 or Burgundy or of malt liquor with lunch or dinner improves the 
 appetite for solid food and aids its digestion, it is beneficial, for, as 
 Chambers wrote, " it stays the weariness of the system and allows 
 the nerve force to be diverted to the digestion of the meal " but to 
 labour on and " continue to take this anaesthetic between meals is 
 inconsistent " ; and " when any extraordinary mental toil is tem- 
 porarily imposed, extreme temperance or even total abstinence 
 should be the rule, for mental activity makes the brain bear less 
 alcohol than rest and relaxation." 
 
 The varieties of beverages named are all better than port, sherry, 
 or the stronger liquors. 
 
 It is a mistake to suppose that violent muscular exercise is an 
 offset to mental strain. Very moderate exercise combined with 
 abundant fresh air and with mental diversion and relaxation are 
 more beneficial, and do not add one kind of material exhaustion 
 to another already present. 
 
 Tobacco and coffee, like alcohol, are stimulants which are use- 
 ful in such cases only in proportion to the moderation in which they 
 are employed. Tea may be allowed in the earlier part of the day 
 if it does not cause wakefulness. 
 
740 RATIONS, DIETARIES 
 
 Following is the dietary at the Lake Erie College, at Painesville, 
 Ohio, for women students : 
 
 DAILY MENU 
 Wednesday, January ij, 1900. 
 Dinner. — Corned beef, mashed potatoes, turnips, bread, butter, 
 rice pudding. 
 
 Thursday, January 18. 
 
 Breakfast. — Baked apples, hominy grits, creamed dried beef, 
 bread, butter, milk, coffee. 
 
 Luncheon. — Cheese, pudding, raspberry jam, bread, butter, milk, 
 tea. 
 
 Dinner. — Roast beef, potatoes, parsnips, bread, butter, chocolate 
 pudding. 
 
 Friday, January ip. 
 
 Breakfast. — Oranges, wheat breakfast food, corned-beef hash, 
 corn rolls, butter, milk, coffee. 
 
 Luncheon. — Oyster stew, wafers, bananas, bread, butter, tea. 
 
 Dinner. — Pot roast, potatoes, beets, bread, butter, brown betty, 
 lemon sauce. 
 
 Saturday, January 20. 
 
 Breakfast. — Wheat breakfast food, bacon, baked potatoes, bread, 
 butter, milk, coffee. 
 
 Luncheon. — Beef in gravy, pickles, sauce, milk, bread, butter, tea. 
 
 Dinner. — Lamb chops, potatoes, canned peas, bread, butter, 
 cherry tapioca, cream. 
 
 Sunday, January 21. 
 
 Breakfast. — Oranges, wheat breakfast food, fried mush, maple 
 sirup, bread, butter, milk, coffee. 
 
 Luncheon. — At evening on Sunday. Stewed apricots, cake, milk, 
 tea, bread, butter. 
 
 Dinner. — Stewed chicken, mashed potatoes, cranberries, bread, 
 butter, cottage pudding, hard sauce. 
 
 Monday, January 22. 
 
 Breakfast. — Bananas, wheat breakfast food, rolls, codfish balls, 
 bread, butter, milk, coffee. 
 
 Luncheon. — Beet salad, raspberry jam, milk, bread, butter, tea. 
 
 Dinner. — Hamburg steak, browned potatoes, squash, bread pud- 
 ding. 
 
 Tuesday, January 23. 
 
 Breakfast. — Hominy grits, minced lamb, milk, bread, butter, 
 coffee. 
 
 Luncheon. — Pea soup, crackers, bananas, tea, bread, butter. 
 
DIET IN COMMERCIAL LIFE 741 
 
 Dinner. — Roast pork, baked sweet potatoes, cole-slaw, bread, 
 butter, dates. 
 
 Wednesday, January 24. 
 
 Breakfast. — Bananas, hominy grits, bacon, potato cakes, bread, 
 butter, milk, coffee. 
 
 Luncheon. — Baked beans, brown bread, pickles, milk, bread, but- 
 ter, tea. 
 
 Dinner. — Roast beef, boiled potatoes, spinach, bread, butter, 
 boiled rice, maple sirup. 
 
 Thursday, January 25. 
 
 Breakfast. — Oranges, wheat breakfast food, meat hash, French 
 toast, bread, butter, milk, coffee. 
 
 Luncheon. — Cheese, gingerbread, bread, butter, cocoa. 
 
 Dinner. — Beefsteak, mashed potatoes, Lima beans, bread, butter, 
 baked potatoes. 
 
 Friday, January 26. 
 
 Breakfast. — Cream of wheat breakfast food, creamed beef, rolls, 
 bread, butter, milk, coffee. 
 
 Luncheon. — Pea soup, croutons, apple butter, bread, butter, tea. 
 
 Dinner. — Baked ham, catsup, stewed tomatoes, potatoes, bread, 
 butter, fruit custard. 
 
 Saturday, January 27. 
 
 Breakfast. — Oranges, wheat breakfast food, beef in gravy, bread, 
 butter, milk, coffee. 
 
 Luncheon. — Boiled rice, stewed prunes, milk, bread, butter, tea. 
 
 DIET IN COMMERCIAL LIFE 
 
 The responsibilities and anxieties of active business life are apt 
 at times to react unfavourably upon digestion, producing dyspepsia, 
 headache, constipation, and biliousness. As a rule, there are few 
 patients less willing to listen to advice in regard to diet and habits 
 of life than the overworked business man engaged in the strife of 
 active competition and with large financial interests at stake. He 
 expects a dinner pill or laxative or the latest fashionable " tonic " 
 to counteract the persistent violation of the simplest dietetic and 
 hygienic laws, and, obtaining temporary relief, goes on overtaxing 
 his alimentary canal, liver, and nervous system, laying the founda- 
 tion of more serious ills, such as lithsemia, arterio-sclerosis, or possi- 
 bly gout, gravel, or cirrhosis. The prevalence of chronic Bright's 
 disease and neurasthenia in this country is by some clinicians of large 
 experience attributed to such causes. Imperfectly oxidised waste 
 materials in the circulation may irritate kidneys and vascular system 
 alike, and long-continued excitation eventually results in structural 
 changes. 
 
742 RATIONS, DIETARIES 
 
 While prescribing remedies for individual symptoms the physi- 
 cian should not neglect to give wholesome counsel concerning diet, 
 and such advice, however little heeded by itself, will sometimes be 
 regarded as an essential part of other remedial measures, and ac- 
 cepted accordingly. The too hasty consumption of food, the neglect 
 of securing proper action of the bowels, and carrying the concerns 
 and worries of the counting-house to the table, combined with loss 
 of sleep and of outdoor exercise, are the principal difficulties which 
 this class of patients must contend against. Three good meals a 
 day should be eaten. The breakfast should be substantial, compris- 
 ing meat or eggs or fish with some cereal and fresh fruit ; and dinner 
 should be the last meal of the day, eaten preferably late — at half past 
 six or seven o'clock — allowing an interval before the meal for recre- 
 ation or diversion. 
 
 The lunch should be the lightest meal of the day, for the reason 
 that it is difficult for many to take it always at a fixed hour, and still 
 more difficult to allow sufficient time for due mastication and diges- 
 tion. Sydney Smith once said, referring to the bad habit of hasty 
 eating, that " many a man digs his grave with his teeth." It is not 
 necessary, nor is it advisable, to eat meat three times a day, and 
 many of these patients who are made dyspeptic by eating meat and 
 vegetables together find that they have less flatulence and discom- 
 fort after meals if they take these classes of foods independently, 
 eating meat and no vegetables or sugars at one meal, and vege- 
 tables without meat at another. The reason for this should be ex- 
 plained to them — namely, that carbohydrates, digested only by alka- 
 line saliva and pancreatic fluid, may interfere with the acid digestion 
 of animal food in the stomach. The luncheon should consist, there- 
 fore, of simple farinaceous food with one or two plainly cooked vege- 
 tables or a salad and a relish of some sort. 
 
 Alcoholic stimulants of any kind are not required, except to 
 counteract exceptional fatigue, and, as a rule, these patients are 
 better without their habitual use. If allowed, they should be drunk 
 at dinner only. Malt liquors taken at luncheon are apt to cause 
 drowsiness and dulness in the afternoon. 
 
 As adjuncts to the dietetic treatment other measures should not 
 be neglected. Cold bathing with vigorous rubbing is desirable on 
 rising, and an occasional Russian or Turkish bath may be service- 
 able if there is a tendency to heavily loaded urine and biliousness. 
 Exercise in the open air is very important. Golfing is of value, but 
 too much walking is fatiguing. Bicycling is much better. It fur- 
 nishes more active exercise and diverts the mind ; but horse- 
 back riding is preferable, even if it can be indulged in but once 
 a week. 
 
 The bowels should be kept active, and fresh fruit and abundant 
 draughts of pure water are the best means for this purpose. 
 
DIET AND TRAVEL 743 
 
 DIET AND TRAVEL 
 
 In travelling one is often placed in circumstances in which it is 
 difficult or impossible to obtain wholesome food, and must either be 
 content with badly cooked or positively repugnant food, or go with- 
 out. Under such conditions it is a decided advantage to have a 
 varied taste, so that something may be found which will not disgust. 
 
 It is difficult to give any but the most general directions for 
 circumstances which are so various. It is a common fault to eat too 
 much when travelling, and the lack of exercise combined with an 
 excess of food results in indigestion, constipation, and biliousness. 
 Sea voyages sometimes benefit invalids and dyspeptics more than 
 the healthy, for the latter, if not seasick at first, often overeat, and 
 suffer in consequence. 
 
 The " stand-up lunch counters " of American railway stations 
 freighted with doughnuts, tough ham, and pie are a constant invi- 
 tation to dyspepsia with the hurried eating of such indigestible arti- 
 cles as they afford, but which the more general introduction of din- 
 ing cars is fortunately replacing, at least for those whose means 
 allow them to consult the best interests of their digestive organs. 
 
 In warm climates olive oil may be often obtained and made to 
 replace rancid butter upon baked potatoes. Much garlic may cause 
 diarrhcea and colic in those unaccustomed to its use, but mustard 
 will counteract its effect. Lemon juice also forms a wholesome 
 relish and aids in checking diarrhoea. It is well to avoid raw or 
 imperfectly cooked ham and sausage of every sort, for fear of para- 
 sitic infection. If the food is inevitably greasy its digestion may be 
 promoted by the use of condiments, such as vinegar, Cayenne, or 
 lemon juice. All milk as well as water drunk should be previously 
 boiled. 
 
 Fresh fruits, crackers, bread, cold meats, soft-cooked eggs, and 
 milk will be found to comprise the most digestible articles for a 
 railway journey, and invalids or travellers who have wandered far 
 from good food supplies do well to carry some of the concentrated 
 preparations which with the aid of a little hot water may be made 
 into a nutritious beverage, such, for example, as malted milk and 
 cereals, beef meal or beef jelly, chocolate, condensed coffee, meat 
 extracts, etc., besides which there is an almost inexhaustible variety 
 of canned foods, meats, vegetables, and fruits from which the trav- 
 eller or explorer may replenish his table. For infants sterilised 
 milk may be carried which will keep fresh for ten days, or canned 
 milk may be provided for a longer period. 
 
 Lime tablets are prepared which may be conveniently used in 
 travelling when fresh lime water is likely to be required for dilution 
 of milk or for use in seasickness. 
 49 
 
744 RATIONS, DIETARIES 
 
 DIET IN PREGNANCY 
 
 It is not customary to adopt any definite system of diet for preg- 
 nancy unless complications arise. If serious vomiting occurs in the 
 early months, this should be treated in the manner described on 
 p. 543. If albuminuria is discovered, meat and other nitrogenous 
 food must be restricted, in accordance with the directions given 
 under albuminuria (p. 496). If the patient becomes very anaemic, 
 without albuminuria, meat, eggs, and milk should be eaten in abun- 
 dance (p. 486). 
 
 The " longings " of pregnant women for various indigestible 
 articles, such as pickles, chalk, etc., are largely mythical, and occur, 
 if at all, only as an accompaniment of a general hysterical con- 
 dition, not as a peculiarity of the period of pregnancy. Pregnant 
 women, however, should live simply and avoid foods which are 
 likely to produce dyspepsia, heartburn, and colic, such as sweets, 
 pastry, fried food, rich sauces, spiced dishes, and heating drinks. 
 They often suffer from constipation, in which case fruits and coarse 
 cereals, such as oatmeal or wheaten grits, may be of service (p. 571). 
 The stomach, especially at night, should not be overloaded. 
 
 The idea formerly prevalent that pregnant women need to eat 
 food containing abundant phosphates and lime salts, to furnish the 
 embryo with material for making bones, as a hen eats lime to make 
 egg shells, is no longer accepted. The salts in question are suffi- 
 ciently contained in an ordinary mixed diet, such as any pregnant 
 woman may eat, if plainly cooked. 
 
 Another theory, equally ingenious and directly opposed to the 
 one above mentioned, is only interesting historically, for efforts to 
 aid Nature in a process which she is abundantly competent to regu- 
 late unaided are: now regarded as futile. This theory was that the 
 agonies of labour would be less severe if the pregnant woman lived 
 upon a diet of fruits and meats, avoiding bread and fresh vegetables 
 during gestation, on the ground that the lime salts which they con- 
 tain would favour early ossification of the infant's bones, and thus 
 make the labour proportionately difficult. 
 
 It will be observed that the first theory favours the child, and 
 the second the mother, but practically it has been found that diet 
 has little or no influence either way, so long as it is digestible, 
 nourishing, and sufficient to keep the mother in good general con- 
 dition. 
 
 DIET FOR PUERPERAL WOMEN 
 
 Within the past thirty years a revolution has been experienced 
 in the dietetic treatment of puerperal women, and they are no longer, 
 as formerly, kept for ten days or a fortnight upon a diet of toast 
 water, " slops," etc., with the idea that semistarvation would keep 
 
DIET FOR PUERPERAL WOMEN 745 
 
 down puerperal fever and " milk fever." This change is largely 
 due to methods of antiseptic midwifery, but the reaction started 
 even earlier, and in 1876 Fordyce Barker, who was one of the first 
 to forsake the old routine, wrote of the puerperal state : " I have 
 never seen the slightest evil result from good, ample, judicious ali- 
 mentation," and " I have had patients eat a good piece of tenderloin 
 steak the day after labour with a relish, and with happy results." 
 
 A pregnant woman may eat her ordinary diet up to the com- 
 mencement of labour. 
 
 If the labour is greatly protracted, the first stage lasting, as it 
 exceptionally does, for more than a few hours, it will not do to let 
 her strength become further exhausted from lack of food, and she 
 must be urged to take stimulating hot broths, gruels, or similar 
 easily digested food. Under the circumstances she is naturally 
 nervous and may decline all food, so she should be given only that 
 which is quickly swallowed without effort. In ordinary cases, how- 
 ever, no food is necessary or desirable during labour. 
 
 Immediately after delivery the woman, exhausted by muscular 
 effort and agonising pain, and possibly also under the influence still 
 of an anaesthetic, needs rest rather than food, and as she is more 
 thirsty than hungry, she may drink freely of water or Vichy. 
 
 On the other hand, many puerperal complications, including 
 mania, are favoured by exhaustion and inanition, and good feeding 
 must not be delayed too long. The nursing woman, moreover, 
 needs a more liberal diet than other patients. Her milk contains a 
 large percentage of proteid and fat, and she also loses proteid sub- 
 stance to a greater or less extent through the lochia. A low diet 
 means poor breast milk, for it diminishes both its fats and proteids. 
 
 Spiegelberg says : " It is a bad practice to allow healthy lying-in 
 women to fast long; they need to be well fed, and if the appetite 
 is good they may be encouraged to eat." If they are well nourished 
 they both sleep and feel better. " Four or five hours after con- 
 finement the patient may be given a cup of hot bouillon or chicken 
 or mutton broth. She usually does not care for meat before the 
 second or third day, but she may have it then. Meanwhile she is 
 allowed broths of any kind, thickened with egg or rice, milk, tea, 
 light farinaceous gruels or puddings, soft-cooked eggs, toast, milk 
 toast, custards." Schroder gives meat and vegetables within a day 
 or two after the conclusion of labour. Lusk recommended a light 
 fluid or semisolid diet for the first three days. Then, after the bowels 
 have moved once or twice and the appetite returns, steak, chops, 
 a piece of fowl or a bird, eggs, and cooked fruits are given. 
 
 Playfair adopted the following system : If the woman is confined 
 in the early morning hours, at 9 A. m. she is given a cup of tea and 
 a piece of toast ; at 1 p. m. a light lunch of some form of predi- 
 gested meat preparation ; at 5 p. m. tea or beef tea, and at 7 p. m. a 
 
 ■ ■ 
 
74-6 RATIONS, DIETARIES 
 
 small bit of chicken with bread and butter or milk toast. Tea again 
 at 9 p. m. He discountenanced a continued use of gruels, " slops," 
 and stimulants. During the next day or two if the patient is hungry, 
 he allowed sweetbread, chicken, fish, eggs, and milk. 
 
 On the whole, the patient's own appetite is a better guide for 
 feeding than are any rules as to the exact time which has elapsed 
 since parturition. She should not be urged to take food, unless 
 greatly exhausted, and the stomach must not be overloaded; but if 
 hungry after the establishment of the milk secretion and after free 
 action of the bowels, she may be allowed a reasonable quantity and 
 variety, though while, still in bed she needs less than if up and 
 about. The occurrence of fever is a contraindication for giving 
 much proteid food except milk, but extreme exhaustion without 
 febrile reaction demands it. 
 
 SELECTION OF A WET NURSE 
 
 The selection of a wet nurse should be based upon the following 
 data: 
 
 Her own general health and digestion must be good, and her 
 bowels not habitually constipated. All evidence of syphilis, scrofula, 
 tuberculosis, or other disease must be rigidly excluded. A primip- 
 ara is to be preferred to a multipara as having milk somewhat 
 richer in fat. 
 
 Her best age is between twenty-two and thirty years, and she 
 should be of good temperament and have cleanly habits. Her period 
 of lactation should not be too widely different from the age of the 
 infant to be nursed. 
 
 The breasts should be firm, and the nipples fairly prominent 
 and free from fissures. Breasts which are always oozing sponta- 
 neously are by no means always the best, for their milk is soon 
 exhausted. 
 
 The nurse's own child, if living, should be examined, for if it has 
 been nursing at the breast its condition is an even better index of 
 suitableness of the mother's milk than her own appearance. 
 
 The child should be in good flesh and firm, without evidence of 
 gastric catarrh, fever, or indigestion, and of good development for 
 its age. 
 
 The question whether it is possible for a wet nurse to transmit 
 her own mental and physical characteristics to the child at her 
 breast has given rise to much discussion, but there is no more reason 
 why she should transmit an evil temper through the food she gives 
 than that a cow should transmit a bland one. An ill-tempered, iras- 
 cible wet nurse may sometimes give milk which disagrees with the 
 child's stomach, but beyond that there is nothing in the belief that 
 she can affect it mentally or morally by this agency. 
 
DIET OF A NURSING MOTHER OR WET NURSE 
 
 747 
 
 The milk which can be expressed from the breast should have 
 the following properties : Reaction alkaline, color an opaque blue- 
 white, specific gravity 1.03 1, taste sweetish. Examined microscop- 
 ically, the fat corpuscles should abundantly fill the field and be of 
 nearly equal size. 
 
 Human breast milk on an average has a specific gravity of 1.031 
 at yo° F., but it varies between 1.017 and 1.036 (Holt). The fat 
 varies less than the sugar and proteids. 
 
 If the specific gravity of the milk is high, and at the same time 
 the percentage of fat is considerable, the gravity must be due to a 
 larger quantity of proteids than usual, because fat tends to lower it. 
 If the fat percentage is small and the specific gravity of the milk is 
 low, the proteids must also be reduced. Holt furnishes the follow- 
 ing convenient table for determining the richness of human milk in 
 fats and proteids, which gives results that are sufficient for practical 
 purposes in examining the milk of a wet nurse : 
 
 
 Specific gravity 
 
 7 o°F. 
 
 Cream — 24 hours. 
 
 Proteids — (calculated). 
 
 Normal average. . . . 
 
 1. 031 
 
 7% 
 
 1-5* 
 
 Healthy variations. . 
 
 I.028 — I.029 
 
 Sfc—12% 
 
 Normal (rich milk). 
 
 Unhealthy " 
 
 I.O32— I.O33 
 
 Below 1 .028 
 14 t< 
 
 High (above io£). 
 Normal (5% — io#). 
 
 " (fair milk). 
 " or slightly below. 
 Low. 
 
 « :: 
 
 Above 1.033 
 
 Low (below 5#). 
 
 High. 
 
 Normal. 
 
 Very low (very poor milk). 
 Very high (very rich milk). 
 High. 
 
 " •• 
 
 " " 
 
 Low. 
 
 Normal (or nearly so). 
 
 To calculate the actual fat from the cream multiply bv three 
 fifths. 
 
 In examining the composition of the milk of a wet nurse it is 
 only fair to the nurse to remember that, like cow's milk, her own 
 contains less fat when the milk is first drawn than after the breast 
 has been nursed for a few moments. 
 
 The quantity of the milk may be best estimated by weighing the 
 infant immediately before and after suckling, when the gain should 
 be between three and six ounces. 
 
 DIET OF A NURSING MOTHER OR WET NURSE 
 
 The diet of the nursing mother or wet nurse must be regulated, 
 to prevent noxious substances from passing into the breast milk and 
 to keep her in good health, so that she does not suffer from consti- 
 pation, indigestion, or anaemia. Her weight should not alter, and 
 if she has menstruated once or twice the milk changes and may 
 disagree. 
 
 If milk does not make her constipated or bilious she may drink 
 
748 RATIONS, DIETARIES 
 
 it abundantly. She may take gruels and meat broths, and she should 
 eat simple nourishing food, meat, eggs, vegetables, and fruits. The 
 latter, even if sour, do not react unfavourably upon the child, pro- 
 vided the mother's digestion is good, and they serve to keep the 
 child's bowels active. The mother should forego the drinking of 
 much tea and coffee. Beer and wine also should not be drunk unless 
 they are especially prescribed as a tonic. Wet nurses often demand 
 beer, ale, or porter with their meals if they have been accustomed to 
 it ; but the popular idea that such beverages are especially beneficial 
 is fallacious. Malt liquor sometimes causes the secretion of more 
 milk, because more fluid is drunk, but the milk is no better for it. 
 A reasonable quantity of fluids should be drunk, however, or the 
 secretion of milk will suffer. The fluid may be in the form of plain 
 or effervescing water, milk, soups, etc. 
 
 The mother or wet nurse should avoid all fatigue, worry, and 
 emotional excitement of any kind, which may inhibit her digestive 
 functions, and should take daily outdoor exercise. 
 
 On the whole, the best indication for the dietetic treatment of 
 the wet nurse is the study of the condition of the child's digestion, 
 bowels, and nutrition. A too meagre diet for the nurse is soon evi- 
 dent in lack of nutrition and development of the infant. 
 
 Drug's in Human Milk. — Not many drugs pass unchanged into 
 the milk which are likely to poison the child through its food, 
 but there are some which should be carefully avoided on this 
 account. Such are belladonna, opium, morphine, and other alka- 
 loids ; iodine and its preparations ; mercury and its salts ; salicylic 
 acid (see p. 57). 
 
 When, for any reason, it becomes necessary to discontinue the 
 nursing and to stop further secretion of milk, the diet should at 
 once be made as dry as possible, and a minimum quantity only 
 of fluid is allowed. 
 
 THE FOOD OF INFANTS 
 
 Size of the Infant's Stomach. — With regard to infant nursing, 
 it is never sufficient to give general directions about an infant's 
 food. The physician should supervise the exact mode of its prepara- 
 tion, and order both the quantity to be given and the intervals at 
 w 7 hich it is to be given. 
 
 Mothers seldom know what is best for their infants in these 
 matters. 
 
 It is therefore well to explain to them fully the facts as to the 
 proper hours for feeding and the amount of food required, and also 
 to give them some idea of the size of the infant stomach, for many 
 have a vague idea that the word " stomach " includes almost the 
 entire abdominal cavity. 
 
THE FOOD OF INFANTS 749 
 
 Rotch gives the following table of capacities of infant stomachs : 
 
 i. Premature 8 months' infant 8 cubic centimetres. 
 
 2. Infant 5 days old 2 5~30 ' ' 
 
 3. Infant 4 weeks old 75 " 
 
 4. Infant 8 " " 96 " 
 
 5. Infant 16 " " 107 " " 
 
 6. Infant 20 " " 108 " " 
 
 It is advisable to show the mother or nurse an empty bottle 
 representing the capacity of the infant's stomach, in order to im- 
 press upon her the danger of overloading it. 
 
 Overfeeding. — It is sometimes said that overfeeding kills more 
 babies than starvation, and certainly it is responsible for a large 
 proportion of the ailments of early infancy, such as gastric catarrh 
 and diarrhoea. This is especially true in summer, when the fretful- 
 ness of the child, which is often mistaken for hunger, may be due to 
 thirst, the external temperature, too warm clothing, or indigestion. 
 At such times Holt advises reducing the bulk of each meal by one 
 quarter and giving the infant more water to drink, for, as he says, 
 infants, like adults, require less food in excessively hot weather. 
 
 It is difficult to impress mothers with the fact that milk should 
 never be given to soothe a baby's fretfulness merely, and " un- 
 methodical and improper feeding is quite as bad as feeding with 
 improper aliments " (Adams). 
 
 The young infant secretes no ptyalin to digest starch, and Biedert 
 finds that the infant stomach does not well digest albumin when its 
 solution is stronger than 1 per cent. 
 
 Methods of Feeding 
 
 Infants may be given their food in one of five ways: I. By 
 mother's milk. II. By milk from a wet nurse. III. By bottle feed- 
 ing. IV. By mixed feeding — i. e., when the mother's or nurse's 
 milk is supplemented by bottle feeding. V. By gavage. 
 
 There is no room for doubt that infants brought up on breast 
 milk are stronger and better able to remain in good health and 
 resist disease than those who are hand fed, for no infant food has 
 ever been devised which is in every way as satisfactory as good 
 mother's milk. 
 
 This method is unquestionably better for the infant in all cases 
 where it is feasible 'than any method of artificial feeding. In lands 
 without cow's milk, such as Japan or the arctic regions, infants are 
 singularly free from digestive disorders. Artificial feeding, if care- 
 lessly performed, is full of dangers to the infant. Statistics might be 
 cited indefinitely, showing the relative high mortality rate among 
 artificially fed infants. For example : In Munich, the mortality rate 
 
750 RATIONS, DIETARIES 
 
 has been 15 for breast-fed infants, against 85 for those artificially 
 fed ; and in England, 42 per cent of the infant mortality is due to 
 digestive disorders, largely among the artificially fed. 
 
 I and II— FEEDING BY THE MOTHER OR WET NURSE 
 
 Starr advises putting the infant to the breast as early as six or 
 eight hours after labour is completed, which is good for both mother 
 and child. For the mother it improves the nipple, stimulates the 
 true milk secretion, and reflexly the uterine contractions ; for the 
 infant it is also desirable, for it insures the ingestion of colostrum. 
 
 Colostrum constitutes the secretion of the first three days. This 
 secretion is mildly laxative, and it cleanses the child's alimentary 
 canal of the waste matter called meconium, which is found within 
 it at birth. 
 
 Colostrum contains an excess of albumin, so that boiling coag- 
 ulates it. It also has large corpuscles, which may be seen with the 
 microscope throughout the first week of lactation, gradually lessen- 
 ing in number. They then rapidly disappear, and none should be 
 present after a fortnight. If found later, the milk is certain to dis- 
 agree and a change of nurse is necessitated. 
 
 Intervals for Feeding. — Infants during the first three days should 
 be nursed only four or five times a day. Water may be given, but 
 no bottle food, which only upsets the stomach and lessens the 
 ability to suck. After this period once every two hours is the proper 
 interval for suckling for the first six weeks or two months. The 
 child should be nursed at this interval between 5 a. m. and 11 p. m., 
 with one feeding only in the middle of the night. If absolute regu- 
 larity is always observed in the hours for nursing, the child's digest- 
 ive organs keep in much better condition, it sleeps better, and is 
 much less likely to be overfed. During the first four or five months 
 of life an infant should be fed once during the night ; after that it 
 need not be fed between 10 p. m. and 7 a. m. When a year old, if 
 strong and well, it need not be fed between 7 p. m. and 7 a. m. If 
 fed or nursed oftener than this, the child receives too much food, 
 and digestion and rest are both disturbed. 
 
 Sometimes an infant will demand milk at night and not take it in 
 the daytime as well as it should, but with a little firmness and by 
 starving it for a few hours until it is really hungry, it can often be 
 trained to suckle in the manner which experience has proved is best 
 for both itself and its mother. 
 
 From fifteen to twenty minutes is sufficient time to keep the 
 child at the breast, and it will often doze off to sleep after nursing. 
 
 As the child grows older the intervals between the hours of 
 nursing are to be prolonged, in accordance with the tables given 
 below (pp. 756, 757), and the child may be allowed to remain a few 
 moments longer at the breast. 
 
THE FOOD OF INFANTS 751 
 
 The infant while sucking should always be held in a comfortable 
 position with the nipple within easy reach. 
 
 After a three-hour interval for feeding has been reached, it may 
 be maintained in many cases until lactation is completed, but after 
 reaching six months of age some infants do better with a three and 
 a half or four hours' interval. 
 
 Infants. born with a cleft lip or palate cannot be properly nursed 
 at the breast, for they are unable to make the necessary vacuum in 
 the mouth to draw the milk. They may be unable to take the bottle 
 successfully, and must then be fed by gavage or with a spoon. 
 
 Ill— FEEDING BY THE BOTTLE 
 
 When it becomes necessary to employ artificial feeding there are 
 two principles upon which it may be conducted. The first and most 
 extensively practised is to endeavour to obtain a food by modifying 
 cow's milk, which corresponds as nearly as possible to the composi- 
 tion of average human milk. The second is to adapt the prepared 
 milk to the needs of each particular infant, as suggested by the 
 state of its digestive organs and existing nutrition and development. 
 The first method seeks to bring the child up to the standard of the 
 milk, the second to bring the milk to the standard of the child. 
 This system of " prescription writing " as applied to milk, in cases 
 of severe illness and great impairment of digestion, is more rational 
 than the older method, but it presupposes much experience and care 
 on the part of the physician. 
 
 Due regard must be had, of course, for the circumstances of 
 those for whom an especially modified diet is ordered. For the very 
 poor, milk is a serious item of expense, and cream and sugar may be 
 out of the question. Condensed milk is usually cheaper in large 
 cities than fresh cow's milk, for less care and expense is involved 
 in its transportation, and it is accordingly much used by the poor. 
 Moreover, in hot weather it keeps without ice, but for reasons given 
 elsewhere (p. 93) it is never to be preferred when good fresh cow's 
 milk is obtainable. It is deficient in protein, and this may be cor- 
 rected by adding meat broth, beef juice, or egg albumin. It is also 
 deficient in fat, and cod-liver oil may be added. 
 
 Cow's milk contains approximately half the quantity of sugar 
 present in human milk. 
 
 Leeds says that the curd derivable from human milk is only one 
 fifth as much as that of cow's milk, and there are other striking 
 differences in regard to the quantity of casein precipitable by acid, 
 as compared with the non-coagulable ingredients of both forms of 
 milk. 
 
 For this reason cow's milk must be diluted for very young infants 
 with two parts of water, in order to bring the casein nearer to the 
 
752 RATIONS, DIETARIES 
 
 right proportion ; but the addition of water reduces the percentage 
 of fat and of sugar. 
 
 Escherich has shown that the infant fed upon diluted cow's milk 
 has to take much more fluid than when nursed by breast milk to get 
 the same quantity of nutriment, with consequent distention and pos- 
 sible enfeeblement of the stomach. 
 
 The disproportion of fat may be counterbalanced by using " top 
 milk " — i. e., the upper layer which forms after the milk has stood 
 for about eight hours, and which contains most of the cream. Milk 
 sugar is then to be added in the proportion of one heaping teaspoon- 
 ful to four ounces of the diluted milk. If cane sugar is used, which 
 is less desirable, as it is more apt to ferment, only one teaspoonful 
 to every six ounces is necessary. 
 
 From a quart of ordinary milk six ounces of top milk may be 
 skimmed, seven ounces from rich, and five from poor milk. In lieu 
 of top milk a mixture of equal parts of cream and of ordinary milk 
 should be used (Holt). 
 
 When the milk causes dyspepsia, and large curds are vomited, 
 it is well to substitute barley water for plain water in the same 
 proportion. 
 
 If pearl barley is used it should be boiled a long time — for six 
 or eight hours — the water being replaced as it evaporates. The 
 proportion usually employed is two tablespoonfuls of barley to the 
 quart of water. After careful straining through a linen cloth, a pinch 
 of salt is added, and when cool the fluid is ready for use. Instead 
 of pearl barley, one of the barley flours may be employed. This 
 answers the purpose as well, and has the advantage of requiring 
 much less time, boiling for half an hour being sufficient. 
 
 Holt gives the following formulae for an infant two months old 
 receiving twenty-four ounces a day : 
 
 Top milk. 8 ounces. 
 
 Barley water 16 " 
 
 Milk sugar 6 heaping teaspoonfuls, or 
 
 Cane sugar 4 " " 
 
 The quantity is to be slightly increased, but the proportion may 
 remain the same until the seventh or eighth month, when the mix- 
 ture should be changed to — 
 
 Top milk 19 ounces. 
 
 Barley water 19 " 
 
 Milk sugar 9 teaspoonfuls, or 
 
 Cane sugar 5 " 
 
 In answer to the question, " Can a child one year old take plain 
 cow's milk?" Holt says: "Many children can, but the majority do 
 better when the milk is modified by the addition of cream and water, 
 or by the use of diluted top milk. After standing six hours six 
 
THE FOOD OF INFANTS 753 
 
 ounces should be taken off from the top of the milk bottle and ten 
 ounces more should then be poured off and the two mixed. This 
 may be diluted with an equal quantity of water or barley water." 
 
 It is generally conceded that fresh raw cow's milk derived from 
 a healthy cow, and carefully kept from germ contamination, is a 
 more wholesome food for babies than milk which is either boiled, 
 sterilised, Pasteurised, or peptonised. But in cities always, and 
 everywhere in summer, it is difficult or impossible to obtain such 
 milk, and one or other of the means of disinfection becomes im- 
 perative. 
 
 The heat required for sterilisation in some manner destroys the 
 vital properties of nuclein of the milk (Starr). 
 
 Peptonised milk is used much less for infant feeding than for- 
 merly, for it has been found that they do not thrive if continuously 
 fed upon it. 
 
 Care of the Milk. — In order to keep milk fresh and pure for 
 infant use in hot weather it should be at once artificially cooled, and 
 if intended for city consumption, during transportation both car and 
 delivery wagon should be supplied with ice, so that the milk tem- 
 perature never rises above 50 F. The milk when received at the 
 dealer's should also be kept in refrigerators, for it is exceedingly 
 important that it should not become lukewarm even temporarily. 
 It is an undoubted advantage to have the whole system of milk 
 supply under proper inspection and licensing. The cows when 
 stabled should be kept in clean, well-ventilated quarters, and should 
 always have the udders washed before milking. Every receptacle 
 used for holding the milk should be thoroughly scoured with boiling 
 water each day, but after first rinsing with cold water. If this pro- 
 cess is reversed, particles of scalded milk may cling to the pail or 
 can and give rise to subsequent fermentation. Milk should never 
 be allowed to stand about in uncovered vessels, especially in a bath- 
 room, near an open sewer pipe or drain, or in a damp cellar. 
 
 When given to the infant the milk, as well as all infant food, 
 should be moderately warmed to approximate its bodv temperature 
 (99° F.). 
 
 When the milk temporarily disagrees it becomes necessary to 
 substitute for it some other form of food. Useful formulae for this 
 purpose are given by Starr as follows : 
 
 Substitutes for Milk in Infant Feeding (Starr) 
 
 Veal broth [\ lb. of meat to the pint) f 3 jss. 
 
 Barley water f § jss. 
 
 Mix. 
 
 '. each, one and a half 
 
 Barley water, ^ 
 
 Milk sugar half a drachm. 
 
 Give one portion at two months. 
 
 ounce. 
 
754 RATIONS, DIETARIES 
 
 Raw beef juice (one teaspoonful every two hours) will " be re- 
 tained when everything else is rejected." 
 
 Both barley water and lime water are sometimes added when 
 temporary looseness of the bowels occurs. 
 
 In using lime water (carbonate of lime) as a diluent of cow's milk 
 in infant feeding, it should be remembered that in the latter the 
 phosphate of lime is four times greater in quantity than in human 
 milk (Leeds), and it is of questionable utility to continue the practice 
 beyond the requirements of a temporary fit of indigestion. 
 
 Many persons suppose that the milk from a single cow is to be 
 preferred to the mixed milk of several animals, and formerly some 
 dairies used to supply such milk in separate bottles. It has been 
 proved, however, that there is less variation in the quality of mixed 
 milk, and the infant is not so apt to become dyspeptic while tak- 
 ing it. 
 
 The milk of fancy breeds of cows, such as that of thoroughbred 
 Alderneys or Durhams, is often too rich both for infants and in- 
 valids. 
 
 IV— MIXED FEEDING 
 
 There is no harm whatever in partly feeding infants with the 
 bottle who are at the same time being nursed. If the mother is 
 suffering from want of sleep she will be of more value to her infant 
 if allowed to sleep at night while her child is hand-fed once or twice. 
 When the breast milk is insufficient or poor in quality the child must 
 be fed by hand several times a day in addition to nursing. A hungry, 
 ill-nourished child cries continuously in a fretful manner and nurses 
 irregularly, either taking the breast too long and eagerly or stopping 
 too soon if it cannot obtain the milk without much effort. The 
 sleep is fitful, the abdomen is tender and usually distended with gas. 
 There may be vomiting, and the stools are malodorous and contain 
 milk curds. Sometimes such babies may be given the bottle for 
 the greater part of their food for a few days, until the mother's milk 
 is found to agree with them better, and thus the necessity for abso- 
 lute weaning may be postponed. 
 
 Infants who are brought up to take the bottle once or twice at 
 night, being nursed at the breast in the daytime, are usually more 
 easily weaned when the period for entire hand-feeding arrives. 
 
 When a mother who has abundant milk supply is obliged to be 
 temporarily absent from her infant beyond the period when a meal 
 is due, she may beforehand express into a clean glass a little milk 
 which may be kept and fed to the child with a teaspoon while the 
 mother is away. 
 
 V— GAVAGE 
 
 When infants have irritable stomachs, gastric catarrh, or when 
 they persistently refuse food or are too feeble and marasmic to take 
 
THE FOOD OF INFANTS 755 
 
 sufficient food, they are fed by the method of " gavage," which con- 
 sists in pouring liquid nourishment into the stomach through a 
 glass funnel attached to a catheter. A soft-rubber catheter (No. 7) 
 may be used. The child is wrapped in a sheet to restrain the arms, 
 and then laid on its back upon a table. The catheter is passed 
 through the mouth for a distance of about 8 inches, and warm 
 milk or broth and, if necessary, medicines may be poured in. 
 
 Weaning 
 
 The period for weaning varies considerably, according to the 
 health and vigour of both mother and infant. As a rule, it should 
 be between the tenth and eighteenth month, ordinarily not before 
 the tenth or twelfth month has been passed. Many infants are 
 nursed for fifteen months, but after, if not before the eighteenth 
 month the mother's milk deteriorates, and the child's needs will be 
 better met by bottle feeding. There can be no fixed rule about this, 
 however, and much depends upon the nationality and social position 
 of the mother. The poor, for reasons of economy, sometimes nurse 
 their children longer than is good for them, and many foreigners in 
 this country seem able to nurse their infants longer than native 
 Americans. 
 
 The eruption of the eight incisor teeth, which should be com- 
 plete by the end of the first year, is often regarded as an indication 
 for weaning. At this time the digestive organs become stronger, 
 the saliva becomes more abundant, and the appearance of the an- 
 terior molar teeth is a sign that the child is gradually preparing 
 for solid food. 
 
 Usually, even though the anterior molar teeth are cut, the child, 
 if weaned, should still be fed chiefly upon milk until the eighteenth 
 month. It is best not to wean a child during very hot weather, but 
 when this is imperative milk only should be given, otherwise a small 
 quantity of beef juice, egg, etc., may be allowed by degrees. 
 
 An infant may be weaned at any time, and occasion may require 
 its being done suddenly, but ordinarily the process should occupy 
 at least one or two months. When the child is nine or ten months 
 of age the bottle may be given once a day in place of the breast; 
 later two or three times, and so on, until at the end of a year the 
 weaning is completed. This, however, is a very general rule, sub- 
 ject to modifications necessitated by the ill health of mother or 
 child, or by hot weather, etc. 
 
 The circumstances which necessitate earlier weaning than the 
 period after the twelfth month may be due to the condition of the 
 infant, who may have malformation of the mouth or be congenitally 
 too feeble to suckle, or rendered so by some disease, such as rickets 
 or hereditary syphilis, or the condition of the mother may be at 
 
756 
 
 RATIONS, DIETARIES 
 
 fault, either from constitutional disease, such as tuberculosis or syph- 
 ilis, from local disease, abscess, or malformation of the nipples, from 
 insufficient or poor milk, or from the recurrence of menstruation 
 or pregnancy. 
 
 If an infant be nursed after the mother's milk has grown poor in 
 quality it may acquire rickets and digestive disorders. 
 
 The following directions for weaning an infant from the bottle 
 and for feeding during the second year are concisely given by Holt 
 in his admirable brochure on The Care and Feeding of Infants. 
 They summarise concisely a very large experience : 
 
 " At ten months the bottle or breast milk may be supplemented 
 by a little beef juice or a portion of a soft-boiled tgg. If the bottle 
 is given, arrowroot or farina may be added to one feeding each 
 day. . . . 
 
 " A child should always be weaned as early as eighteen or twenty 
 months, but it can be easily done at twelve or fifteen months. . . . 
 During the second year a healthy child never requires more than 
 five, and some do better with four, meals during the latter half of 
 the year. . . . 
 
 " If five meals are given, the best hours are 7 a. m., 10 a. m., 
 1 p. m., 4 p. m., 7 p. m., with nothing whatever during the night. It 
 is better to make the 10 A. m. and 4 p. m. meals rather smaller than 
 the others." 
 
 Starr gives the following mixture in commencing weaning at 
 the tenth month : 
 
 Weaning Mixture at Ten Months (Starr) 
 
 Cream , f § ss. 
 
 Milk f I iv. 
 
 Sugar of milk § j. 
 
 Water f § jss. 
 
 If disorder of digestion occurs, return temporarily to the breast. 
 
 Holt presents the following table, based on the measurement of 
 forty infant stomachs and the weighing of infants immediately be- 
 fore and after nursing. The table gives the averages computed 
 from such data, but the robust will require a little more, and the 
 feeble will take less food. The measurements are in ounces : 
 
 Age. 
 
 Quantity suckled at one feeding. 
 
 Number of feedings. 
 
 Total daily amount. 
 
 2 weeks 
 
 2 
 
 8 
 
 16 
 
 1 month 
 
 3 
 
 8 
 
 24 
 
 2 months 
 
 4 
 
 7 
 
 28 
 
 4 months 
 
 5 
 
 6 
 
 30 
 
 6 months 
 
 5^-6 
 
 6 
 
 33-36 
 
 9 months 
 
 7-71 
 
 5 
 
 35-38 
 
 12 months 
 
 8-9 
 
 5 
 
 40-45 
 
THE FOOD OF INFANTS 
 
 757 
 
 After the twelfth month three pints is the limit of digestive 
 capacity for food for the stomach for one day. If the child seems 
 to need more nourishment, the strength of the food, but not its bulk, 
 may be increased. 
 
 Quantity of Food required in the First Year of Infancy (Rotch) 
 
 During the ist week 
 
 At the 3d week 
 
 At the 6th week 
 
 At the 3d month 
 
 At the 4th month 
 
 At the 6th month 
 
 At the 10th or 12th month 
 
 At each feeding. 
 
 2 
 3 
 
 4 
 
 6 
 
 Number of daily 
 feedings. 
 
 IO 
 IO 
 
 Total daily 
 amount. 
 
 IO OZ. 
 
 15 " 
 
 16 " 
 24 " 
 28 " 
 30 " 
 40 " 
 
 Holt's " Schedule for Feeding an Average Child in Health " for the First 
 
 Year 
 
 Age. 
 
 Number of 
 meals. 
 
 Interval by day 
 between meals. 
 
 Night feed- 
 ings, IO P. M. 
 to 6 A. M. 
 
 Quantity for 
 each meal. 
 
 Quantity for 
 24 hours. 
 
 
 IO 
 IO 
 
 9 
 
 8 
 
 7 
 6 
 6 
 
 5 
 5 
 
 2 hours. 
 2 " 
 2 " 
 
 2i « 
 
 3 
 3 
 3 
 3 
 3 
 
 2 
 
 2 
 
 I 
 I 
 I 
 
 I OZ. 
 
 ii " 
 
 3 " 
 
 4 " 
 5* " 
 6 " 
 
 i\ " 
 
 8 " 
 
 
 2 to 3 weeks 
 
 4 weeks 
 
 15 " 
 20 " 
 
 6 " . 
 
 24 " 
 28 " 
 
 
 e " 
 
 33 " 
 
 36 « 
 
 371 " 
 40 " 
 
 6 " 
 
 12 " 
 
 Note. — A large child may be given a few ounces more in the 24 hours than the 
 quantity above specified, a small child a little less. A large child may pass from one 
 formula to the next a little more rapidly than at the time specified, but a small child, 
 or one with feeble digestion, will have to proceed more slowly. The hours for feeding 
 should in all cases be observed with regularity. 
 
 Chrys tie's Table for Infant Feeding 
 
 Age. 
 
 ist week 
 
 2d to 4th week. . 
 2d to 3d month. 
 3d to 4th month. 
 4th to 5th month 
 
 6th month 
 
 8th month 
 
 10th month 
 
 Interval. 
 
 2 hours. 
 
 2 " 
 
 3 " 
 
 3 " 
 
 3 " 
 
 3 " 
 
 3 " 
 
 3 " 
 
 Number of 
 feedings in 
 24 hours. 
 
 IO 
 
 9 
 
 6 
 6 
 6 
 6 
 6 
 5 
 
 Amount of 
 
 food at 
 
 each feeding. 
 
 3 
 4 
 
 4-4l 
 5 
 6 
 
 Total amount 
 in 24 hours. 
 
 IO OZ 
 
 131 
 18 
 24 
 24-27 
 30 
 
 36 
 40 
 
 The foregoing tables differ only in a few unimportant details — 
 less, in fact, than the digestive powers of infants differ from each 
 other. 
 
758 
 
 RATIONS, DIETARIES 
 
 cq 
 
 
 
 f^sV^Ss 
 
 J el 
 
 ° 2 r. 
 
 
 u 
 
 ^ o3 
 
 E <*- > •- 
 O ^ w 
 
 £r ci 'o'o 2 
 
 S£ 
 
 d TJ "" 
 
 o c 
 
 O rt cs 
 
 *H £JS 
 
 o c 
 H g 
 
 X 
 X 
 bM 
 
 x B x 
 
 X ci bKj 
 bbO CA3 i+H 
 
 I 
 
 
 
 g « a 
 £ ea § 
 
 r £^-a 
 
 ^ en — 
 
 o be 
 
 ffi^ 
 
 o •- 
 
 £ T 13 £ 
 
 O . O .Og 
 
 S 
 
 "< lJ 
 
 bjO 5 " s " s f^ 
 
 •- S Oh 2 fc « q 
 
 ■< o 
 
 rt cnn3 _ 
 
 co d ■■ g - 2 
 
 <-> 2 
 
 C fa 
 
 
 v_ O JJ — i el g 
 
 O "+h T" ■•" O 
 
 < « 
 
 bK) 4> 
 
 < Pi 
 
 
 d 
 
 -C ,£3 
 
 d d 
 
 <J < 
 
 o 
 
 5 cj "^ nd . _2» 
 
 x 
 
 .5 
 
 bbO bO bbO 
 
 
 
 in 
 > 
 fcK> 
 
 in D w 
 
 .SS ST 
 
 Vw ^ 2 v_ 
 
 
 
 ^3« 
 
 2§ 
 
THE FOOD OF INFANTS 759 
 
 Artificial Infant Foods 
 
 Very young infants fed upon " proprietary " or " prepared " baby 
 foods, to the greater or less exclusion of mother's or good cow's 
 milk, soon become rhachitic or scorbutic. Wiederhofer says that 
 " the numerous infant foods, although much bepuffed, are of no 
 value whatever." This is certainly true of all non-malted amyla- 
 ceous foods. The common fault of nearly all such preparations is 
 that they contain too much sugar or starch and too little fat — which 
 latter is very difficult to preserve without becoming rancid. For 
 example: Prof. Leeds says that Mellin's food has only 0.15 part 
 fat in 144.74, and Nestle's food only 1.91 part in 139.69, but human 
 milk has 3.90 per cent and cow's has 3.66 per cent. 
 
 Two extreme conditions are seen in such infants — those who are 
 emaciated and marasmic, and those who are stout and apparently 
 robust, but whose strength and power of resistance to disease is 
 very deceptive. As described by Holt : " When children are fed 
 upon foods lacking in fat, the teeth come late, the bones are soft, the 
 muscles flabby," whereas " children fed upon foods containing too 
 much sugar are frequently very fat, but their flesh is very soft, they 
 walk late, and they perspire readily about the head and neck." They 
 present a variety of rhachitic deformities, and are subject to catarrhal 
 and other diseases. Such foods should never be fed to young in- 
 fants unless under a physician's direction. For the further discussion 
 of this topic the reader is referred to the section upon Prepared 
 Farinaceous Foods, p. 148. 
 
 Another objection to feeding infants with starchy food, even 
 when partially converted by diastase into dextrin and maltose, is 
 that the final products are unlike the carbohydrate of normal milk 
 (lactose), and it is doubtful whether they are as readily assimilated 
 and as useful in the obscure metabolic processes of infant growth. 
 
 Predigested proteid foods, such as somatose and various forms 
 of meat extracts, albumoses, etc., are sometimes used to re-enforce 
 the milk of very young infants by addition to it. This is a mistake, 
 for the cow's milk is already too rich in proteids. If temporary 
 indigestion requires their use, they should be substituted for milk, 
 and not given with the idea of re-enforcing it. 
 
 Infant Stools. — The stools of the infant should be observed from 
 time to time in order to ascertain whether the milk is being prop- 
 erly digested. 
 
 The stools of an infant fed exclusively on milk should number 
 two (or only one) a day, and be of uniform soft consistence, smooth, 
 of inoffensive odour, and of a gamboge-yellow colour. If meat juice 
 or meat broth of any kind is given, the stools usually become darker. 
 If too much is given they become acid, malodorous, very dark 
 brown, and diarrhceal. 
 50 
 
760 RATIONS, DIETARIES 
 
 Abnormal appearances of the stools will be found described in 
 connection with the dietetic treatment of infantile diarrhoea (p. 556). 
 When farinaceous or any amylaceous food is being given, it is well 
 to test the stools with a few drops of tincture of iodine which im- 
 parts a purple colour to any particles of undigested starch which 
 they may contain. 
 
 Nursing Bottles. — Ever since the influence of bacteria upon the 
 fermentation of milk has been established the necessity for observing 
 carefully the most minute details for cleansing all the infant's feeding 
 utensils has been apparent. 
 
 The necessity for use of the bottle for feeding is always to be 
 regretted on account of the difficulty of keeping the milk from 
 bacterial infection. Adams says : " One of the greatest nuisances in 
 infantile life is the popular feeding bottle. It probably causes more 
 intestinal diseases in the infant under two years of age than any 
 other article." 
 
 The use of nursing bottles with long rubber tubing is to be 
 unhesitatingly condemned, although it saves trouble in holding the 
 bottle. It is impossible to keep the tubing sterile. The bottle 
 should be of pure glass, white, of half-pint capacity, with a wide 
 mouth and a sloping neck, and never with a shoulder, which pre- 
 vents cleaning every part of the interior with a sterilised cotton 
 swab. 
 
 A measure of ounces should be blown in the side, and it should 
 be fitted with a short black rubber nipple, which can be removed 
 and turned inside out for thorough cleansing. This short nipple 
 has the further advantage that the child is less apt to be left by 
 the nurse alone with the bottle. The latter is a slovenly way to 
 feed an infant, and should be discountenanced, for the child gets 
 its milk with periods of delay and irregularity. The bottle may slip 
 out of reach, or after it is empty the child keeps on sucking or draws 
 in air, and obtains the milk at uneven temperatures, or sometimes 
 the child goes to sleep with the nipple in its mouth, and, awaking, 
 it finishes the bottle. " The sucking power of the child is to a great 
 extent produced by the muscles at the posterior portion of the 
 mouth ; if this action is carried on to too great an extent it has a ten- 
 dency to contract the width of the mouth and cause protrusion of 
 the teeth " (Cryer). For these reasons the nurse should always 
 continue holding the bottle in a comfortable position for the child 
 until it has taken its portion. This usually requires a few minutes 
 less time than is occupied in nursing at the breast. The usual time 
 is not above ten minutes (Dencke). Any residue in the bottle should 
 be at once thrown away, and not warmed over for a second feeding. 
 
 For washing the milk bottles a solution of sodium bicarbonate 
 or salicylate, a teaspoonful to the pint, should be first used, after 
 which they must be thoroughly scalded in boiling water. If fitted 
 
FOOD FOR YOUNG CHILDREN 761 
 
 with a plug of sterilised baked absorbent cotton they will remain 
 sterile until ready for use. 
 
 When from six to eight teeth have appeared the bottle can usu- 
 ally be discarded. 
 
 Care of the Infant's Mouth. — Cryer says that mothers or nurses 
 in caring for the infant " will give attention to dirty hands or face 
 and bathe the body daily, but how few keep the mouth as clean ! 
 The teeth should be gently and thoroughly brushed with a small 
 soft tooth brush as soon as they make their appearance. . . . Fer- 
 mentation of residual portions of milk remaining in the mouth of 
 the infant after feeding is a prolific source of gastric curd, intesti- 
 nal irritation, giving rise to colic and diarrhoea. The mouth of the 
 child should therefore be kept carefully cleansed, and before each 
 feeding be washed out with a solution of boric acid in distilled water 
 applied on a soft linen rag." 
 
 Weighing of Infants. — The systematic weighing of infants at 
 least once a week is a very useful indication of the progress in 
 nutrition and growth which they are making, and it should not be 
 neglected. 
 
 Budin reported some interesting experiments with three classes 
 of infants — namely, (1) suckled, (2) partly suckled, partly artificially 
 fed, (3) artificially fed. During the first fortnight of life he found 
 that the gain in weight was considerably more rapid with suckled 
 infants, but during the first year of life the infant will gain as much 
 weight if fed upon cow's milk as if suckled. Roughly speaking, the 
 infant's weight should be doubled in the first five months of life and 
 trebled in the first year. 
 
 Premature Infants. — The feeding of premature infants demands 
 unusual care. Their bodies are small ; their vitality is low ; their 
 digestion is feeble, and their rate of heat loss is rapid. They are 
 sometimes advantageously reared in incubators. They are often 
 too weak to suckle or even to take the bottle unless they are very 
 carefully hand-fed so as to obtain the milk without effort. It may 
 be best to feed them by gavage. This method takes less time than 
 any other. A small, feeble, puny infant at nine months of age may 
 not take as much as ten ounces of milk a day, and yet keep alive. 
 Such a baby must be fed at shorter intervals than the rule allows for 
 well-developed infants at the same age, and a two-hour interval will 
 often be best. Newborn premature infants may at first require feed- 
 ing every hour, not over a drachm or two of milk being given at 
 a time. 
 
 FOOD FOR YOUNG CHILDREN 
 
 The infant, although weaned, should receive all its food from 
 the bottle until at least the twelfth month, and then very gradually 
 a few other articles than milk or beef juice may be added. 
 
762 RATIONS, DIETARIES 
 
 Children often do best, however, upon a milk diet up to the end 
 of the second year. 
 
 " Towards the end of the second year all the milk teeth have 
 cut through, and the digestive functions have greatly increased in 
 power. The lower maxilla becomes stronger, the muscles of masti- 
 cation more powerful, the cavity of the mouth larger, the lips more 
 fleshy, the oesophagus wider; the salivary glands are better devel- 
 oped, and secrete a larger quantity of saliva ; the shape of the stom- 
 ach changes, and its walls grow thicker, the intestinal canal longer 
 and more capacious ; in short, all the digestive organs are more 
 adapted to an animal diet. At this period milk alone could not 
 satisfy the child. It may be dispensed morning and evening, but 
 during the day more substantial food is of absolute necessity " 
 (Ammon). 
 
 Should illness of any kind occur after a child has been put upon 
 solid diet, it should at once be given only fluid food again, and this 
 does not mean a diet of tea and toast water, but of milk or meat 
 broths. 
 
 Servants are often very careless in regard to the food which they 
 put within reach of young children, who wish to eat everything 
 they see, and ignorant mothers sometimes give children at the 
 breast tea, coffee, or beer, and their older children are allowed to 
 eat such substances as the skin of potatoes and fruits, sausages, 
 or canned corn, with the result of causing acute gastritis or con- 
 vulsions. 
 
 On the other hand, children should not be allowed to grow up 
 with too little variety in taste. An occasional departure from strict 
 rules or a single indulgence in some ordinarily prohibited article 
 may do no harm, but serve to gratify and educate the child. 
 
 Young children of four or five years of age or more, commonly 
 crave sugar, but do not care for fatty foods. They are apt also to 
 like vegetable acids, and are therefore fond of fruits. These acids 
 are wholesome, and the fruit is laxative and healthful when ripe and 
 fresh. 
 
 It may seem superfluous to separately name the chief prohibited 
 substances which must be kept from young children, but experience 
 proves the contrary, and when common sense is lacking in those 
 who are entrusted with their care, a written list of these foods should 
 be given them. If the child's food is too coarse, too much energy 
 is diverted in the attempt to digest it, and this is at the expense 
 of normal growth and development. Young children should be kept 
 out of the pantry and kitchen, where their attention is attracted by 
 forms of food which they cannot have. 
 
 It is estimated by Edward Smith that in proportion to its weight, 
 the growing child requires about three times as much carbonaceous 
 food as the adult and six times as much animal food. 
 
FOOD FOR YOUNG CHILDREN 763 
 
 Foods Forbidden to all Young Children 
 
 The following articles are particularly indigestible for children, 
 and should not be allowed them under four years of age, and some 
 of them should not be given at any period of childhood : Fried food 
 of all kinds, game, salt food, the flesh of swine in all forms, pickles, 
 salads, condiments, except salt, " stews," the " dressing " of fowl, 
 sauces, visceral foods (such as liver, kidneys, tripe, etc.), all raw 
 vegetables, potatoes (except baked), tomatoes in any form; the 
 coarser vegetables, such as beets, turnips, cabbage, etc. ; fancy bread, 
 cake, and pastry ; griddle cakes, canned food of all kinds ; fancy con- 
 fectionery, sweets, and preserves ; cheese, rich soups, jellies, dried 
 or unripe and overripe fruits (bananas, so often given to young 
 children, are very bad for them), nuts, fruits with large seeds, such 
 as grapes, the skin of all poultry, fruits, or vegetables. 
 
 All food should be plainly and thoroughly cooked. No greasy 
 or highly seasoned dishes are permissible, and as a rule twice-cooked 
 meats are indigestible. 
 
 Tea, coffee, and alcohol in every form must be withheld. The 
 two former beverages interfere with digestion and make the child 
 nervous, and the latter lays the foundation for a permanent alcohol 
 habit. Soda water with sirups should not be given. Too much 
 water should not be allowed with meals, and what is given should 
 not be ice cold. 
 
 Children, as they grow up, should continue to observe regularity 
 in the hours for taking meals, and the habit of perpetually nibbling 
 at cake, crackers, and confectionery between meals should not be 
 tolerated. It is best for young children not to be put to sleep 
 immediately after their most substantial meal of the day. As they 
 require a nap in the early afternoon, many advise giving this meal 
 at 4 p. m. 
 
 The following is a useful summary (taken in part from Holt) of 
 
 General Rules for Feeding Young Children 
 
 1. Allow time for meals. 
 
 2. See that the food is thoroughly masticated. 
 
 3. Do not allow nibbling between meals. 
 
 4. Do not tempt the child with the sight of rich and indigestible 
 food. 
 
 5. Do not force the child to eat against its will, but examine the 
 mouth, which may be sore from erupting teeth ; and examine the 
 food, which may not be properly cooked or flavoured. 
 
 If good food is refused from peevishness merely, remove it and 
 do not offer it again before the next meal time. 
 
 6. In acute illness reduce and dilute the food at once. 
 
764 RATIONS, DIETARIES 
 
 7. In very hot weather give about one fourth or one third less 
 food, and offer more water. 
 
 The young infant depends wholly upon animal food, and derives 
 the necessary carbon largely from the sugar of milk. The older 
 child lives in part only upon animal food, and begins to derive addi- 
 tional carbon from bread and other cereal foods. 
 
 Quantity of Food Required. — Experiments have been made by 
 Ueffelmann, Hasse, and others, to determine the necessary percent- 
 age of albuminous food required per diem per kilogramme of body 
 weight, by growing children, with the following result : 
 
 Albumin. 
 
 Average weight of child. 
 
 At 2 years 
 
 At 3 to 5 years.. 
 At 8 to 11 years. 
 
 4 grammes. 
 
 3-5 
 
 2.5 " 
 
 12.5 kilogrammes. 
 
 15 
 
 24 
 
 Thus it is seen the percentage of albuminous food required di- 
 minishes as the child gains in weight, and more carbohydrate food 
 is used to replace it. 
 
 The daily average quantity of food required by each child in an 
 aggregate of twenty-eight healthy children between the ages of two 
 and three years is reported by Starr to be as follows: Bread, 7.5 
 ounces; butter, 0.98 ounce; meat (beef), 4.6 ounces; potatoes, 3.9 
 ounces ; milk, 32.6 fluid ounces. The daily average for each child 
 in an aggregate of twelve children between the ages of three and 
 six years was: Milk, 48.6 fluid ounces; beef, 12.1 ounces; rice, 13 
 ounces; bread, 10.3 ounces; butter, 1.08 ounce. The daily average 
 for each child in an aggregate of twenty-four children between the 
 ages of four and ten years was: Roast beef, 12.46 ounces; bread, 
 10.23 ounces ; potatoes, 10.03 ounces ; butter, 0.99 ounce ; milk, 38.5 
 fluid ounces. 
 
 Dietaries for Young Children 
 
 The following diets are recommended by Starr as types for use 
 from the period of weaning up to three and a half years or more : 
 
 Diet from the Twelfth to the Eighteenth Month (Starr) 
 
 7 a. m., stale bread soaked in a breakfast cup of new milk. 
 
 10 a. m., milk, six ounces, and soda biscuit, or a thin slice of 
 buttered bread. 
 
 2 p. m., beef tea, six ounces, bread, and a tablespoonful of rice 
 and milk pudding. 
 
 6 p. M., same as first meal. 
 
 10 p. m., a tablespoonful of Mellin's food in eight ounces of milk. 
 
 In alternation a lightly boiled egg with bread crumbs and six 
 ounces of milk may be given at 7 a. m., and at 2 p. m. a mashed 
 
FOOD FOR YOUNG CHILDREN 765 
 
 baked potato moistened with four tablespoonfuls of beef tea, two 
 tablespoonfuls of junket. 
 
 The following is the sample diet given by Holt for a child eight- 
 een months old : 
 
 First Meal. — A tablespoonful of some cereal with salt and one 
 tablespoonful of cream, one half pint of milk. 
 
 Second Meal. — One half pint of milk. 
 
 Third Meal. — One tablespoonful of scraped meat, two small 
 pieces of dried bread, half a pint of milk. 
 
 Fourth Meal— Milk. 
 
 Fifth Meal — Milk with farina or arrowroot. 
 
 Instead of scraped meat (p. in), beef juice (p. 114) or a soft 
 cooked egg may be substituted occasionally. Of the beef juice from 
 one to three tablespoonfuls may be given at a time. 
 
 " The quantity of milk allowed at a single feeding for a child 
 during the second year should be from eight to ten ounces during 
 the first half and from ten to twelve ounces during the latter half 
 of the year " (Holt). 
 
 Diet from the Eighteenth to the Thirtieth Month (Starr) 
 
 7 a.m., new milk, eight ounces; the yolk of an egg lightly 
 boiled ; two thin slices of bread and butter, or else milk, and two 
 tablespoonfuls of well-cooked oatmeal or wheaten grits, with sugar 
 and cream. 
 
 1 1 a. m., milk, six ounces, with a soda biscuit or bread and 
 butter. 
 
 2 p. m., one tablespoonful of rare mutton pounded to a paste, 
 bread and butter, or mashed potatoes moistened with good dish 
 gravy, a saucer of junket ; or else a breakfastcupful of beef tea or 
 mutton or chicken broth, a thin slice of stale bread, a saucer of rice 
 and milk pudding. 
 
 6.30 p. m., a breakfastcupful of milk with bread and butter, or 
 soft milk toast. 
 
 Diet from Two and a Half to Three and a Half Years of Age (i. e., for 
 Children who have cut their Milk Teeth) (Starr) 
 
 7 a. m., one or two tumblers of milk, a saucer of thoroughly 
 cooked oatmeal or wheaten grits, a slice of bread and butter. 
 
 11 a. M. (if hungry), a tumbler of milk or a teacupful of beef tea 
 with a biscuit. 
 
 2 p. m., a slice of underdone roast beef or mutton, or a bit of 
 roast chicken or turkey, minced as fine as possible, a mashed baked 
 potato moistened with dish gravy, a slice of bread and butter, a 
 saucer of junket or rice and milk pudding. 
 
 7 p. m., a tumblerful of milk and a slice or two of soft milk toast. 
 
j66 RATIONS, DIETARIES 
 
 Diet from Three and a Half Years up (Starr) 
 
 Breakfast. — Every day : Milk, porridge and cream, bread and 
 butter. 
 
 One dish only each day : Fresh fish, eggs lightly boiled, eggs 
 poached, eggs scrambled, eggs (plain omelet), chicken hash, stewed 
 kidney, stewed liver. 
 
 Sound fruits may be allowed before and after the meal, according 
 to taste, as oranges without pulp, grapes (seeds not to be swal- 
 lowed), peaches, thoroughly ripe pears, and cantaloupes. 
 
 Dinner. — Every day : Clear soup, meat roasted or broiled and 
 cut into small pieces, bread and butter. 
 
 Two dishes each day : Potatoes baked, potatoes mashed, spinach, 
 stewed celery, cauliflower, hominy, macaroni (plain), peas, string 
 beans (young), green corn (grated). 
 
 Junket, rice-and-milk or other light pudding, and occasionally 
 ice cream, may be allowed for dessert. 
 
 Supper. — Every day : Milk, milk toast or bread and butter, 
 stewed fruit. 
 
 From the third to the fifth year the child has twenty teeth, and 
 often three meals a day suffice, although from the third to the fourth 
 year four may be given. After three years of age it is not possible 
 to lay down definite rules for the quantity of food allowed. In 
 health, the appetite may be taken as a fair guide, and the child will 
 not eat too much if taught to eat very slowly and thoroughly chew 
 each mouthful. 
 
 When the second set of teeth begin to replace the deciduous 
 or milk teeth, which gradually decay, digestion is sometimes inter- 
 fered with temporarily from lack of ability to masticate thor- 
 oughly, and food should be subdivided before it is offered to 
 the child. 
 
 The following rules for meats and vegetables for young children 
 are given by Holt : 
 
 " Meats. — After eighteen months, if most of the teeth are pres- 
 ent, once daily, finely bruised or scraped rare roast beef, roast lamb, 
 broiled mutton chop or beefsteak, white meat of chicken or turkey, 
 fresh fish boiled or broiled — bones the only objection. 
 
 " Vegetables. — Potatoes (not till after second year) roasted, peas, 
 asparagus tops, spinach, string beans, boiled onions, stewed celery ; 
 all should be very well cooked, in season, and fresh." 
 
 Fruits are very wholesome food for young children from three 
 or four years onward, provided they are properly selected and not 
 allowed in excess, which is almost the only source of trouble from 
 them. They serve to keep the blood in good condition, favor diges- 
 tion, and prevent constipation. After the fifteenth month two to 
 six teaspoonfuls of orange juice may be given, and a little later the 
 
FOOD FOR YOUNG CHILDREN j6j 
 
 soft pulp of two or three stewed prunes, or a half-baked or stewed 
 apple. 
 
 A child three or four years of age may have a piece of ripe pear, 
 peach, or plum, or strawberries in season. Cherries and bananas 
 should be forbidden. Grape juice is allowed without the skin or 
 seeds. During very hot weather great caution should be observed 
 in giving fruit of any kind to infants. 
 
 Bread, rice, oatmeal, and other cereal foods should always enter 
 largely into the dietary of healthy children after they are able to 
 digest them. Their fats should be derived chiefly from butter and 
 cream. The best fruits for them are oranges, cooked apples, and 
 stewed prunes. 
 
 Children between three and four years of age should be fed 
 when in health four times a day — at 7 a. m., 10.30 a. m., 1.30 p. m., 
 and 6 p. m. The following is 
 
 Holfs "Sample Diet for a Child Four Years Old" 
 
 First Meal. — Half an orange, one and a half tablespoonfuls of 
 oatmeal or hominy, well salted, with two tablespoonfuls of cream, 
 but no sugar, and one glass of milk. 
 
 Second Meal. — A glass of milk or cup of broth and one slice of 
 stale bread. 
 
 Third Meal. — Meat — either steak, chop, or chicken — one green 
 vegetable (e. g., spinach), one starchy vegetable (e. g., potato), water 
 to drink, stewed prunes for dessert. 
 
 Fourth Meal. — Bread and milk or milk toast. 
 
 Desserts for Children 
 
 " After two and a half years — plain custard, ice cream (not oftener 
 than once a week), rice pudding (no raisins), baked apple, stewed 
 prunes " (Holt). 
 
 The following rules for feeding young children are given by 
 Adams : 
 
 When the child has its first sixteen teeth it is to be given more 
 varied food than before, such as stale bread and butter, crackers, 
 mashed potato and gravy, scraped beef sandwiches with salt or 
 sugar, a piece of rare beef, or a chicken bone to suck. He gives 
 during the period of sixteen teeth : 
 
 6 a. m., a cup of milk, cream biscuit, or slice of buttered bread; 
 8 a. M., stale bread broken and soaked in a tumblerful of rich milk; 
 12 m., slice of buttered bread, half a pint of weak beef tea, or mutton 
 or chicken broth ; 4 p. M., tumblerful of milk with cracker or a slice 
 of buttered bread ; 8 p. m., a tumblerful of milk with bread or 
 crackers. 
 
 At the end of the period of sixteen teeth : 
 
768 RATIONS, DIETARIES 
 
 6 a.m., bread or crackers with half a pint of milk; 8 a.m., a 
 tablespoonful of oatmeal, cracked wheat, or cornmeal mush with 
 milk and a couple of slices of buttered bread; 12 m., bread and 
 butter, milk, and a soft-boiled egg ; 4 p. m., a piece of rare roast 
 beef to suck, mashed boiled potatoes, moistened with dish gravy, 
 bread and milk, and a small portion of rice, jelly, or farina ; 8 p. m., 
 milk and bread or crackers. 
 
 Adams usually prefers, however, to give milk and oatmeal water 
 or barley water through the second summer. 
 
 If the child vomits sour food, a little alkali should be added to 
 the food (sodium bicarbonate, etc.). Diarrhoea may be excited by a 
 too solid diet. 
 
 He prescribes for a child with all the milk teeth, and able to 
 walk, up to the third year: 
 
 8 a. m., well-cooked oatmeal, wheaten grits, or cornmeal mush, 
 with a liberal supply of milk, cold bread and butter, a piece of finely 
 cut, tender beefsteak or a soft-boiled egg] 12 m., bowl of chicken or 
 oyster soup, or weak beef tea, milk with bread or crackers, and 
 butter; 4 p.m., roast beef, mutton, chicken, or turkey, fresh white 
 fish, mashed white potato moistened with gravy, bread and butter, 
 and rice and milk ; 8 p. m., milk with bread or crackers. 
 
 Bread and milk or butter may be given between the first and sec- 
 ond meal or before the first, also ripe fruit later. 
 
 For a child from the third to the fifth year Adams gives : 
 
 Breakfast. — Cornmeal mush, oatmeal, wheaten grits, hominy, 
 plenty of cream ; potatoes, baked or stewed ; eggs, poached, soft- 
 boiled, omelet ; fish, fresh broiled ; meats : beef hash, broiled steak, 
 stewed liver and kidneys, lamb chops, chicken fricassee ; tomatoes, 
 sliced ; bread (cold) ; light Graham, entire wheat, corn muffins 
 (plain), and occasionally Graham, corn, and rice cakes ; fresh, ripe 
 fruit. 
 
 Luncheon. — Soups: oyster, clam, bean, chicken, consomme; vege- 
 tables: potatoes, baked or stewed, sliced tomatoes; beefsteak, lamb 
 chop, cold roast lamb ; cold rolls, soda crackers ; fruits in season ; 
 rice and milk. 
 
 Dinner. — Soups : consomme, oyster, cream of barley, potato ; 
 fish : baked, broiled, or boiled ; roast beef, chicken, lamb ; stewed 
 potatoes, rice, cauliflower, macaroni, peas, tomatoes, beans ; bread, 
 well-cooked wheat. Dessert : rice and milk, light pudding, ice 
 cream, fruits, and berries. 
 
 Teething and Food 
 
 Much illness and digestive disturbance in infancy and early child- 
 hood is popularly ascribed to " teething," and the gums do occa- 
 sionally become swollen and inflamed during dentition, but the evils 
 
DIET FOR SCHOOL CHILDREN 769 
 
 of this process are exaggerated in the lay mind and wrong feeding 
 is much more often accountable for the disturbance. In regard to 
 this matter Adams says, " My experience has taught me that when- 
 ever the child has become ill during this physiological process, some 
 other cause than the mere cutting of the teeth can be found to 
 account for the illness." 
 
 Sleep and Feeding 
 
 The relation of sleep to infant feeding is very well summarised 
 by Adams as follows : " A young infant has nothing to do but eat 
 and sleep. As soon as he is fed he will take a nap and will prob- 
 ably sleep for an hour and a half. After the first year the naps 
 become shorter and less frequent. During the second year a nap 
 in the morning after breakfast, one in the afternoon about one or two 
 o'clock for an hour or an hour and a half are usually sufficient, and 
 these naps should be insisted upon for the rest of his mind and body, 
 and to enhance his growth and health. As the child attains the 
 third year, he can usually drop the morning nap. The afternoon 
 one should be insisted upon very soon after the child has its noon- 
 day meal, in winter as well as in summer." 
 
 DIET FOR SCHOOL CHILDREN 
 
 Too much attention cannot be given by teachers to the diet of 
 the pupils under their care in boarding schools, and they should 
 exercise some supervision in regard to the matter in day schools 
 as well, for the subject is often ill understood by parents. 
 
 The age for training most school children is from the tenth to 
 the seventeenth or eighteenth year. During the entire time both 
 mind and body are undergoing development, which in many in- 
 stances is exceedingly rapid, and in the midst of this period the 
 condition of puberty is attained, which in itself requires additional 
 care and watchfulness, especially in girls. 
 
 With the present system of kindergarten training the attendance 
 at school of most children begins much younger than the age men- 
 tioned. Throughout the whole school period the growth of the 
 body is continued until almost completed. The individual organs 
 and structures increase in actual size, and there are unusual de- 
 mands, therefore, upon the functions of absorption and assimilation. 
 The food must be abundant and of the proper character to furnish 
 new tissue and to yield energy in the form of heat and muscular 
 activity. The former condition is met by a proper allowance of 
 animal food in the diet, and the latter by sufficient hydrocarbona- 
 ceous material. The food should also contain salts of lime, to meet 
 the requirements of formation of the bones and teeth. While the 
 
7/0 RATIONS, DIETARIES 
 
 material or structural development of the body progresses, there is 
 also a marked development in the functions of the various organs ; 
 the muscles are trained to act with vigor and with proper co-or- 
 dination, and the nervous system is constantly receiving and storing 
 new impressions and regulating their transmission and the proper 
 relations of inhibitory and reflex actions. The metabolic processes 
 of the body are extremely active and the digestive secretions are 
 vigorous. To maintain the proper standard, therefore, of growth 
 and development requires care in the selection of the right quantity 
 and quality of " fuel " or food for the body, and the lack of such 
 care too often lays the foundation for future disease, or results in 
 an enfeebled constitution with greatly diminished resisting power of 
 coping with emergencies which may arise. 
 
 Many children inherit feeble constitutions or diatheses, such as 
 the tuberculous, which must be combated throughout the whole 
 period of childhood. Such children are better kept at home, where 
 they can be under constant observation and proper dietetic treat- 
 ment, or country schools can be found for them where such matters 
 are made the subject of special consideration. 
 
 Many cases of anaemia and chlorosis, which are so commonly 
 seen in young girls during or shortly after the attainment of the 
 condition of puberty, are directly traceable to malnutrition from 
 faulty diet. Girls take much less exercise than boys, as a rule, and 
 are more apt to become constipated. This difficulty may be en- 
 hanced by a lack of sufficient fresh vegetables or fruit in their diet, 
 and if prolonged it is enough in itself to cause anaemia. The latter 
 may also be brought about by insufficient good animal food. It 
 should be the imperative duty of every head master of a school for 
 children to realise the responsibilities of rightly developing the 
 physical constitutions of those entrusted to his care, and to make 
 a thorough study of the questions of dietetics involved. He should 
 remember that the mind keeps on developing long after the body, 
 and that the period under discussion is one in which the constitution 
 of the individual is established for the remainder of life, and success 
 in digestion and assimilation is of greater importance than success 
 in mental attainments. 
 
 Variety. — An important consideration in school diet is to pre- 
 vent monotony, which becomes so common from economic reasons, 
 or more often from carelessness. It is much easier to yield to 
 routine and force of habit or to leave the matter to the indiscre- 
 tions of an unintelligent cook. But a little study and thought ex- 
 pended upon this subject can always result in furnishing variety in 
 a wholesome diet without material increase of expense. 
 
diet for school children 7/1 
 
 Hours for Meals 
 
 The hours for study and for meals should be so regulated that 
 sufficient time should be allowed before each meal for children to 
 wash and prepare themselves comfortably without going to the 
 table excited by hurry, and they should be required to remain at 
 the table throughout a fixed time, never being allowed to hastily 
 swallow their food in order to complete an unfinished task or game. 
 An interval of half an hour or more should intervene for recreation 
 after meals, in order that digestion may be well under way before 
 any mental exertion is required. Constant nibbling at food between 
 meals should be forbidden ; it destroys the appetite, increases the 
 saliva, and interferes with gastric digestion. The number of meals 
 for children should be adapted to the age of the pupils. For young 
 children from ten to twelve or thirteen years of age it may be neces- 
 sary to furnish food somewhat oftener than for older ones. 
 
 If children live at a distance from their school, or if they are 
 weak and easily fatigued and inclined to sleep over in the morning, 
 their hours for study should be so adjusted that they are never 
 obliged to hurry their eating in order to be on time for school work. 
 The teachers should consider themselves quite as responsible for 
 regulating this matter as are the parents. 
 
 Children should never be hurried oft" to school in the morning 
 with an insufficient and rapidly eaten breakfast. Their appetites 
 are often poor at this hour from the effects of an ill-ventilated 
 sleeping apartment, and if they are subsequently kept at school for 
 five hours without luncheon they are very ill prepared for mental 
 work. Or they ride to school without exercise after a hasty break- 
 fast, take a hurried cold lunch at noon, and perhaps a warmed-over 
 late dinner, and at six or seven o'clock a fourth meal, after which 
 they are expected to study and go to bed. 
 
 The fact is being more and more realised by teachers and the 
 public in general that the breaking down of health at school is 
 quite as often, if not oftener, due to impoverished nutrition as to 
 overwork. 
 
 A fact which is sometimes overlooked in the dietetic treatment of 
 growing children is that their digestive processes are so active that 
 the stomach is emptied somewhat sooner than in the case of adults, 
 and their meals being' promptly absorbed, it is natural for them to 
 become hungry if the intervals between the hours of eating are pro- 
 longed. In some schools, children are given their last meal of the 
 day at six o'clock in the evening, and they may not breakfast until 
 seven or half past seven or even later, leaving an interval of over 
 thirteen hours during which they have no food at all. The even- 
 ing meal is usually made light, on the ground that they can sleep 
 better, and it is, therefore, sooner digested. Robust children can 
 
7J2 RATIONS, DIETARIES 
 
 perhaps thrive on this treatment, but those less strong are injured 
 by it. For some school children of from ten to fourteen years of 
 age it will be much better to give the evening meal later, at, say, 
 half past seven o'clock, and the breakfast at seven, and if they 
 awaken hungry during the night there is no harm in their having 
 a glass of milk and a cracker. 
 
 Very delicate children whose appetites are poor and who do not 
 do proper justice to their regular meals should be given an extra 
 allowance of hot broth or hot milk or an occasional cup of chocolate 
 with bread and butter and rusk between meals. 
 
 These general rules are applicable to those children who, 
 during one or two years, seem to develop with extraordinary sud- 
 denness and rapidity, growing sometimes two inches or more in 
 six months and attaining a height quite disproportionate to their 
 frames. The demands of this rapid growth must be met by proper 
 nutrition or serious subsequent impairment of vitality may result. 
 Such children should have their meals made tempting by good cook- 
 ing and pleasant variety as well as an agreeable appearance of the 
 food. 
 
 Meat which is carved in unsightly masses and vegetables which 
 are sodden and tasteless will be refused, and an ill attempt is made 
 to supply the deficiency in proper food by eating indigestible candy, 
 nuts, etc. Children often have no natural liking for meat, and pre- 
 fer puddings, pastry, or sweets when they can obtain them, and it 
 is the more important that meat should be made attractive to them 
 at the age when they need it. 
 
 It is unnecessary to discuss further questions which after all 
 must be controlled by tact and circumstances of individual cases, 
 and the line must be drawn with care between making a child too 
 fastidious on the one hand in regard to the nature of its food, and 
 on the other impairing its constitution by monotony of diet and 
 ill-cooked viands. Children at school should be especially required 
 to eat slowly, for the habit of fast eating is almost contagious, and 
 as it is much easier to acquire than to overcome, the foundation of 
 dyspepsia and lifelong discomfort may be laid in this way in child- 
 hood. 
 
 A Sample Diet 
 
 If early rising is insisted upon, a child should never be set at any 
 task before breakfast, especially in winter, and if it is not expedient 
 to serve a full breakfast at half past six or seven the child should be 
 given a bowl of hot milk and bread, or a cup of cocoa with a roll, 
 or other light food : breakfast may be served later after the first 
 exercises of the morning, and should be a substantial meal with 
 animal food in the form of either fish, or eggs, or cold meat of some 
 sort, with porridge of wheaten grits, or hominy with milk or cream 
 
DIET FOR SCHOOL CHILDREN 773 
 
 and abundant sugar, also bread and butter, with some sweets in the 
 form of jam, or marmalade, or stewed fruit. Dinner, which should 
 always be served near the middle of the day, should comprise meat, 
 potatoes, with one or two green vegetables, and some form of sweet 
 pudding. The supper it is generally admitted should comprise only 
 easily digestible articles of food, and such substances as pastry, 
 cheese, and meats are better omitted. It should consist of either a 
 porridge with milk or cream, or a light farinaceous pudding of rice, 
 tapioca, sago, and the like, with bread and butter, and some simple 
 form of preserve, or stewed apples or prunes, or very light plain 
 cake, or a good bowl of nutritious broth with bread or crackers 
 may be substituted for the porridge or pudding. It will sometimes 
 be found best to serve this meal at seven o'clock or half past seven, 
 and if hungry the child may be given a slice of bread and butter 
 and a cup of weak tea or coffee, mostly hot milk, at half past five or 
 six o'clock. 
 
 Sample Diet from a Well-known Boys' School in New England 
 
 Breakfast, 7.30 a. m. — Oatmeal. Bread and butter. Stew or 
 hashed meat, or beefsteak or chops. Twice a week, griddle cakes 
 with sirup. 
 
 Dinner, 1 p. m. — Soup. Fish once or twice a week. Meat, either 
 roast beef, beefsteak, mutton, or chicken. Potatoes and green vege- 
 tables in season. Pudding, or pie, or plain cake, and lemonade. 
 Fruit. 
 
 Supper, 7 p. m. — Cold meat, or hashed meat, or fish balls. Pota- 
 toes. Bread and butter. Cake. Preserved fruits. 
 
 Time allowed for Meals. — Breakfast and supper, each half an 
 hour ; dinner, three quarters of an hour. Intervals of rest or recre- 
 ation for the younger boys (thirteen to fourteen years), after break- 
 fast, half an hour ; before dinner, three quarters of an hour ; after 
 dinner, two hours and a half ; before and after supper, fifteen minutes. 
 
 On Sundays, breakfast an hour and dinner half an hour later 
 than on week-days, and supper five hours after dinner. 
 
 Some of the more important articles of school diet require special 
 mention. 
 
 Bread, as a rule, should be made of whole meal, but must not 
 be too coarse. The advantage of this bread for children consists in 
 its containing a larger proportion of salts, which they need, than is 
 found in refined white flour, and butter should be freely served with 
 it, to supply the deficiency of fats which exist in wheat. Children 
 need fat, but they do not digest meat fat well, as a rule, and are very 
 apt to dislike it. They will often take suet pudding, however, when 
 hot mutton fat disagrees. 
 
 Milk should be freely supplied not only in the form of puddings 
 and porridges, but as an occasional beverage, and children should 
 
774. RATIONS, DIETARIES 
 
 be made to understand that when hungry they can obtain a glass 
 of milk, or a bowl of crackers or bread and milk, for the asking. 
 
 Chambers says : " The best luncheon that a growing young man 
 can have is a dish of roast potatoes well buttered and peppered and 
 a draught of milk." 
 
 Fresh Fish, eggs, and bacon are all wholesome and serviceable 
 foods for children, and 
 
 Meat, as a rule, may be given twice a day, but not oftener. It 
 may sometimes be advisable to give it but once a day when fish or 
 eggs are supplied ; it should, however, always be given at least once 
 daily, and better twice to rapidly growing children. Large, strong 
 boys require a great deal of meat, and its use should not be stinted. 
 The larger boys may eat from seven to nine or even twelve ounces 
 of cooked meat as a ration, although many children may not require 
 so much, the smaller boys doing well with from five to six ounces 
 and the older boys with from seven to eight ounces daily. 
 
 During midwinter, when fresh vegetables are almost unobtain- 
 able in severe climates, vigorous boys sometimes have too much 
 meat given them, and Yeo calls attention to the fact that eczema 
 may be produced in them by a too exclusive animal diet. 
 
 Sweets. — The greater number of children have a natural craving 
 for sweets. The important role of sugars in furnishing energy for 
 the body has been discussed (p. 13), and the energy developed in 
 active childhood necessitates the consumption of a larger proportion 
 of sugar than is required by adults. The craving of children for 
 confections, candy, etc., furnishes a true indication of the actual 
 requirements of Nature, and it must be admitted that a certain 
 amount of wholesome candy, like plain molasses candy, not only 
 does most children no harm, but may serve them as an excellent 
 food. The main difficulty with such forms of sugar, however, is that 
 children are not furnished with a proper porportion of sugar with 
 their meals, and the meals themselves are not so regulated as to 
 prevent their becoming very hungry between times ; consequently, 
 if they can obtain candy, which satisfies them for the time, they 
 eat too much, with the result of producing more or less dyspepsia 
 and diminishing the normal appetite. If pains be taken to give, 
 such children a slice of bread and butter with a little honey or jam 
 between meals and a proper proportion of saccharine food with 
 their meals, they are much less likely to obtain candy surreptitiously 
 and gorge themselves with it. Simple forms of well-cooked pastry 
 and of cakes with stoned raisins should be furnished as dessert occa- 
 sionally. It is better to give such food from time to time with 
 the meals under proper supervision than to have children indulge 
 themselves in it. 
 
 Alcohol in every form should be absolutely excluded. If given 
 during early youth it is particularly prone to develop a taste which 
 
DIET FOR SCHOOL CHILDREN 775 
 
 may become uncontrollable in later years. The only exceptions to 
 this rule are some sickly and anaemic children who are especially 
 under the physician's care. 
 
 Habit. — Many children acquire a habit of dislike or even disgust 
 for certain articles of food, which become so fixed in later life that 
 they find it very inconvenient, especially when placed in circum- 
 stances, as in travelling, where one cannot always obtain the accus- 
 tomed diet, and giving in to such habit is often a serious obstacle 
 to normal development. There are children who acquire a dislike 
 for meat and who persistently refuse to take it, until they become 
 anaemic and feeble, and there are others who refuse fresh vegetables, 
 which they need. It is a great misfortune for a child to be indulged 
 in such likes or dislikes. With a little tact and persuasion the re- 
 pugnance can usually be overcome before the habit becomes rooted, 
 and these questions are very largely a matter of proper education. 
 How often is the physician baffled in the treatment of a severe 
 •disease like typhoid fever, which requires the use of a milk diet, by 
 the patient's insisting that he has never been able to drink milk 
 since childhood ! If there be any taste which is natural to all men 
 it is that for milk, upon which all must live during early infancy ; 
 and while it is better after a certain period of growth to restrict the 
 quantity of milk in the diet, there is no reason at all why children 
 should not retain a normal fondness for it. There are, no doubt, 
 cases in which it seriously disagrees (see p. J2), but they are ex- 
 ceptional as compared with the number of persons who can digest 
 milk, when properly prepared, w T ith perfect ease, but whose antipa- 
 thy for it prevents them from taking it in the emergencies which 
 may befall them in acute disease. 
 
 Children who object to vegetables can sometimes learn to eat 
 them when cooked in an unusually attractive manner or served in 
 soup. 
 
 Overeating should be guarded against, for habits of gluttony 
 may be acquired in youth, especially between puberty and full de- 
 velopment, which are never overcome, and which may lead to vis- 
 ceral distention and hypertrophy, obesity and other troubles, which 
 develop in adult life. The habit of slow eating should be insisted 
 upon. 
 
 Exercise. — As a general rule, active muscular exercise in children 
 disturbs their digestive processes far less than mental effort when 
 taken immediately after meals, and every adult is familiar with the 
 romping which children can undertake straightway after dinner, 
 often, though not always, with impunity, whereas a proportionate 
 amount of exercise on the part of an adult might produce a severe 
 dyspeptic attack. It is well to allow children to play but moderately 
 immediately after eating, and to require no mental work of them 
 at such time. 
 51 
 
77& RATIONS, DIETARIES 
 
 For some reason the diet in girls' schools is often much less 
 carefully regulated than in corresponding schools for boys. This 
 applies not only in the United States, but it has been found the 
 common experience in England and France ; it is the more unfor- 
 tunate, since girls from their greater delicacy of constitution, espe- 
 cially at the period of puberty, require more careful nurture. Differ- 
 ences in habits and exercise and outdoor recreation, no doubt in 
 part, are responsible for the comparative lack of proper development 
 in some girls' schools as compared with boys', but this should be 
 recognised and regulated with as much care as the diet. 
 
 During the establishment of puberty it is best for children to 
 avoid stimulating and highly seasoned food, and eating late at night, 
 which is apt to excite the sexual organs reflexly and cause lascivi- 
 ous dreams. Alcohol should be wholly forbidden. Its use by young 
 girls is said to bring menstruation earlier. Some articles of diet 
 have a reputed aphrodisiac effect, but this is very slight; such are 
 oysters, eggs, peppers, and champagne. 
 
 HOSPITAL DIETARIES 
 
 Statistics of the most economical quantity and quality of food 
 for men in health, and under different conditions of activity, have 
 been very accurately and practically determined, but such data for 
 invalids are in most cases unobtainable, and obviously so, for the 
 condition of individual cases and the severity of diseases are con- 
 stantly varying, and no definite rules for the exact quantity of food 
 needed could be formulated which would be of general application. 
 For this reason in many hospitals no attempt is made to classify the 
 diet beyond the very elementary subdivisions, consisting, first, of 
 milk diet — i. e., milk alone, or of milk with a little bread, and light 
 farinaceous food ; secondly, the " full diet," which is commonly 
 known either by that name or as " house diet " or " ordinary diet." 
 Where no further general classification of the diet is attempted, it is 
 customary to have a supplementary list of foods, usually called 
 " articles of special diet," from which the visiting physician or sur- 
 geon is to select appropriate food for individual cases. The expres- 
 sion " low diet," indicating that for the very sick patients, is an 
 unfortunate one, as it may have a depressing sound. In other insti- 
 tutions, where more care is bestowed upon diet, it is found both 
 convenient and practical to subdivide the diet under several addi- 
 tional headings; the diet under each heading to contain only spe- 
 cially selected and classified foods. This arrangement is to be highly 
 commended, as it not only saves much time and confusion, but is 
 economical to the institution in preventing waste, instead of sending 
 a large number of full diets from the kitchen to the ward, where 
 the lighter or more easily digestible articles are selected for the 
 
HOSPITAL DIETARIES 777 
 
 sicker patients by possibly inexperienced nurses, much of the food 
 being returned uneaten. If the diet is assorted in the kitchen and 
 sent to the ward in a properly classified condition — that is, so many 
 rations of each specified class — there is very much less waste and 
 confusion. 
 
 Under this system, the subdivisions which it is found practical 
 and advantageous to adopt are the following : 
 
 I. Milk Diet, consisting of from two and a half to three quarts 
 of milk per diem, and nothing else. 
 
 II. Convalescent Diet, or half diet, or light diet, as it is variously 
 called, intended for patients convalescing from acute disease, or for 
 patients who are unable to digest the full house diet. In the average 
 medical ward the majority of patients live usually upon this diet, 
 which is not adapted for the special requirements of any particular 
 disease, but is simply light, nutritious, and easy of digestion, and 
 is therefore serviceable in a very large number of cases which do 
 not need more careful selection of food. 
 
 III. Farinaceous Diet, from which animal food, with perhaps 
 the exception of milk and butter, is excluded. This diet is not of 
 very general use, but is temporarily serviceable in some forms of 
 disease, such as chronic Bright's disease and acute gout. 
 
 IV. Nitrogenous Diet, or animal food, which is somewhat more 
 used than the preceding diet, and from which sugars and almost all 
 forms of starchy food excepting a little dried bread, toast, or Graham 
 bread, are excluded. This diet is particularly serviceable in cases 
 of flatulent dyspepsia, chronic gastric catarrh, and dilatation of the 
 stomach, in which the starches and sugars invariably undergo acid 
 fermentation, with eructations and flatulence. It also serves for 
 diabetics, with slight modification. 
 
 V. House or Full Diet should be the most economical diet for 
 the hospital upon which patients who have nearly completed their 
 convalescence may be placed, as well as those patients, including 
 certain medical cases and a large number of minor surgical cases, 
 whose digestive organs are in normal condition. It usually in- 
 cludes the coarser articles of food, sometimes corned beef and cab- 
 bage, potatoes, codfish, etc., and it is very often the general diet 
 for the servants and attendants in hospitals as well as patients. 
 
 VI. Articles of Special Diet. — Under this list are included lux- 
 uries and delicacies, such as oysters, jellies, custards, etc., and extra 
 allowances of eggs, chicken, cream, and fruits, which may be desir- 
 able to furnish in a few individual cases. 
 
 With a system arranged upon this plan, as will be seen by the 
 accompanying sample tables, used in some of the representative 
 hospitals, the ordering of the diet is simplified for the visiting physi- 
 cian or surgeon, and is less likelv to be relegated by him to sub- 
 ordinates than it is if he is obliged to spend the time required for 
 
77% RATIONS, DIETARIES 
 
 selecting a separate menu for each patient in the ward. The limita- 
 tions of each separate diet should be distinctly understood by all 
 the attendants and nurses, and a printed diet list of articles included 
 under the headings " nitrogenous diet," " farinaceous diet," etc., 
 should be conspicuously posted in the ward dining or service rooms. 
 The daily variations within the limits of these diets should be regu- 
 lated by the superintendent of the hospital or an assistant, whose 
 special duty it is to provide the food for the institution, and select 
 such articles as will give reasonable variety, due allowance being 
 made for variations in regard to price and season of the year. 
 
 In many large hospitals not only is the arrangement of the diet 
 imperfect, but the details of preparing and serving food are so in- 
 efficiently supervised that there is great loss from waste and imper- 
 fect cooking, and the additional expense of employing one or two 
 specially trained persons to superintend these matters would be 
 more than counterbalanced by the saving in the waste and in the 
 benefit to the patients. 
 
 Overfeeding. — Too much food is often given hospital patients 
 by overzealous nurses, who are anxious to hasten convalescence. 
 This is particularly true in the treatment of simple surgical cases 
 where there is no special digestive disorder. A man accustomed 
 to doing eight hours of active physical labour when put to bed for 
 six weeks or more with his leg immobilised for a fracture, does 
 not need to be constantly stuffed with large quantities of food, and 
 yet such patients, if the matter is not carefully directed, will be often 
 found to receive full house diet, which in itself is ample for the 
 working attendants of the hospital, and in addition to be given two 
 or three quarts of milk a day as a beverage. The natural result is 
 constipation, indigestion, with a heavily coated tongue and more or 
 less biliousness, which in turn is counteracted by a compound ca- 
 thartic pill or a dose of calomel. I have known of night nurses 
 going through wards with pitchers of milk, and pouring out tum- 
 blerfuls for any patients who were at all thirsty, quite irrespective 
 of any supervision. In a large hospital, where the monthly con- 
 sumption of milk is from ten thousand to fifteen thousand gal- 
 lons, it may be easily seen that its indiscriminate use as a bever- 
 age is an item of very considerable and unnecessary expense to 
 the institution, besides being an actual detriment to many of the 
 patients. 
 
 Another undesirable tendency among American hospital die- 
 taries is to include too much meat. The ordinary hospital menu 
 compared, for instance, with that of the agricultural labourer, shows 
 this fact very strikingly. Not over four ounces of cooked meat 
 (without bone) need be allowed in the meal for men. 
 
 Fish Diet. — In some hospitals in addition to the subdivisions 
 of the diet above given, a " fish diet " may be ordered, which is 
 
HOSPITAL DIETARIES 779 
 
 very useful and should be generally adopted. In the London Fever 
 Hospital this diet consists of a ration of bread ten ounces and fish 
 eight ounces (the uncooked measure), such as haddock, cod, or sole, 
 or some similar fish, potatoes eight ounces, cocoa one ounce, with 
 half an ounce of sugar and a sixth of a pint of milk. This is a 
 serviceable and economical form of diet for a considerable class of 
 patients for whom large quantities of meat are not only unnecessary 
 but injurious. 
 
 Broth Diet. — In children's hospitals a diet is sometimes classified 
 as the " broth diet," i. e., mutton broth flavoured with vegetables, 
 and bread and butter, with milk ; or a " beef-tea diet," in which the 
 beef tea replaces the broth ; and in the lighter diet of children, 
 gruels, bread and molasses, and simple articles of farinaceous food 
 such as farina, cornstarch, rice, etc., should play an important role. 
 Sometimes such diet goes under the name of " soft food." 
 
 In some of the English hospitals, as in the London Fever Hos- 
 pital, beer is allowed with the full diet, and in this hospital also a 
 discrimination is made in ordering the diet according to sex, females 
 being given from two to four ounces less bread and two to three 
 ounces less meat than males. This discrimination is not usually 
 made in American hospitals. 
 
 Sample Hospital Dietaries 
 dietary of the new york hospital 
 
 " All patients shall be furnished the regular house diet, unless 
 otherwise specially directed by the attending physician or surgeon. 
 As a substitute for the house diet, there may be furnished, on the 
 order of the attending physician or surgeon only, either of the fol- 
 lowing : 
 
 " i. Restricted diet. 
 
 " 2. Milk diet. 
 
 " The attending physician or surgeon shall specify, on the occa- 
 sion of his first visit to a patient, which diet shall be furnished. 
 This duty may not be delegated to the house physician or house 
 surgeon, except that, on the admission of a patient to a ward, 
 it shall be the duty of either to give instruction on the subject to 
 the nurse in charge, and such instruction shall be followed until 
 the first visit of the attending physician or surgeon. 
 
 " The wards shall be supplied with blanks, called diet lists. The 
 head nurse shall carry one of these with her regularly when accom- 
 panying the attending physician or surgeon on his visits, and shall 
 note down carefully all his instructions as to diet ; he shall sign 
 these lists before leaving the ward. 
 
 " Milk diet, or restricted diet, may not be ordered in addition 
 to the regular house diet, but only as a substitute therefor, but the 
 
780 RATIONS, DIETARIES 
 
 attending physician or surgeon may order items of special diet in 
 particular cases. 
 
 " Lists denning the different classes of diet shall be furnished 
 each attending physician and surgeon. 
 
 " Cards, appropriately inscribed, shall be placed at the head of 
 each bed, which shall designate the class of diet, and also the amount 
 of stimulant, which is furnished each patient. 
 
 " A diet kitchen is established, under the direction and control 
 of the directress of nurses, wherein articles of special diet shall be 
 prepared and served as ordered. 
 
 " Daily House Diet 
 
 ''Breakfast. — Oatmeal or hominy; tea or coffee, with milk and 
 sugar ; bread and butter. 
 
 "Dinner. — Potatoes; bread and butter; one or more of the fol- 
 lowing vegetables : turnips, sweet potatoes, beets, spinach, squash. 
 
 " Supper. — Tea with milk and sugar ; bread and butter ; stewed 
 or fresh fruit. 
 
 "In addition on Sunday. — Breakfast: eggs. Dinner: roast beef, 
 cornstarch pudding. Monday. — Breakfast : baked potatoes. Din- 
 ner : stock soup, stewed beef or mutton, rice pudding. Tuesday. — 
 Breakfast : mutton chops. Dinner : pea soup, roast mutton, bread 
 pudding. Wednesday. — Breakfast : fried or stewed potatoes. Din- 
 ner : roast beef, cornstarch pudding. Thursday. — Breakfast : eggs. 
 Dinner : stock soup, stewed beef or mutton, tapioca pudding. Fri- 
 day. — Breakfast : salt mackerel or codfish. Dinner : bean soup, 
 baked fish, beans, rice pudding. Saturday. — Breakfast : beefsteak, 
 Dinner : corned beef, cabbage, bread pudding. 
 
 " Restricted Diet 
 
 " Breakfast. — Tea or coffee (with milk and sugar), farinaceous 
 food (with milk), eggs. 
 
 " Dinner. — Soup ; either of the following: raw oysters, roast beef, 
 steak, chicken with vegetables, pudding (bread, rice, tapioca, or corn- 
 starch). 
 
 " Supper. — Tea (with milk and sugar), bread (with butter), fruit 
 (fresh or dried). 
 
 " Milk Diet 
 
 " Six pints of milk daily. • 
 
 " Articles of Special Diet 
 
 " Milk, eggs, beef tea, oysters, cornstarch, chops, steak, chicken, 
 chicken soup, rice, broth, farina, ice cream, as ordered by the attend- 
 ing physician or surgeon. 
 
 " Salt fish, jellies, custards, gruels." 
 
HOSPITAL DIETARIES 78 I 
 
 At the New York Hospital a carefully graduated diet list, made 
 out in ounces per capita, was formerly in use, but it was found both 
 unnecessary and unpractical. Separate tables are laid for the pa- 
 tients, nurses, and servants ; but the amount of food is estimated 
 in a general way, the terms being based rather upon the cost price 
 per capita than upon the number of ounces, and it is proportioned 
 by the housekeeper and her assistants with due regard to economy. 
 
 DIETARY OF THE PRESBYTERIAN HOSPITAL, NEW YORK, 1901 
 
 Although the diet is very satisfactory and ample at the Presby- 
 terian Hospital, New York, the food allowance per capita for patients 
 is not separately estimated, and the house diet, convalescent diet, 
 and diet for the servants on pages 782-783 are all originally pre- 
 pared in bulk, and subsequently subdivided by the cooks and nurses 
 under the order of the visiting physicians and surgeons, but without 
 regard as to accurate measurement of quantity in ounces. 
 
 The diet sheet on page 784 is in daily use in the wards at the 
 Presbyterian Hospital, New York city. It will be observed that 
 it is properly classified according to quality as well as quantity. It 
 was introduced several years ago after a careful comparison with 
 diets of other institutions, and it has proved very practical. It is 
 the most liberal and best-classified diet of any hospital with which 
 I am familiar. 
 
 DIETARY IN BELLEVUE, GOUVERNEUR, FORDHAM, AND 
 HARLEM HOSPITALS, NEW YORK, 1901 
 
 Monday 
 
 Breakfast. — Coffee, one pint, with half an ounce of milk and half 
 an ounce of sugar ; bread, five and one third ounces, and a quarter 
 of an ; ounce of butter; oatmeal, one ounce; crackers, one ounce; 
 milk, one quart. 
 
 Dinner. — Roast beef, eight ounces; rice, one ounce; soup, one 
 pint ; potatoes, eight ounces ; vegetables, four ounces ; bread. 
 
 Supper. — Tea, one pint, with half an ounce of milk and half an 
 ounce of sugar ; five and one third ounces of bread and a quarter 
 of an ounce of butter ; one ounce of stewed apples. 
 
 Tuesday 
 
 Breakfast. — Coffee, one pint, with half an ounce of milk and half 
 an ounce of sugar ; bread, five and one third ounces, and a quarter 
 of an ounce of butter ; hominy, one ounce ; crackers, one ounce ; 
 milk, one quart. 
 
 Dinner. — Mutton stew, eight ounces ; potatoes, eight ounces ; 
 vegetables, four ounces ; bread, five and one third ounces ; bread 
 pudding, two and a half ounces. 
 
782 
 
 RATIONS, DIETARIES 
 
 House Diet. 
 
 Convalescent Diet. 
 
 Nitrogenous Diet. 
 
 BREAKFAST. 
 
 BREAKFAST. 
 
 BREAKFAST. 
 
 Tea or coffee (milk and 
 
 Tea or coffee (milk and 
 
 Tea or coffee (milk 
 
 sugar). 
 
 sugar). 
 
 Bread and butter — 
 
 Bread and butter — 
 
 Bread and butter — 
 
 Graham bread. 
 
 White bread, or 
 
 White bread, or 
 
 
 Graham bread, or 
 
 Graham bread, or 
 
 
 Corn bread, or 
 
 Corn bread, or 
 
 
 Rolls, or Toast. 
 
 Rolls, or Toasl. 
 
 
 Porridge — 
 
 Porridge — 
 
 
 Oatmeal, or 
 
 Hominy, or 
 
 
 Wheaten grits, or 
 
 Farina. 
 
 
 Indian meal, or 
 
 
 
 Hominy, or 
 
 
 
 Farina, or Samp. 
 
 
 
 Meats — 
 
 Meats — 
 
 Meats — 
 
 Hash, or 
 
 Eggs, or 
 
 Eggs, or 
 
 Eggs, or 
 
 Fresh fish, or 
 
 Fresh fish, or 
 
 Salt fish, or 
 
 Stew (plain). 
 
 Stew without vegeta- 
 
 Fresh fish, or 
 
 
 bles, or 
 
 Stew. 
 
 
 Meat hash without po- 
 tatoes. 
 
 DINNER. 
 
 DINNER. 
 
 DINNER. 
 
 Soup — 
 
 Soup — 
 
 Soup- 
 
 Stock, or 
 
 Stock, or 
 
 Stock, or 
 
 Mutton broth, with bar- 
 
 Chicken, or 
 
 Chowder. 
 
 ley or vegetable, or 
 
 Mutton broth, with bar- 
 
 
 Chowder. 
 
 ley or vegetable. 
 
 
 Dry bread. 
 
 Dry bread. 
 
 Graham bread. 
 
 Meats — 
 
 Meats- 
 
 Meats — 
 
 Beef (roast or boiled), or 
 
 Beef (roast or boiled), or 
 
 Beef (roast or boiled), or 
 
 Mutton (roast or boiled), or 
 
 Chicken, or 
 
 Mutton(roast or boiled),or 
 
 Corned beef, or 
 
 Fish (fresh). 
 
 Fresh fish, or 
 
 Fresh fish, or 
 
 
 Irish stew. 
 
 Irish stew. 
 
 
 
 Vegetables — 
 
 Vegetables — 
 
 Vegetables — 
 
 Potatoes, baked, boiled, 
 
 Potatoes (baked), or 
 
 Spinach, or 
 
 or mashed, and 
 
 Rice, or 
 
 Lettuce, or 
 
 Tomatoes, or 
 
 Macaroni, or 
 
 Celery, or 
 
 Baked beans, or 
 
 Samp. 
 
 String beans. 
 
 French beans, or 
 
 
 
 Turnips, or 
 
 
 
 Beets, or 
 
 
 
 Rice, or 
 
 
 
 Macaroni, or Samp. 
 
 
 
 Pudding — 
 
 Pudding — 
 
 Pudding — 
 
 Rice, or 
 
 Rice or 
 
 Custard. 
 
 Bread, or 
 
 Bread, or 
 
 
 Tapioca, or 
 
 Tapioca, or 
 
 
 Farina, or 
 
 Farina, or 
 
 
 Corn starch, or Custard. 
 
 Corn starch, or Custard. 
 
 
 SUPPER. 
 
 SUPPER. 
 
 SUPPER. 
 
 Tea (sugar and milk). 
 
 Tea (milk and sugar). 
 
 Tea (milk). 
 
 Bread and butter, or 
 
 Bread and milk, or 
 
 Graham bread and but- 
 
 Toast and butter. 
 
 Milk toast, or 
 
 ter, or 
 
 
 Bread and butter, or 
 
 Bread and milk. 
 
 
 Toast and butter. 
 
 Eggs, or 
 
 Fruit — 
 
 Fruit — 
 
 Cold meat. 
 
 Apples, stewed or baked, or 
 
 Apples, stewed or baked, or 
 
 
 Prunes, or Pears. 
 
 Prunes, or Pears. 
 
 
HOSPITAL DIETARIES 
 
 783 
 
 Farinaceous Diet. 
 
 Milk Diet. 
 
 Extras. 
 
 BREAKFAST. 
 
 BREAKFAST. 
 
 ORDERED ONLY BY THE 
 
 Tea or coffee (milk and 
 
 One quart of milk. 
 
 ATTENDING PHYSICIAN 
 
 sugar). 
 
 
 OR SURGEON. 
 
 Bread and butter — 
 
 
 Mutton chops. 
 
 White bread, or 
 
 
 Beefsteak. 
 
 Graham bread, or 
 
 
 Scraped beef. 
 
 Corn bread, or 
 
 
 Beef tea (made with hy- 
 
 Rolls, or 
 
 
 drochloric acid). 
 
 Toast. 
 
 
 Chicken (broiled, fricas- 
 
 Porridge — ■ 
 
 
 seed, or roast). 
 
 Hominy, or 
 
 
 Chicken broth. 
 
 Farina, or 
 
 
 Eggs- 
 
 Indian meal. 
 
 
 Milk. 
 Oysters. 
 Clam broth. 
 Gruels. 
 Crackers. 
 Gingerbread. 
 Custard. 
 Milk toast. 
 
 DINNER. 
 
 DINNER. 
 
 
 Soup — 
 
 One quart of milk. 
 
 
 Vegetable, or 
 
 
 
 Macaroni, or 
 
 
 
 Barley broth. 
 
 
 
 Dry bread. 
 
 
 
 Vegetables — 
 
 
 
 Baked potatoes and 
 
 
 
 Tomatoes, or 
 
 
 
 French beans, or 
 
 
 
 Rice, or 
 
 
 
 Macaroni, or 
 
 
 
 Samp. 
 
 
 
 Pudding — 
 
 
 
 Rice, or 
 
 
 
 Bread, or 
 
 
 
 Tapioca, or 
 
 
 
 Farina, or 
 
 
 
 Cornstarch. 
 
 
 
 SUPPER. 
 
 SUPPER. 
 
 
 Tea (milk and sugar). 
 
 One quart of milk. 
 
 
 Bread and milk, or 
 
 
 
 Milk toast, or 
 
 
 
 Hominy, or 
 
 
 
 Boiled rice, or Farina. 
 
 
 
 Fruit — 
 
 
 
 Apples stewed or baked, or 
 
 
 ' 
 
 Prunes, or Pears. 
 
 
 
7 8 4 
 
 RATIONS, DIETARIES 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 
 
 
 i 
 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 m 
 
 Names of Patients. 
 
 a 
 
 V 
 
 C 
 
 H 
 
 » 
 
 "5 
 '•B 
 
 c 
 1) 
 u 
 
 V 
 
 > 
 
 c 
 o 
 U 
 
 4> 
 
 3 
 O 
 
 c 
 u 
 
 1 
 
 2 
 
 "5 
 
 O 
 <u 
 o 
 cS 
 
 a 
 
 CJ 
 
 fa 
 
 a 
 1 
 
 . 
 
 
 
 w 
 
 
 
 
 cJ 
 
 
 
 
 P* 
 
 
 
 
 
 
 
 
 O 
 
 
 "£ 
 
 
 d 
 
 
 Q 
 
 u 
 
 £ 
 
 
 
 T3 
 
 CS 
 
 ^J 
 
 c 
 
 t/J 
 
 o 
 
 u 
 
 <D 
 
 
 p 
 
 u 
 
 •Si 
 
 3 
 
 
 o 
 
 u 
 
 "5 
 
 
 
 h 
 
 H 
 
 3 
 
 > 
 C 
 
 o 
 U 
 
 
 
 — 
 
 
 a 
 
 
 
 
 
 
 
 
 
 r/l 
 
 
 
 
 
 
 
 
 C 
 
 
 
 
 0) 
 
 
 
 
 
 
 
 
 
 
 
 
 Ed 
 
 
 
 
 PUl 
 
 
 
 
 <— 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 £ 
 
 " 
 
 
 
HOSPITAL DIETARIES 785 
 
 Supper. — Tea, one pint, with half an ounce of milk and half an 
 ounce of sugar ; bread, five and one third ounces ; butter, a quarter 
 of an ounce. 
 
 Wednesday 
 
 Breakfast. — Coffee, one pint, with half an ounce of milk and half 
 an ounce of sugar ; five and one third ounces of bread and a quarter 
 of an ounce of butter ; rice, one ounce ; crackers, one ounce ; milk, 
 one quart. 
 
 Dinner. — Roast beef, eight ounces; barley soup, one pint; pota- 
 toes, eight ounces ; bread, five and one third ounces. 
 
 Supper. — Tea, one pint, with half an ounce of milk and half an 
 ounce of sugar; bread, five and one third ounces, and a quarter of 
 an ounce of butter; stewed prunes, one ounce. 
 
 Thursday 
 
 Breakfast. — Coffee, one pint, with half a pint of milk and half an 
 ounce of sugar ; five and one third ounces of bread and a quarter of 
 an ounce of butter ; oatmeal, one ounce ; crackers, one ounce ; milk, 
 one quart. 
 
 Dinner. — Beef stew, eight ounces ; potatoes, eight ounces ; vege- 
 tables, four ounces ; bread, five and one third ounces. 
 
 Supper. — Tea, one pint, with half a pint of milk and half an ounce 
 of sugar ; five and one third ounces of bread and a quarter of an 
 ounce of butter ; one ounce of stewed apples. 
 
 Friday 
 
 Breakfast. — Coffee, one pint, with half an ounce of milk and half 
 an ounce of sugar ; five and one third ounces of bread and a quarter 
 of an ounce of butter ; two eggs ; crackers, one ounce ; milk, one 
 quart. 
 
 Dinner. — Baked fish, eight ounces ; potatoes, eight ounces ; vege- 
 tables, four ounces; bread, five and one third ounces; rice pudding, 
 two and a half ounces. 
 
 Supper. — Tea, one pint, with half a pint of milk and half an ounce 
 of sugar : five and one third ounces of bread and a quarter of an 
 ounce of butter. 
 
 Saturday 
 
 Breakfast. — Coffee, one pint, with a quarter of a pint of milk and 
 a quarter of an ounce of sugar ; five and one third ounces of bread 
 and a quarter of an ounce of butter ; hominy, one ounce ; crackers, 
 one ounce ; milk, one quart. 
 
 Dinner. — Mutton stew, eight ounces ; potatoes, nine ounces ; 
 vegetables, four ounces ; bread, five and one third ounces. 
 
786 RATIONS, DIETARIES 
 
 Supper. — Tea, one pint, with milk half a pint, and half an ounce 
 of sugar; bread, five and one third ounces; butter, a quarter of an 
 ounce ; stewed prunes, one ounce. 
 
 Sunday 
 
 Breakfast. — Coffee, one pint, with half a pint of milk and half an 
 ounce of sugar ; five and one third ounces of bread and a quarter of 
 an ounce of butter ; crackers, one ounce ; milk, one quart ; two eggs. 
 
 Dinner. — Corned beef, eight ounces; bean soup, one pint; pota- 
 toes, eight ounces ; bread, five and one third ounces ; cornstarch 
 pudding, two and a half ounces. 
 
 Supper. — Tea, one pint, with half a pint of milk and half an ounce 
 of sugar; bread, five and one third ounces, and butter, a quarter of 
 an ounce. 
 
 Milk Diet 
 
 To be prescribed by attending physicians or surgeons. 
 
 Articles of Special Diet 
 Beefsteak, half a pound ; beef tea, one pint ; chicken, half a 
 pound ; chicken soup, one pint ; rice and milk, one pint ; two eggs ; 
 milk, one quart. 
 
 DIETARY OF THE ROOSEVELT HOSPITAL, NEW YORK 
 
 The ward diet of the Roosevelt Hospital, New York city, is 
 classified as follows : 
 
 Full Diet 
 
 Daily. — Meat, dressed, eight ounces ; potatoes, eight ounces ; 
 bread, twelve ounces ; butter, one ounce ; sugar, two ounces and a 
 half ; milk, half a pint ; coffee, half an ounce ; tea, an eighth of an 
 ounce. On Sundays, Tuesdays, and Thursdays, other vegetables in 
 addition to potatoes, two ounces ; bread, rice, or tapioca pudding. 
 On Mondays and Wednesdays, soup, one pint. On Fridays, fish. 
 
 Breakfast. — Coffee with sugar and milk, bread and butter, por- 
 ridge of oatmeal, wheaten grits, or samp. 
 
 Dinner. — Sunday : Roast beef, potatoes, tomatoes, or other vege- 
 table, bread, and bread pudding. Monday : Soup, boiled mutton, 
 potatoes, and bread. Tuesday : Corned beef, twelve ounces ; cab- 
 bage or turnips, potatoes, and bread. Wednesday : Soup, roast beef r 
 potatoes, and bread. Thursday : Soup, boiled beef, potatoes, onions, 
 tapioca, sago, or farina pudding, and bread. Friday : Fish, boiled 
 or roast beef, potatoes, bread, boiled rice sweetened with sugar and 
 milk, and raisins. Saturday : Stew of mutton, potatoes, and bread. 
 
 Supper. — Tea with sugar and milk, bread and butter, baked 
 apples, or stewed pears, or prunes, or green or dried apple sauce, and, 
 on Sundays, gingerbread varied, alternate weeks, with currant buns. 
 
HOSPITAL DIETARIES 
 
 78/ 
 
 Half Diet 
 Daily. — Meat, dressed, four ounces ; potatoes, four ounces ; bread, 
 six ounces ; of other articles, the same as in full diet. 
 
 Milk Diet 
 Daily. — Milk, two pints; bread, twelve ounces; rice or samp, 
 two ounces ; butter, one ounce. 
 
 Extras 
 In addition to the above, the following extras may be ordered 
 by the visiting physicians and surgeons : Beefsteak, chicken soup, 
 gruel, beef tea, oysters or clams, cornstarch, mutton chops, milk, 
 rice, chicken, eggs. 
 
 DIETARY OF THE JOHNS HOPKINS HOSPITAL, BALTIMORE 
 
 At the Johns Hopkins Hospital the Free Ward Diet is liberal, 
 but no attempt is made to classify the food qualitatively as served 
 to the wards. A sample Sunday menu given there is the following. 
 It is expensive, owing to the excess of animal food : 
 
 Breakfast. — Corned-beef hash, oatmeal, toast, eggs, bread and 
 butter, coffee or tea, and milk. 
 
 Dinner. — Soup, roast beef, potatoes, rice, turnips, toast, pud- 
 ding and milk, bread and butter. 
 
 Supper. — Cold roast beef or pressed corned beef, bread and but- 
 ter, coffee or tea, and milk. 
 
 DIETARY FOR LIVERPOOL INFIRMARY 
 
 Sample Diet suggested for the Liverpool Infirmary and other English 
 
 Hospitals 
 
 
 Sick. 
 
 Normal. 
 
 Convalescence. 
 
 Breakfast, 
 8.30 A. M. 
 
 \ pt. milk. 
 
 3 oz. bread or oatmeal. 
 
 f pt. of new milk. 
 6 oz. bread. 
 2 oz oatmeal. 
 
 1 pt. new milk. 
 8 oz. bread. 
 3 oz. oatmeal. 
 
 
 If cocoa or coffee is given with sugar, omit the oatmeal and give \ pt. 
 of milk. 
 
 Dinner, 
 1 . 30 P. M. 
 
 \ pt. of milk, made into 
 pudding with rice, sago, 
 etc. 
 
 \ pt. beef tea. 
 
 4 oz. bread. 
 
 Meat, 4 oz. (men). 
 
 " 3 oz. (women). 
 Bread, 6 oz. 
 Potato, 8 oz. 
 Cheese, \ oz. 
 
 Meat, 4 oz. 
 " 3 oz. 
 Bread, 8 oz. 
 Potato, 8 oz. 
 Cheese, 1 oz. 
 
 
 Same for all as the breakfast, but with addition of a cereal. 
 
 Supper, 
 6.30 to 7 P.M. 
 
 
 f pt. broth with boiled 
 
 meat. 
 Salt ad libitum. 
 
 
 Bed at 8 P. M. 
 
 Malt liquor as exceptional treat. 
 
 1 Total bread, 18 oz. 
 
 Total bread, 
 24 oz. 
 
788 RATIONS, DIETARIES 
 
 DIETARY OF THE COOK COUNTY HOSPITAL, CHICAGO 
 
 In the Cook County Hospital, of Chicago, the official diets are 
 f our — y\z., ward diet, light diet, special diet, milk diet. 
 
 Extras may be ordered, such as chickens, chops, beefsteak, eggs, 
 cream, crackers, lemons, or additional butter, milk, sugar, sirup, and 
 vinegar. 
 
 Here again no special attempt is made to classify foods quali- 
 tatively. 
 
 The following is a sample midsummer diet, from a smaller hos- 
 pital, having about seventy beds, in which attention is economically 
 given to variety in food cookery which would be impossible in a 
 larger institution without incurring needless expense : 
 
 WARD DIETARY OF THE NEW YORK INFIRMARY FOR WOMEN 
 AND CHILDREN, 1901 
 
 Sunday 
 
 Breakfast. — Full Diets : Hominy with milk, fish balls or creamed 
 fish, brown bread or biscuit, coffee with milk and sugar, fresh fruit. 
 Half Diets : Hominy with milk, toast, coffee, fresh fruit. 
 
 Dinner.— -Full Diets : Soup, bread, roast beef, sweet or white 
 potatoes, spinach or tgg plant, pudding. Half Diets : Clam broth, 
 toast, chicken or beef jelly, rice, or ice cream. 
 
 Supper. — Full Diets : Pressed beef or cream salmon, bread and 
 butter, cocoa. Half Diets : Indian meal porridge and milk, toast, 
 cocoa, fruit. 
 
 Monday 
 
 Breakfast. — Full Diets : Oatmeal and milk, bread and butter, 
 poached eggs on toast, coffee with milk and sugar. Half Diets : 
 Oatmeal, eggs on toast, coffee, fresh fruit. 
 
 Dinner. — Full Diets : Soup, bread, roast lamb, spaghetti, toma- 
 toes or lima beans, rice pudding or prune pudding or cottage pud- 
 ding. Half Diets : Chicken broth, toast, spaghetti, rice pudding or 
 cottage pudding. 
 
 Supper. — Full Diets : Baked potatoes and bacon or creamed beef 
 or toast, bread and butter, tea, fruit. Half Diets : Hominy and milk, 
 bread and butter or toast, tea, fruit. 
 
 Tuesday 
 
 Breakfast. — Full Diets : Wheat flakes and milk, beef mince or 
 hash, bread and butter, coffee. Half Diets : Wheat flakes, buttered 
 toast, coffee, fresh fruit. 
 
 Dinner. — Full Diets : Soup, bread, steak, cresses, potatoes, beans 
 or carrots or beets, boiled or baked custard or ice cream. Half 
 Diets : Mutton broth, rice, toast, custard or ice cream. 
 
HOSPITAL DIETARIES 789 
 
 Supper. — Full Diets : Brown bread and butter, cream cheese or 
 boiled eggs or sliced beef, fruit, cocoa. Half Diets : Oatmeal jelly 
 and milk, toast, fruit, cocoa. 
 
 Wednesday 
 
 Breakfast. — Full Diets : Hominy with milk, lamb mince or lamb 
 with cream sauce, bread, butter, coffee. Half Diets : Hominy with 
 milk, buttered toast, boiled eggs, coffee, fresh fruit. 
 
 Dinner. — Full Diets : Soup, bread, chicken, potatoes or rice, peas, 
 tapioca or fruit pudding or custard. Half Diets : Broth, rice, toast, 
 tapioca. 
 
 Supper. — Full Diets : Spaghetti and tomato or sliced tomatoes or 
 baked corn, bread and butter, tea, fruit. Half Diets : Wheat flakes 
 and milk, toast, tea, fruit. 
 
 Thursday 
 
 Breakfast. — Full Diets : Oatmeal and milk, fresh fish, bread and 
 butter, coffee. Half Diets : Oatmeal and milk, toast, coffee, fresh 
 fruit. 
 
 Dinner. — Full Diets: Soup, bread, braised beef, macaroni, spin- 
 ach or string beans, wine jelly or fruit jelly. Half Diets : Chicken 
 broth, macaroni, toast, wine jelly. 
 
 Supper. — Full Diets : Beef stew or cream toast or pea soup, bread 
 and butter, cake, fruit, cocoa. Half Diets : Cream toast, cocoa, fruit. 
 
 Friday 
 
 Breakfast. — Full Diets : Wheat flakes and milk, scrambled eggs 
 on toast, bread and butter. Half Diets : Wheat flakes and milk, 
 eggs, toast, coffee, fresh fruit. 
 
 Dinner. — Full Diets : Soup, bread, fish, potatoes, tomatoes or 
 peas, bread pudding or Indian pudding or ice cream. Half Diets : 
 Lamb broth, rice, bread pudding or ice cream. 
 
 Supper. — Full Diets : Chowder or boiled eggs, bread and butter, 
 tea, fruit. Half Diets : Oatmeal jelly, toast, tea, fruit. 
 
 Saturday 
 
 Breakfast. — Full Diets : Indian meal porridge and maple sirup 
 or milk, beef ragout, bread and butter, coffee. Half Diets : Indian 
 porridge, toast, coffee. 
 
 Dinner. — Full Diets : Soup, bread, steak, potatoes, cauliflower or 
 squash. Half Diets : Chicken broth, toast, rice, rennet custard, blanc 
 mange. 
 
 Supper. — Full Diets : Lamb stew or baked beans, bread and but- 
 ter, tea, fruit. Half Diets : Wheat flakes and milk, toast, tea, fruit. 
 
 Food which may be ordered by resident or attending physicians 
 when daily diet is not adequate or suitable : 
 
 Beefsteak, chops, chicken, beef jelly, chicken jelly, scraped beef 
 
790 RATIONS, DIETARIES 
 
 balls, raw beef sandwiches, clam broth, crackers, extra eggs and 
 milk, gruels, oatmeal jelly, wine or fruit jelly, cold beef extract 
 made with hydrochloric acid. 
 
 Average Daily Dietary for Adult Women Patients, iqoi, not including 
 Milk, Eggs, or Beef Tea for Special Cases 
 
 Flour, meal, rice, or beans, uncooked \ ounce. 
 
 Bread 8 ounces. 
 
 Butter and fat i\ " 
 
 Sugar. 2 " 
 
 Breakfast cereals, uncooked I ounce. 
 
 Meat or fish, dressed but uncooked 8 ounces. 
 
 Potatoes, dressed but uncooked 5 to 6 
 
 Fresh or canned vegetables, cooked 4 to 5 
 
 Stewed or fresh fruit, prepared or cooked 3 to 4 
 
 Soup & pint or 8 
 
 Milk 1 " " 16 
 
 Coffee £. " " 8 
 
 Tea or cocoa \ " " 8 
 
 Eggs, one every other day \ ounce. 
 
 NEW YORK STATE HOSPITAL— PROPOSED DIETARY 
 
 Austin Flint recommends the following dietary and food supply 
 for the New York State Hospital : 
 
 " The table is intended for patients not upon extra diet and 
 attendants only, and I have suggested that 25 per cent in the rations 
 of meat, flour, and potatoes be added for workers." 
 
 Daily Ration 
 
 Meat, with bone, including salted meats, fresh and salted 
 
 fish, and poultry 12 ounces. 
 
 Flour, to be used in making bread and in cooking (may in 
 
 part be substituted by cornmeal and macaroni) 12 " 
 
 Potatoes 12 " 
 
 Milk 16 " 
 
 One egg 2 " 
 
 Sugar 2 " 
 
 Butter 2 
 
 Cheese 1 ounce. 
 
 Rice, hominy, or oatmeal \\ " 
 
 Beans or peas (dried). i£ " 
 
 Coffee (in the berry and roasted) % " 
 
 Tea(black) \ " 
 
 Supplies for One Hundred Persons for Thirty Days 
 
 Meat, with bone, including salted meat, fresh and salted 
 
 fish, and poultry, total 2,250 pounds. 
 
 Flour (may be in part substituted by cornmeal and macaroni) 2,250 " 
 
 Potatoes 2,250 " 
 
 Milk 1,500 quarts. 
 
 Eggs . 250 dozen. 
 
 Sugar 490 pounds. 
 
 Butter 430 
 
 Cheese 215 " 
 
 Rice 108 
 
 Hominy 108 " 
 
 Oatmeal 108 " 
 
 Coffee 180 
 
 Tea 26 " 
 
HOSPITAL DIETARIES 791 
 
 " Flour should be interchangeable, on this basis, with potatoes, 
 rice, hominy, and oatmeal. Butter and cheese may be interchange- 
 able in the proportion of one pound of butter to two pounds of 
 cheese; and eggs and milk, in the proportion of two eggs to one 
 pint of milk. There are occasions when eggs may be substituted 
 with advantage for meat. This may be done on the basis of eight 
 eggs for one pound of meat. When fruits, fresh and dried, are used 
 in abundance, a reduction may be made in eggs, butter, cheese, and 
 milk." 
 
 DIETARY OF THE UTICA STATE HOSPITAL FOR THE INSANE 
 
 Monday 
 Breakfast. — Cold corned beef, oatmeal, boiled potatoes, bread 
 and butter, tea or coffee. 
 
 Dinner. — Roast beef, boiled potatoes, gravy, boiled rice, bread 
 and butter, tea. 
 
 Supper. — Roll, bread, sirup, butter, tea. 
 
 Tuesday 
 
 Breakfast. — Cold roast beef, oatmeal, boiled potatoes, bread and 
 butter, tea or coffee. 
 
 Dinner. — Vegetable soup, boiled mutton, boiled potatoes, bread 
 and butter, and tea. 
 
 Supper. — Molasses cookies, bread and butter, tea. 
 
 Wednesday 
 
 Breakfast. — Roast mutton, oatmeal, boiled potatoes, bread and 
 butter, tea or coffee. 
 
 Dinner. — Roast veal, boiled potatoes, Indian pudding, gravy, 
 bread and butter, tea. 
 
 Slipper. — Stewed prunes, bread and butter, tea. 
 
 Thursday 
 
 Breakfast. — Cold roast veal, oatmeal, boiled potatoes, bread and 
 butter, tea or coffee. 
 
 Dinner. — Baked salt pork, baked beans, boiled potatoes, bread 
 and butter, tea. 
 
 Supper. — Cheese, roll, bread, sirup, butter, tea. 
 
 Friday 
 Breakfast. — Codfish, oatmeal, boiled potatoes, bread and butter, 
 tea or coffee. 
 
 Dinner. — Fresh fish, boiled potatoes, dried raspberry pie, bread 
 and butter, tea. 
 
 Supper. — Sugar cookies, bread and butter, tea. 
 52 
 
792 RATIONS, DIETARIES 
 
 Saturday 
 
 Breakfast. — Cold roast beef, oatmeal, boiled potatoes, bread and 
 butter, tea or coffee. 
 
 Dinner. — Corned beef, boiled cabbage, boiled potatoes, bread 
 and butter, tea. 
 
 Supper. — Corn and wheat bread, cheese, butter, tea. 
 
 Sunday 
 
 Breakfast. — Boiled eggs, oatmeal, boiled potatoes, bread and 
 butter, tea or coffee. 
 
 Dinner. — Cold boiled ham, boiled potatoes, pickled beets, canned 
 corn, bread and butter, tea. 
 
 Supper. — Ginger cookies, bread and butter, tea. 
 
 Fresh vegetables and fruits in their season. 
 
 Extra diet may be ordered as follows : Milk toast, dry toast, egg 
 on toast, beef tea, beefsteak, chops, ham, scrambled eggs, fried and 
 boiled eggs, baked custard, cornstarch, rice and milk, gruel, sauce,, 
 hot milk, and chocolate. For each patient the daily allowance is : 
 
 Butter . . i-i- oz. 
 
 Sugar ii " 
 
 Potatoes 1 1 5 " 
 
 Coffee f - " 
 
 Tea \ " 
 
 Flour ir \ " 
 
 Fresh beef 10 " 
 
 Fresh vegetables in season and in varying amount. 
 
 Extra Diet 
 
 f Milk toast (for breakfast) ) _. 
 I n c /^ i -i , x r 1 hree times a day. 
 
 ! Beef tea (Cybils's extract) j 3 
 
 Acute mania. i Grud ^ njght) 
 
 [ Milk (about three quarts daily) 
 r Breakfast — Egg on toast (no coffee). 
 Melancholia. -j Dinner — Steak (rare) or chops, fresh vegetables. 
 
 I Supper — Gruel, sauce (apple), custard or boiled -egg. 
 
 Milk, one quart. 
 
 Three eggs. 
 
 Cod-liver oil. 
 
 Whisky. 
 ■{ Sugar. 
 
 Melancholia, re- 
 fusing food fed 
 
 by tube twice j ~~f~ 
 ... Salt. 
 
 j Pancreatin, three grains. 
 
 Pepsin, three grains. 
 [ Sodium bicarbonate, fifteen grains. 
 
 This amount given twice a day is varied once a week by chicken 
 or mutton broth. 
 
 " Two of the patients fed by tube with this combination for over 
 a year remained in good condition " (Steele). 
 
HOSPITAL DIETARIES 
 
 793 
 
 Full Dietaries for Children at Various English Hospitals (Chambers) 
 
 Age. 
 
 Bread. 
 
 Butter. 
 I OZ. 
 
 ? 
 
 Milk. 
 
 Meat. 
 
 Vegeta- 
 bles. 
 
 Under 7. 
 Under 7. 
 
 Un- 
 limited. 
 12 oz. 
 
 ipt. 
 
 2 OZ. 
 2 oz. 
 
 4 oz. 
 3 oz. 
 
 Under 8. 
 
 5£oz. 
 
 About 
 } oz. 
 
 ipt- 
 
 2 OZ. 
 
 4 oz. 
 
 Under 8. 
 
 8 oz. 
 
 About 
 
 ? 
 
 2 OZ. 
 
 4 oz. 
 
 Above 8. 
 Under 9. 
 
 8 oz. 
 6 oz. 
 
 I oz. 
 
 About 
 
 1 oz. 
 
 ? 
 
 Ipt- 
 ipt. 
 
 3 oz. 
 broth, 
 ipt- 
 
 2 OZ. 
 
 6 oz. 
 
 6 oz. 
 
 Under 9. 
 Under 10. 
 Under 10. 
 
 7 oz. 
 12 oz. 
 6 oz. 
 
 \ oz. 
 f oz. 
 
 ? 
 
 ipt. 
 ipt. 
 
 lipt. 
 
 4 oz. 
 2 oz. 
 2 eggs. 
 
 4 oz. 
 4 oz. 
 
 ? 
 
 Pudding. 
 
 Hospital. 
 
 Unlimited. St. George's. 
 London. 
 
 Twice 
 a week. 
 i pint. 
 
 Children's Hospital, 
 Great Ormond Street, 
 and Evelina Hospi- 
 tals. 
 
 Leeds Infirmary. 
 
 Gruel, Children's, Great Or- 
 \ pint. mond Street, and 
 
 Evelina Hospitals. 
 \ pint gruel Birmingham General 
 or broth, j Hospital. 
 To order, j St. Bartholomew's. 
 6 oz. ' St. Thomas's. 
 8 oz. j King's College. 
 
 Diet of Northeastern Hospital for Children, London 
 
 
 Milk diet. 
 
 Fish diet. 
 
 Full diet. 
 
 Breakfast, 7 A. M. . . . 
 
 Milk, \ pt. ; bread, 
 
 Milk or cocoa, -£ pt. ; 
 
 Milk or cocoa, \ pt. ; 
 
 
 2 oz., with butter. 
 
 bread, 2-Joz., with 
 
 bread, i\ oz., with 
 
 
 
 butter. 
 
 butter. 
 
 Dinner, 12 M 
 
 Milk, ■£ pt. ; rice or 
 
 Fish, boiled, 2-J oz. ; 
 
 Roast, boil'd, or minc'd 
 
 
 other milk pud- 
 
 potatoes, mashed, 
 
 mutton, or roast or 
 
 
 ding. 
 
 3 oz ; bread, 1 
 
 minced beef, i\ oz. ; 
 
 
 
 oz. ; milk pud- 
 
 mashed potatoes, 4 
 
 
 
 ding. 
 
 oz., to alternate with 
 green vegetables ; 
 bread, 1 oz. ; milk 
 pudding. 
 
 Tea, 3.30 p. M 
 
 Milk, i pt. ; bread, 
 
 Milk, £ pt. ; bread, 
 
 Bread, i\ oz., with but- 
 
 
 2 oz., with butter. 
 
 2 -J oz., with trea- 
 
 ter, treacle, or drip- 
 
 
 
 cle or butter. 
 
 pings ; milk, \ pt. 
 
 Supper, 6 p. m 
 
 Biscuit (cracker) or 
 
 Bread, 2 oz., with 
 
 Bread, 2 oz., with but- 
 
 
 slice of bread and 
 
 butter, or cracker. 
 
 ter, or cracker. 
 
 
 butter. 
 
 
 
 DIETARIES OF ARMY HOSPITALS 
 
 United States Army Hospitals 
 
 Special Diet. — The medical officer will select from this list ac- 
 cording to his discretion : Bread, butter, coffee, tea, toast (dry), toast 
 (milk), eggs (boiled), eggs (poached), milk, beefsteak, milk por- 
 ridge, ham, beef extract, oatmeal mush and milk, chicken (stewed), 
 chicken broth, mutton chop, mutton broth, chocolate, oysters 
 
794 RATIONS, DIETARIES 
 
 (stewed), beef tea, rice (boiled), farina pudding, cornstarch, crack- 
 ers (soda or cream), potatoes (baked), potatoes (mashed), beef es- 
 sence, macaroni (boiled), canned peaches (stewed), canned apples 
 (stewed), canned pears, grapes, oranges, lemons, apples, water- 
 melons, cantaloupes, etc. 
 
 The following comprises the list of articles allowed in the ration 
 of the U. S. A. post hospitals : 
 
 Breakfast 
 
 Bread 6 ounces. 
 
 Butter \ ounce. 
 
 Coffee i pint. 
 
 Tea I " 
 
 Toast, dry 4 ounces. 
 
 Toast, milk 6 " 
 
 Eggs, boiled 1 
 
 Eggs, poached 1 
 
 Milk 12 ounces. 
 
 Beefsteak 6 " 
 
 Milk porridge 1 pint. 
 
 Ham 4 ounces. 
 
 Beef essence 2 " 
 
 Dinner 
 
 Bread 4 ounces. 
 
 Chicken, stewed 6 " 
 
 Chicken broth 1 pint. 
 
 Mutton chop 6 ounces. 
 
 Mutton broth I pint. 
 
 Milk 12 ounces. 
 
 Oysters, stewed 1 gill. 
 
 Beef tea 12 ounces. 
 
 Rice, boiled 1 ounce. 
 
 Farina pudding 4 ounces. 
 
 Cornstarch pudding 4 " 
 
 Milk porridge 1 pint. 
 
 Beefsteak 6 ounces. 
 
 Potatoes, mashed 6 " 
 
 Beef essence 2 " 
 
 Supper 
 
 Tea 1 pint. 
 
 Butter -£- ounce. 
 
 Bread 4 ounces. 
 
 Toast, dry 4 " 
 
 Milk 12 " 
 
 Eggs 1 
 
 Milk porridge 1 pint. 
 
 Beef essence 2 ounces. 
 
HOSPITAL DIETARIES 
 
 795 
 
 Following is the diet list issued in 1900 for a large United States 
 Army General Hospital (at the Presidio of San Francisco) : 
 
 United States Army General Hospital 
 
 Breakfast. 
 
 Dinner. 
 
 Supper. 
 
 Sunday. 
 Oatmeal and milk. 
 Ham and eggs. 
 Bread and butter. 
 Fruit. 
 Coffee. 
 
 Monday. 
 Germea and milk. 
 Beefsteak. 
 Fried potatoes. 
 Bread and butter. 
 Fruit. 
 Coffee. 
 
 Tuesday. 
 Oatmeal and milk. 
 Sausage. 
 Fried potatoes. 
 Bread, butter, coffee. 
 Fruit. 
 
 Wednesday. 
 Milk toast. 
 Beefsteak. 
 
 Bread, butter, coffee. 
 Fruit. 
 
 Thursday. 
 Germea and milk. 
 Hash. 
 
 Bread, butter, coffee. 
 Fruit. 
 
 Friday. 
 Oatmeal and milk. 
 Bacon and eggs. 
 Bread, butter, coffee. 
 Fruit. 
 
 Saturday. 
 Germea and milk. 
 Beefsteak. 
 Fried potatoes. 
 Bread, butter, coffee. 
 Fruit. 
 
 Vermicelli soup. 
 Roast veal, sage dressing, or 
 Turkey or chicken and dressing. 
 Stewed peas. Mashed potatoes. 
 Farina pudding. Fruit. 
 Bread and butter. Coffee. 
 
 Roast beef. 
 
 Mashed potatoes. String beans. 
 
 Tapioca pudding. 
 
 Bread and butter. Fruit. 
 
 Coffee. 
 
 Vegetable soup. 
 
 Baked pork and beans. 
 
 Baked tomatoes. 
 
 Bread pudding. 
 
 Bread, butter, cocoa, fruit. 
 
 Roast mutton with dressing. 
 Mashed potatoes. 
 Corn or fresh vegetables. 
 Chocolate pudding. Fruit. 
 Bread, butter, coffee. 
 
 Oyster soup. 
 
 Corned beef and cabbage. 
 Boiled potatoes. Radishes. 
 Rice pudding. Fruit. 
 Bread, butter, coffee. 
 
 Baked fish with sauce. 
 Plain boiled potatoes. 
 ; Fresh salad. 
 Farina pudding. Fruit. 
 Bread, butter, cocoa. 
 
 1 Roast beef, veal, or pork. 
 
 Mashed potatoes. 
 
 Hot slaw. Cauliflower. 
 
 Bread pudding. 
 , Bread, butter, coffee. 
 
 Veal stew or boiled ham. 
 
 Apple sauce. 
 
 Cake. 
 
 Bread and butter. 
 
 Tea. 
 
 Codfish balls or hash. 
 
 Bread and butter. 
 
 Pickles. 
 
 Jam. Sweet crackers. Prunes. 
 
 Tea. 
 
 Fried liver and bacon. 
 
 Corn bread and sirup or 
 
 Biscuits 
 
 Bread, butter, tea. 
 
 Fruit. 
 
 Mutton stew. 
 Pickles. Sweet crackers. 
 Bread, butter, tea. 
 Peach cobbler. 
 
 Sliced roast beef. 
 
 Macaroni and cheese. 
 
 Preserves. 
 
 Bread and butter. 
 
 Tea. 
 
 Salmon salad. Potato salad. 
 
 Apple sauce. 
 
 Ginger crackers. 
 
 Bread and butter. 
 
 Tea. 
 
 Baked hash or stew. 
 Stewed prunes. 
 Assorted cakes. 
 Bread and butter. 
 Tea. 
 
796 
 
 RATIONS, DIETARIES 
 
 [/ LIGHT DIET 
 
 Breakfast. 
 
 Dinner. 
 
 Supper. 
 
 Sunday. 
 
 
 
 Oatmeal and milk. 
 
 Rice soup. 
 
 Milk toast. 
 
 Soft-boiled eggs. 
 
 Farina pudding. 
 
 Cup custard. 
 
 Milk toast. Coffee. 
 
 Coffee. 
 
 Tea. 
 
 Monday. 
 
 
 
 Germea and milk. 
 
 Plain tomato soup. 
 
 Farina mush and milk. 
 
 Milk toast. 
 
 Bread pudding with lemon sauce. 
 
 Sweet crackers. Jelly. 
 
 Boiled eggs. 
 
 Coffee. 
 
 Toast. 
 
 Coffee. 
 
 
 Tea. 
 
 T ties day. 
 
 
 
 Oatmeal and milk. 
 
 Barley soup. , 
 
 Biscuits or corn bread. 
 
 Boiled eggs. 
 
 Tapioca pudding. 
 
 Maple sirup. Boiled rice. 
 
 Coffee. 
 
 Cocoa. 
 
 Milk toast and tea. 
 
 Wednesday. 
 
 
 
 Oatmeal and milk. 
 
 Consomme vermicelli. 
 
 Sweet crackers. Jam. 
 
 Soft-boiled eggs. 
 
 Cornstarch pudding. 
 
 Milk toast. 
 
 Coffee. 
 
 Vanilla sauce. Coffee. 
 
 Tea. 
 
 Thursday. 
 
 
 
 Germea and milk. 
 
 Oyster soup. 
 
 Macaroni and cheese. 
 
 Boiled eggs. 
 
 Rice pudding. 
 
 Milk toast. Maple sirup. 
 
 Coffee. 
 
 Coffee. 
 
 Tea. 
 
 Friday. 
 
 
 
 Oatmeal and milk. 
 
 Fish chowder. 
 
 Tapioca pudding. 
 
 Boiled eggs. 
 
 Farina pudding. 
 
 Milk toast. Ginger crackers. 
 
 Milk toast. 
 
 Cocoa. 
 
 Boiled eggs. 
 
 Coffee. 
 
 
 Tea. 
 
 Saturday. 
 
 
 
 Oatmeal and milk. 
 
 Vermicelli soup. 
 
 Germea mush. 
 
 Boiled eggs. 
 
 Sago pudding. 
 
 Assorted cakes. Jelly. 
 
 Coffee. 
 
 Coffee. 
 
 Milk toast. 
 Tea. 
 
HOSPITAL DIETARIES 
 
 797 
 
 In addition to the regular diet table a special diet list is pro- 
 vided for use of ward surgeons for cases requiring this class of diet 
 it also contains a list of broths intended for liquid diets. 
 
 Daily Order List of Special Diet 
 
 U. S. A. General Hospital, 
 Ward Presidio of San Francisco, igoo. 
 
 
 B. 
 
 D. 
 
 S. 
 
 
 
 
 Number of light diets 
 
 
 
 
 
 
 
 Number of full diets 
 
 
 
 
 Stewed chicken 
 
 
 
 
 
 
 
 Chopped beef 
 
 
 Steaks 
 
 
 Mutton chops 
 
 
 Baked potatoes 
 
 French-fried potatoes 
 
 
 Saratoga chips 
 
 Creamed potatoes 
 
 
 Baked apples 
 
 
 Wine jelly 
 
 Cup custard 
 
 
 Milk toast 
 
 Poached eggs 
 
 
 Coffee 
 
 
 Tea 
 
 
 
 
 Broths 
 Beef broth 
 
 
 
 
 
 
 
 Mutton broth 
 
 
 Chicken broth 
 
 i 
 
 i 
 ! 
 
 
 Consomme broth 
 
 
 Oyster broth 
 
 
 
 
 Ward Officer. 
 
 British Army Hospitals 
 
 The following statement is quoted from a report made by Col. 
 Alfred A. Woodhull, who was sent abroad by the U. S. Army De- 
 partment to investigate certain medical features of the British army : 
 
 ''The British army uses seven [diets], known as tea, milk, beef 
 tea, chicken, convalescent, roast, and varied. Each is formulated 
 with exactness, and parts of two diets may not be ordered together. 
 The tea diet is : Bread, twelve ounces ; tea, half an ounce ; sugar, 
 two and a half ounces; milk, six ounces. The varied diet is: Beef 
 or mutton, twelve ounces without, or fifteen ounces with, bone ; 
 bread, eighteen ounces ; tea, half an ounce ; sugar, one and a half 
 ounce ; milk, six ounces ; butter, one ounce ; potatoes, sixteen 
 ounces ; vegetables, four ounces, with salt, pepper, and mustard, and 
 
79 8 
 
 RATIONS, DIETARIES 
 
 optionally wine, spirits, malt liquors, and diet drinks may be ordered. 
 These diets represent the extremities of the scale through which 
 the others run. The ordinary drinks allowed for patients are : 
 Barley water, rice water, gruel, and lemonade, each prepared by 
 formula." 
 
 Prussian Army Hospitals 
 
 According to Roth and Lex, in four grades of diet in Prussian 
 military hospitals the proportionate allowance of food classes is as 
 follows : 
 
 
 I. 
 
 II. 
 
 III. 
 
 IV. 
 
 Albumin 
 
 ii5 
 
 55 
 
 522 
 
 81 
 
 39 
 
 315 
 
 52 
 
 32 
 
 179 
 
 18 
 
 Fat 
 
 15 
 127 
 
 Carbohydrates 
 
 
 French Army Hospitals 
 
 Kirchner gives the following analysis of the nutrient ingredients 
 of the seven different classes into which diet in the French military 
 hospitals is divided. " Absolute diet " (diete absolue) is practical 
 starvation, at most, only a little toast water being given, and is of 
 service for such cases as may require exclusive rectal feeding. 
 
 
 Albumin. 
 
 Fats. 
 
 Carbohydrates. 
 
 Full diet 
 
 Grammes. 
 119 
 
 91 
 70 
 
 35 
 19 
 14 
 
 Grammes. 
 
 57 
 47 
 39 
 25 
 17 
 36 
 
 Grammes. 
 448 
 
 357 
 225 
 
 134 
 
 89 
 89 
 
 f- diet 
 
 \ " 
 
 | " 
 
 i " 
 
 Bread diet 
 
 Absolute diet 
 
 
 
APPENDIX 
 
 RECEIPTS FOR INVALID FOOD AND BEVERAGES, 
 SUITABLE FOR FEVERS AND CONVALESCENCE 
 FROM ACUTE ILLNESS 
 
 BEVERAGES 
 
 i. Demulcent and Nutritive 
 
 Barley Water (Pavy). — Take two ounces of pearl barley and 
 wash well with cold water, rejecting the washings. Afterwards boil 
 with a pint and a half of water for twenty minutes in a covered 
 vessel, and strain. The product may be sweetened and flavoured 
 with lemon peel, or lemon peel may be introduced while boiling is 
 carried on. Lemon juice is also sometimes added to flavour. A 
 bland, demulcent, and mildly nutritive beverage. 
 
 Barley Water (Bartholow). — Wash two ounces of pearl barley 
 with cold water. Then boil it for five minutes in some fresh water, 
 and throw both waters away. Then pour on two quarts of boiling 
 water, and boil it down to a quart. (Stir and skim occasionally.) 
 Flavour with thinly cut lemon rind ; add sugar to taste, but do not 
 strain unless at the patient's request. 
 
 Barley Water (Ringer). — To a tablespoonful of pearl barley 
 washed in cold water add two or three lumps of sugar, the rind of 
 one lemon, and the juice of half a lemon. On these pour a quart 
 of boiling water, and let the mixture stand for seven or eight hours. 
 Strain. The barley water should never be used a second time. Half 
 an ounce of isinglass may be boiled in the water. If not needed at 
 once, these barley preparations should be kept in the refrigerator 
 and warmed when required. 
 
 Rice Water or Mucilage of Rice (Pavy). — Thoroughly wash one 
 ounce of rice with cold water. Then macerate for three hours in 
 a quart of water kept at a tepid heat, and afterwards boil slowly 
 for an hour, and strain. A useful drink in dysentery, diarrhoea, and 
 irritable states of the alimentary canal. It may be sweetened and 
 flavoured in the same way as barley water. 
 
 799 
 
800 APPENDIX 
 
 Demulcent Drink (Ringer). — Take a pinch of isinglass, and boil 
 it in half a pint of new milk with half a dozen bruised sweet almonds 
 and three lumps of sugar. 
 
 Linseed Tea (Chambers). — Whole linseed, white sugar, each one 
 ounce ; licorice root, one half ounce ; lemon juice, two ounces. Mix. 
 An agreeable demulcent. 
 
 Flaxseed Tea. — One half cupful of flaxseed to one quart of boil- 
 ing water ; boil thirty minutes and let stand a little while near the 
 fire to thicken more. Strain, and add lemon juice and sugar. 
 
 Currant Jelly (Fagge). — Red or black currant jelly, dissolved in 
 hot or cold water or strained tamarind tea, make excellent invalid 
 beverages. 
 
 2. Diuretic and Refrigerant 
 
 Lemonade (Pavy). — Pare the rind from a lemon thinly, and cut 
 the lemon into slices. Put the peel and sliced lemon into a pitcher 
 with one ounce of white sugar, and pour over them one pint of 
 boiling water. Cover the pitcher closely, and let stand until cold. 
 Strain or pour off the liquid. 
 
 Citron may be used instead of lemon, and it likewise furnishes a 
 grateful and refrigerant beverage. 
 
 Lemonade, Effervescing (Ringer). — To the expressed juice of a 
 large lemon add a lump or two of sugar previously lightly rubbed 
 on the rind. Pour on it half a pint of cold or iced water. To cause 
 it to effervesce put it into a large tumbler and add half a teaspoon- 
 ful of bicarbonate of soda or potash. Stir and drink while effer- 
 vescing. A very agreeable and refreshing beverage. 
 
 Lemonade (Ringer). — Pare the rind of three lemons as thin as 
 possible, add one quart of boiling water and a quarter of an ounce 
 of isinglass. Let them stand till next day covered ; then squeeze 
 the juice of eight lemons upon half a pound of lump sugar; when 
 the sugar is dissolved, pour the lemon and water upon them, mix 
 all well together, strain, and it is ready for use. 
 
 Orangeade (U. S. Army Hospitals). — One orange. One tea- 
 spoonful of sugar. Three fourths of a coffee cup of water (six 
 ounces). Wash and wipe the orange. Squeeze the juice into the 
 sugar. Add the cold water, previously boiled. Strain and serve. 
 
 Cream-of-tartar Drink. — Potus Imperialis. — Imperial Drink 
 (Pavy). — Dissolve a drachm or a drachm and a half of cream of 
 tartar in a pint of boiling water, and flavour with lemon peel and 
 sugar. When cold, strain and take ad libitum as a refrigerant drink 
 and diuretic. 
 
 Cream-of-tartar Whey (Pavy). — Stir a quarter of an ounce of 
 cream of tartar (a large teaspoonful piled up) into a pint of boiling 
 milk, and strain. A refrigerant and diuretic drink, which is ren- 
 dered more agreeable by the addition of sugar. 
 
FLUID BEEF PREPARATIONS 8oi 
 
 White Wine Whey or Posset (Pavy). — To half a pint of milk 
 while boiling in a saucepan add one wineglassful of sherry, and 
 afterwards strain through a muslin cloth. Sweeten with pounded 
 sugar according to taste. A useful diuretic drink in colds and mild 
 febrile disorders. For a child, give a tablespoonful every two or 
 three hours. 
 
 Wine Whey. — Milk, one pint ; wine of pepsin, one teaspoonful. 
 Heat gently to 115 or 120 F., let stand, break the curd, strain, 
 and add sherry in the proportion of 1 to 4 or 6. Drink cold. 
 
 Tamarind Whey (Pavy). — Stir two tablespoonfuls of tamarinds 
 into a pint of milk while boiling, and afterwards strain. This forms 
 a refrigerant and slightly laxative drink. 
 
 Mulled Wine (Ringer). — Boil some spice, cloves, nutmeg, cinna- 
 mon, or mace in a little water just to flavour the wine ; then add a 
 wineglassful of sherry or any other wine and some sugar ; bring it 
 to the boiling point, and serve with sippets of toast. If claret is 
 used, it will require more sugar. The vessel for boiling the wine 
 should be scrupulously clean. 
 
 FLUID BEEF PREPARATIONS 
 
 Beef Juice (Bartholow). — Broil quickly some pieces of round or 
 sirloin of a size to fit in the cavity of a lemon squeezer previously 
 heated by being dipped in hot water. The juice, as it flows away, 
 should be received into a hot wineglass, and, after being seasoned 
 to the taste with salt and a little Cayenne pepper, taken while hot. 
 
 Beef Essence (Yco). — Cut the lean of beef into small pieces and 
 place them in a wide-mouthed bottle securely corked, and then 
 allow it to stand for several hours in a vessel of boiling water. This 
 may be given to infants, who can not take milk, in teaspoonful doses, 
 and in larger quantities to adults. 
 
 Beef Tea (Germain See). — Meat cut into small pieces, cold water 
 added, and then gradually heated to 140 or 160 F. Press, strain, 
 and flavour with salt and pepper. This is much inferior to the 
 preparations made with hydrochloric acid. 
 
 Beef Tea {Pavy). — Put a pound of finely minced beef into a 
 suitable vessel with a pint of cold water. Let it stand for an hour, 
 stirring occasionally. Place the vessel containing the beef into a 
 saucepan of water, place over the fire, and allow the water to boil 
 gently for an hour (or the vessel containing the beef tea may be put 
 into an ordinary oven for an hour). Pass the beef tea through a 
 strainer. It contains a quantity of fine sediment, which should be 
 drunk with the liquid. Flavour with salt. In this process the beef 
 extract should not be exposed to a temperature of more than 170 F. 
 
 Beef Tea (Bryee). — Lean beef, chopped fine, free from fibre, one 
 pound ; water, one pint ; sodium bicarbonate, ten grains ; simmer 
 
802 APPENDIX 
 
 half an hour in a glass-covered preserve jar, decant the fluid, squeeze 
 the meat to a pulp in a lemon squeezer, return both to jar, add 
 extract of pancreas, cover, keep at 140 F. for twelve hours^ shaking 
 occasionally. When an acid taste appears, boil two or three minutes 
 to stop further fermentation. 
 
 This tea, it is claimed, equals the same bulk of peptonised milk 
 in nutrient value. 
 
 Chrystie's Beef Tea. — Macerate for one hour one pound of finely 
 minced lean beef in a pint of water, containing fifteen grains of 
 sodium chloride and five drops of dilute hydrochloric acid, at ioo° F. 
 
 Filter through cheese cloth, and wash the residue with half a pint 
 of fresh water. The filtrate is transparent, has a not unpleasant 
 taste, and contains a considerable amount of albuminoids. A child 
 of two years may take two or three ounces daily. 
 
 Beef Tea (Bartholozv). — Chop fine a pound of lean beef free from 
 fat, tendons, etc., and digest with a pint of cold water for two hours. 
 Let it simmer on the stove for three hours, at a temperature never 
 over 160 F. Make up the water lost in evaporation by adding cold 
 water, so that a pint of beef tea shall represent a pound of beef. 
 Strain, and carefully express all fluid from the beef. 
 
 Beef Tea (U. S. Army Hospital Receipt for Twelve Men).— Bed, 
 twelve pounds ; salt, one ounce. 
 
 Directions. — The beef should be lean and juicy, and cut into small 
 pieces. Put it into one gallon and a half of cold water with the 
 salt. Let it boil gently three hours. If it should boil away too 
 fast, add the requisite quantity of boiling water and let it boil fifteen 
 minutes longer. When done it should measure twelve pints. Set it 
 aside to cool. Remove every particle of grease, and heat when 
 required. In case of a deficiency of fresh beef, use the beef extract 
 supplied in the hospital stores. 
 
 Beef Extract (U. S. Army Hospital Receipt for Twelve Men). 
 
 Directions. — Infuse a third of a pound of fresh beef, finely minced, 
 in fourteen ounces of cold soft water, to which a few drops (four or 
 five) of muriatic acid and a little salt (from ten to eighteen grains) 
 have been added. After digesting for an hour to an hour and a 
 quarter, strain it through a sieve and wash the residue with five 
 ounces of cold water, pressing it to remove all soluble matter. The 
 mixed liquid will contain the whole of the soluble constituents of the 
 meat (albumin, creatin, etc.), and it may be drank cold or slightly 
 warmed. The temperature should not be raised above ioo° F., as 
 at the temperature of 113 F. a considerable portion of the albumin, 
 a very important constituent, will be coagulated. 
 
 Meat Extract (Rosenthal and Lcube). — One thousand giammes of 
 lean meat, minced fine, are placed in a porcelain vessel with one 
 thousand grammes of water, and twenty centigrammes of dilute 
 hydrochloric acid. This is placed in a closed Papin's digester and 
 
BROTHS AND SOUPS 803 
 
 boiled for ten to fifteen hours. The mass is then taken out and 
 rubbed in a mortar to a paste. It is again boiled in the closed 
 digester for another sixteen to twenty hours ; after this it is neutral- 
 ised with pure sodium carbonate, and evaporated to a sirupy con- 
 sistence. 
 
 Restorative Beef Essence (Ringer). — Take one ounce of fresh 
 beef, free from fat, chop fine, and pour over it eight ounces of soft 
 water, add five or six drops of dilute hydrochloric acid, and fifty 
 or sixty grains of common salt, stir it well, and leave for three hours 
 in a cool place. Then pass the fluid through a hair sieve, pressing 
 the meat slightly, and adding gradually toward the end of the strain- 
 ing about two more ounces of water. The liquid thus obtained is of a 
 red colour, possessing the taste of soup. It should be taken cold, a 
 teaspoonful at a time. If preferred warm, it must not be put on the 
 fire, but heated in a covered vessel placed in hot water. 
 
 BROTHS AND SOUPS 
 
 Chicken Broth (Bartholozv). — Skin and chop up fine a small 
 chicken or half a large fowl, and boil it, bones and all, with a blade 
 of mace, a sprig of parsley, and a crust of bread, in a quart of water 
 for an hour, skimming it from time to time. Strain through a coarse 
 colander. 
 
 Chicken, Veal, or Mutton Broth (Yeo). — Chicken, veal, or mutton 
 broth may be made like beef tea, substituting chicken, veal, or mut- 
 ton for beef, boiling in a saucepan for two hours, and straining. 
 For chicken broth the bones should be crushed and added. For 
 veal broth the fleshy part of the knuckle should be used. Either 
 may be thickened and their nutritive value increased by the addition 
 of pearl barley, rice, vermicelli, or semolina. 
 
 Mutton and Chicken Broths (Osier). — Mince a pound of either 
 chicken or mutton, freed from fat, put into a pint of cold water, and 
 let stand in a cold jar on ice two to three hours. Then cook three 
 hours over a slow fire, strain, cool, skim off fat, add salt, and serve 
 hot or cold. Such broth is much better than any manufactured meat 
 preparations. Good mutton broth is difficult to make on account of 
 the meat containing so much fat. 
 
 Chicken Broth (U. S. Army Hospital Receipt for Tzvehe Men). — 
 Chicken, one ; salt, two ounces ; flour, two ounces. 
 
 Directions. — Cut the chicken into pieces. Put it with the salt into 
 the kettle with twelve pints of cold water. Let it simmer gently 
 two or three hours, carefully and frequently skimming off the grease. 
 Make a paste of the flour with some cold water ; stir it in and boil 
 ten minutes longer. It should measure ten pints when done. 
 
 Mutton Broth (U. S. Army Hospital Receipt for Twelve Men).— 
 Mutton, six pounds ; salt, two ounces ; rice, two ounces. 
 
804 APPENDIX 
 
 Directions. — Break the bones without separating the meat. Put 
 it into twelve pints of cold water, with the salt and rice or barley. 
 Boil gently two hours and a half, carefully removing all the scum 
 and fat. If the broth should boil away too much, add the requisite 
 quantity of boiling water to make twelve pints, and let it boil fifteen 
 minutes longer. 
 
 Invalid Broths. — To one pound of chopped lean meat, either 
 chicken, mutton, or beef, add one pint of cold water (or one pint 
 and a half on ice for a young infant), let stand in a covered glass 
 fruit jar for four to six hours, cook for three hours in a closed jar 
 over a slow fire, strain, cool, skim off the fat, clear with egg, season, 
 and feed warm or cold. 
 
 Bouillon (Broth) as used in the Hospitals of Paris (Yea), — Raw 
 meat, without bone, one kilogramme ; fresh vegetables, four hun- 
 dred grammes (about one pound) ; salt, ten grammes (about one 
 hundred and fifty grains). Boil very slowly over a gentle fire. 
 
 Nourishing Soup (Ringer). — Stew two ounces of the best well- 
 washed sago in a pint of water till it is quite tender and very thick ; 
 then mix it with half a pint of good boiling cream and the yolks of 
 two fresh eggs. Blend the whole carefully with one quart of essence 
 of beef. The beef essence must be heated separately, and mixed 
 while both mixtures are hot. A little of this may be warmed at a 
 time. 
 
 Consomme. — Consomme may be flavoured with vegetable extracts 
 or expressed juice of vegetables boiled in it. Thicken soups with 
 arrowroot, ground rice, or cornflour. 
 
 Beef Tea with Oatmeal (Anderson). — This forms a very nutritious 
 food. Take two tablespoonfuls of oatmeal and two of cold water 
 and mix them thoroughly ; then add a pint of good beef tea which 
 has just been brought to the boiling point. Boil together for five 
 minutes, stirring it well all the time, and strain through a hair 
 sieve. 
 
 SOLID MEAT PREPARATIONS 
 
 Raw-meat Diet (Ringer). — From two ounces of rump steak take 
 away all fat, cut into small squares without entirely separating the 
 meat, place in a mortar, and pound for five or ten minutes ; then add 
 three or four tablespoonfuls of water and pound again for a short 
 time, afterwards removing all sinew or fibre ; add salt to taste. Be- 
 fore using, place the cup or jar containing the pounded meat in 
 hot water until just warm. 
 
 Or scrape the beefsteak with a sharp knife and, after removing 
 all fat and tendon, if not already in a complete pulp, pound in a 
 mortar. Flavour with salt and pepper. This may be taken in the 
 form of a sandwich between thin bread and butter or mixed with 
 water to the consistence of cream. If preferred, the meat may be 
 
SOLID MEAT PREPARATIONS 805 
 
 rolled into balls with a little white of egg and broiled for two min- 
 utes, or until the outside turns gray — just long enough to remove 
 the raw taste. 
 
 This diet is excellent for children with diarrhoea, also for adults 
 who suffer from irritable bowels or chronic diarrhoea. 
 
 Scraped Beef (U. S. Army Hospitals). — Cut a piece of steak 
 from the round, about half a pound in weight and about an 
 inch thick. Lay it on a clean meat board and with a dull knife 
 scrape out the pulp until there is nothing left but stringy fibre. 
 Season the scraped pulp with salt and make it into small cakes. 
 Broil for two minutes either by direct heat over a clear fire, or by 
 heating a clean pan or plate and, when hot, placing the meat on it. 
 Have both sides cooked sufficiently. This is a safe food for a patient 
 beginning to take solid nourishment. Scraped beef may be prepared 
 very easily over an alcohol lamp. 
 
 Scraped-beef Sandwiches (U. S. Army Hospitals). — Place a piece 
 of round steak on a meat board and scrape out all of the pulp with 
 a dull knife ; add to the pulp a little salt and pepper and enough 
 raw beef juice to make it into a firm jelly. Have stale bread cut 
 into very thin slices and spread the beef pulp on them; cut the 
 sandwiches quite small. Never use butter in making beef sand- 
 wiches. 
 
 Meat Biscuits (Parkes). — Mix together, cook, and bake one 
 pound of flour, one pound of meat, one quarter of a pound of suet, 
 one half pound potatoes with a little sugar, onion, salt, pepper, and 
 spices. A palatable meat biscuit, weighing about one pound and a 
 quarter, containing 10 to 12 per cent of water, is thus obtained which 
 keeps quite unchanged for four months. 
 
 Raw-meat Sandwiches (from Food). — Three ounces of raw beef 
 or mutton, one ounce of very fine bread crumbs, one teaspoonful 
 of sugar ; cut the meat very fine, rub it through a hair sieve, then 
 pound it in a mortar into a paste. Mix with it the bread crumbs, 
 sugar, a little salt and pepper ; spread it between thin slices of either 
 brown or white bread and butter. 
 
 Chicken Jelly (Adams). — Clean a fowl that is about a year old, 
 remove skin and fat ; chop fine, bones and flesh, place in pan with 
 two quarts of water ; heat slowly ; skim thoroughly ; simmer five to 
 six hours ; add salt, mace, or parsley to taste, strain ; cool. When 
 cool, skim off the fat. 
 
 The jelly is usually relished cold, but may be heated. Give often 
 in small quantities. 
 
 Enema of Meat and Pancreas (Lcubc). — Mince from one hundred 
 and fifty to three hundred grammes of meat, and mix with fifty to 
 one hundred grammes of finely chopped pancreas, free from fat. 
 Beat the mixture into a paste with a pestle or spoon, adding a little 
 lukewarm water to make it of a suitable consistence for injection 
 
806 APPENDIX 
 
 through the enema tube. Use warm ; if cold it may excite the rec- 
 tum and cause expulsion. If thought desirable, from twenty-five to 
 fifty grammes o£ fat may be mixed intimately with the mass by 
 the help of a warm pestle. A syringe with a wide nozzle must 
 be used. 
 
 MILK PREPARATIONS 
 
 Milk-and-cinnamon Drink (Ringer). — Boil in one pint of new 
 milk sufficient cinnamon to flavour it pleasantly, and sweeten with 
 white sugar. This may be taken cold with a teaspoonful of brandy, 
 and is very good in cases of diarrhoea. Children may take it warm 
 without brandy. 
 
 Albuminised Milk (U. S. Army Hospitals). — Beat up the white of 
 an egg till light. Add a good-sized pinch of salt, and four ounces 
 of fresh, cool milk which has been sterilised. A little sugar may 
 be added if desired. 
 
 Milk Punch. — Make by adding brandy or whisky or rum to milk 
 in the proportion of about one to four or six parts of milk ; flavour 
 with sugar and nutmeg ; shake well. 
 
 Sherry or Brandy and Milk (Ringer). — To one tablespoonful of 
 brandy or one wineglassful of sherry, in a bowl or cup, add pow- 
 dered sugar and a very little nutmeg to taste. Warm a breakfast 
 cupful of new milk and pour into a pitcher. Pour the contents from 
 a height over the wine, sugar, etc. The milk must not boil. 
 
 Rum and Milk (F other gill). — Half a pint of new milk, one egg, 
 one to two teaspoonfuls of powdered sugar, grated nutmeg, one to 
 two teaspoonfuls of good old Jamaica rum. Mix. 
 
 Junket (Anderson). — Sweeten with white sugar one pint of good 
 milk. If wine is allowed, a dessertspoonful of sherry is an improve- 
 ment. Heat to new milk warmth, pour into a shallow dish, and stir 
 in two teaspoonfuls of essence of rennet. This will form a slight 
 curd. Grate a little nutmeg over it or add a pinch of powdered 
 cinnamon. Serve when quite cold. In cold weather the milk should 
 be placed in a warm room to set. An excellent food, and good sub- 
 stitute for milk in typhoid fever, etc. 
 
 Artificial Human Milk (Frankland). — Allow one third of a pint 
 of new milk to stand twelve hours, remove the cream, and mix it 
 with two thirds of a pint of perfectly fresh cow's milk. Take the 
 milk from which the cream was removed and put a piece of rennet 
 about an inch square (fluid rennet may be employed) into it. Keep 
 the vessel containing it in a warm place until the milk is fully 
 curdled, an operation requiring five to fifteen minutes, according 
 to the activity of the rennet, which should be removed as soon 
 as the curdling commences, and put into an eggcup for use on 
 subsequent occasions, as it may be employed daily for a month or 
 two. Break up the curd repeatedly, and carefully separate the whole 
 
EGG PREPARATIONS 807 
 
 of the whey, which should then be rapidly heated to boiling in a 
 small tin pan, placed over a spirit or gas lamp. During the heating 
 a further quantity of casein [albumin?], technically called " fleet- 
 ings," separates, and must be removed by straining through clean 
 muslin. Now dissolve one hundred and ten grains of powdered 
 sugar of milk in the hot whey, and mix it with two thirds of a pint 
 of new milk to which the cream from the other fluid has already 
 been added, as already described. The artificial milk should be used 
 within twelve hours of its preparation. 
 
 Biedert's Cream Mixture. — Mix four ounces of cream with twelve 
 ounces of warm water and add one half ounce of milk sugar. 
 
 Koumiss (Anderson).— -To one pint of new milk add three ounces 
 of water, three ounces of old koumiss (for a ferment), and one ounce 
 of saturated solution of sugar of milk. Put all in a large jug, cover 
 carefully, and set the jug in a warm place for twenty-four hours. 
 By that time a thick crust will have formed on the surface of the 
 mixture ; beat this up thoroughly and mix all well. Then put the 
 whole into champagne bottles, which should be no more than two 
 thirds full, and cork and wire. Shake the bottles daily. The kou- 
 miss will be fit for use in two days, but it is much improved by 
 keeping for about six weeks. It should be drawn off with a tap. 
 
 Home-made Koumiss. — Boil fresh milk, and when nearly cold 
 put into quart bottles, leaving room to shake. Add half an ounce 
 of crushed lump sugar and a piece of Vienna yeast the size of a 
 hazel nut (i. e., twenty grains), cork with new corks, tie down, keep 
 cool, lay the bottles horizontal, but shake twice daily. Ready to 
 drink on sixth day, or earlier in hot, later in cold weather. 
 
 The koumiss can be made thinner by using skimmed milk. 
 
 Home-made Lime Water. — Pour two quarts of hot water over 
 fresh, unslacked lime (size of a walnut), stir till slacked, let stand 
 till clear and bottle. Often ordered with milk to neutralise acidity 
 of the stomach. 
 
 EGG PREPARATIONS 
 
 Eggnog. — Eggnog is made by adding the beaten yolk of egg and 
 a little spirits to a tumblerful of milk, stirring well, adding sugar and 
 the white of the egg, separately beaten. The digestibility of both of 
 these highly nourishing and stimulating preparations is enhanced by 
 the addition of half an ounce of lime water, which does not affect 
 the taste. 
 
 Egg and Wine (Ringer). — Take one egg, half a glass of cold 
 water, one glass of sherry, sugar, and a very little nutmeg grated. 
 
 Beat the egg to a froth with a tablespoonful of cold water. Make 
 the wine and water hot, but not boiling ; pour on the egg, stirring 
 all the time. Add sufficient sugar to sweeten, and a very little nut- 
 meg. Put all into a porcelain-lined saucepan over a gentle fire and 
 53 
 
808 APPENDIX 
 
 stir one way till it thickens, but do not let it boil Serve in a glass 
 with crisp biscuits or sippets of toast. 
 
 Eggnog (Bartholow). — Scald some new milk by putting it, con- 
 tained in a jug, into a saucepan of boiling water, but it must not be 
 allowed to boil. When quite cold beat up an egg with a fork in a 
 tumbler with some sugar ; beat quite to a froth ; add a dessertspoon- 
 ful of brandy and fill up the tumbler with scalded milk. A nutritive 
 drink in acute disease. 
 
 Brandy and Egg Mixture (British Pharmacopoeia). — Rub together 
 the yolks of two eggs and half an ounce of refined sugar, and add 
 four ounces of Cognac and four ounces of cinnamon water. A more 
 generally useful mixture may be made with half this quantity of 
 brandy. 
 
 Stokes's Cognac Mixture. — Best Cognac, distilled water, each 
 fifteen ounces ; yolk of one egg ; sirup, six ounces. Mix. Give a 
 tablespoonful every two or three hours. 
 
 Egg and Brandy Mixture (Anderson). — Beat up three eggs to 
 a froth in four ounces of cold w 7 ater and then add four ounces of 
 brandy. Mix well and sweeten to taste. A little nutmeg may be 
 added. Give a tablespoonful or so at a time. 
 
 Lemonade with Eggs (Ringer). — The juice of four lemons, the 
 rinds of two, half a pint of sherry, four eggs, six ounces of loaf 
 sugar, one pint and a half of boiling water. 
 
 Pare the lemon rind thinly, put it into a pitcher with the sugar, 
 and pour the boiling water on it. Let it cool, then strain, and add 
 the wine, lemon juice, and eggs, previously well beaten and strained. 
 Mix all together and it is ready for use. 
 
 Savoury Custard (Anderson). — Add the yolks of two eggs to a 
 cupful of beef tea, with pepper and salt to taste. Butter a cup or 
 jam pot, pour the mixture into it, and let it stand in a pan of boiling 
 water till the custard is set. 
 
 Milk for Puddings or Stewed Fruit (Ringer). — Boil a strip of 
 lemon and two cloves in a pint of milk ; mix half a teaspoonful of 
 arrow 7 root in a little cold milk and add it to the boiling milk ; stir it 
 until about the consistence of cream. Have ready the yolks of 
 three eggs beaten up well in a little milk. Take the hot milk off 
 the fire and as it cools add the eggs and a tablespoonful of orange- 
 flower water, stirring it constantly till quite cool. Keep it in a very 
 cool place till required for use. 
 
 Rice Soup (Ringer). — Take three ounces of rice, the yolks of two 
 eggs, half a pint of cream or new milk, one quart of stock. 
 
 Boil the rice in the stock and rub half of it through a tammy, 
 put the stock in a stewpan, add the rest of the rice whole, and sim- 
 mer gently for five minutes. Have ready the milk or cream, boiled. 
 Beat the yolks of the eggs and mix them gradually with the cream. 
 Take the soup off the fire, add the cream and egg, stirring them well 
 
FARINACEOUS FOODS 809 
 
 together as you mix them. Heat gradually, but do not boil, or the 
 eggs will curdle. 
 
 A Gruel (Ringer). — Beat an egg to a froth, add a wineglass of 
 sherry, flavour with a lump of sugar, a strip of lemon peel, and a 
 little grated nutmeg. Have ready some gruel, very smooth and hot, 
 stir in the wine and egg, and serve with crisp toast. Arrowroot may 
 be made in the same way. 
 
 Caudle (Yco). — Beat up an egg to a froth ; add a glass of sherry 
 and half a pint of gruel. Flavour with a lemon peel, nutmeg, and 
 sugar. 
 
 FARINACEOUS FOODS 
 
 Arrowroot Blancmange (Ringer). — Take two tablespoonfuls of 
 arrowroot, three quarters of a pint of milk, lemon, and sugar to 
 taste. 
 
 Mix the arrowroot with a little milk to a smooth batter ; put the 
 rest of the milk on the fire and let it boil, sweeten, and flavour it, 
 stirring all the time, till it thickens sufficiently. Put into a mould 
 till quite cold. 
 
 Arrowroot Blancmange (U. S. Army Hospitals). — Two table- 
 spoonfuls of arrowroot. Two thirds pint of hot water. Two table- 
 spoonfuls of sherry or brandy. Two teaspoonfuls of sugar. 
 
 Mix the arrowroot into a smooth paste with three tablespoonfuls 
 of cold water. Add this to the hot water. Bring to a boil, stirring 
 constantly till well blended and free from lumps. Let boil for ten 
 minutes. Add the sugar and sherry or brandy. Beat up quickly 
 and pour into a bowl or mould to cool. Arrowroot blancmange may 
 be made with fresh hot milk or condensed milk diluted. If boiling 
 water is used it causes the starch of the arrowroot, when first poured 
 in, to form into lumps. Hence it is best to have the water not quite 
 at boiling point. 
 
 Arrowroot (Pavy). — Mix thoroughly two teaspoonfuls of arrow- 
 root with three tablespoonfuls of cold water, and pour on them half 
 a pint of boiling water, stirring well meanwhile. If the water is quite 
 boiling, the arrowroot thickens as it is poured on, and nothing more 
 is necessary. If only warm water is used, the arrowroot must be 
 afterwards boiled until it thickens. Sweeten with loaf sugar and 
 flavour with lemon peel or nutmeg, or add sherry, port wine, or 
 brandy, if required. Boiling milk may be employed instead of water, 
 but when this is done no wine must be added, as it would otherwise 
 curdle. 
 
 Oatmeal Gruel (plain) (from Food). — Two tablespoonfuls of oat- 
 meal, one saltspoonful of salt, one scant teaspoonful of sugar, one 
 cupful of boiling water, one cupful of milk. Mix the oatmeal, salt, 
 and sugar together, and pour on the boiling water. Cook for thirty 
 minutes ; then strain through a fine wire strainer to remove the hulls, 
 
8lO APPENDIX 
 
 place again on the stove, add the milk, and heat just to the boiling 
 point. Serve hot. 
 
 Scotch Beef Broth. — To a pint of beef broth which has been care- 
 fully strained and seasoned and from which all the fat has been 
 removed, add a teaspoonful of oatmeal and boil gently for two hours. 
 Strain and serve hot. 
 
 In this preparation the oatmeal should be soft and jellylike, and 
 if too much water evaporates during the boiling, more should be 
 added. 
 
 Cornstarch (U. S. Army Hospital Receipt for Twelve Men). — 
 Cornstarch, six ounces ; milk, three pints ; water, twelve ounces. 
 
 Directions. — Mix the cornstarch into a smooth paste with 
 cold water. The milk and water must be boiling, to which add 
 a little salt. Stir in the cornstarch. Let it boil three or five 
 minutes. 
 
 Farina Pudding (U. S. Army Hospital Receipt for Twelve Men). — 
 Farina, half a pound ; milk, two pints ; water, one pint ; sugar, two 
 and a half ounces ; eggs, four ounces ; nutmeg, half an ounce. 
 
 Directions. — Put the water into a stewpan with a little salt. When 
 it boils, stir in the farina. Let it boil twenty minutes. Stir in the 
 milk, which must be hot. Beat the eggs until they are very light ; 
 mix the sugar with them. Stir in the eggs and sugar with the 
 farina. Add the spice. Put it into a moderate oven and bake a half 
 or three quarters of an hour. 
 
 Farina Gruel (U. S. Army Hospitals). — One tablespoonful of 
 farina. One pint of water. One teaspoonful of sugar. One half 
 teaspoonful of salt. Into one pint of water, raised to boiling, put 
 a half teaspoonful of salt ; then add the farina and cook for twenty 
 minutes. Flavour with sugar and condensed milk, if fresh milk is 
 not available. Strain and serve hot. 
 
 In this recipe, as in others, condensed milk is used in a strength 
 of one teaspoonful to the half pint of gruel. 
 
 Boiled Rice (U. S. Army Hospital Receipt for Twelve Men). — 
 Rice, twelve ounces ; salt, half an ounce ; water, three pints. 
 
 Directions. — Put the salt and water into a stewpan. When boil- 
 ing, add the rice, previously thoroughly washed. Boil for ten min- 
 utes, or until each grain becomes soft. Drain it on a colander. 
 Grease the stewpan with clarified drippings or lard. Put back the 
 rice. Let it swell slowly near the fire, or in a slow oven, for about 
 twenty minutes, until the grains are well separated. 
 
 Rice Gruel (Chambers). — Ground rice, two ounces ; powdered cin- 
 namon, quarter of an ounce ; water, four pints. Boil forty minutes 
 and add a teaspoonful of orange marmalade. 
 
 Rice Gruel (U. S. Army Hospitals). — Two tablespoonfuls of rice, 
 or one tablespoonful of rice flour. One pint of boiling water. One 
 half teaspoonful of salt. One teaspoonful of sugar. Wash the rice 
 
FARINACEOUS FOODS 8ll 
 
 thoroughly in two waters, after removing any specks that may be 
 mixed in the grain. Have the cooking water boiling. 
 
 Rice Milk (Anderson). — Wash two tablespoonfuls of good rice 
 and put it into a saucepan with a quart of milk. Let it simmer 
 gently till the rice is tender, and stir from time to time to prevent 
 burning; sweeten to taste. If desirable, serve with stewed apples 
 or prunes. Sago, tapioca, etc., are prepared in the same way. If 
 an egg is to be added, beat the white and yolk separately, and add 
 them to the rice after it has been taken from the fire. 
 
 Rice and Apple (Ringer). — Boil about two tablespoonfuls of rice 
 in a pint and a half of new milk, and simmer, stirring it from time 
 to time till the rice is quite tender. Have ready some apples, 
 peeled, cored, and stewed to a pulp, and sweetened with a very 
 little loaf sugar. Put the rice round a plate and the apple in the 
 middle, and serve. 
 
 Rice Cream (Ringer). — To a pint of new milk add a quarter of 
 a pound of rice, a lump of butter the size of a walnut, a little lemon 
 peel, and a tablespoonful of powdered sugar. Boil them together 
 for five minutes, then add half an ounce of isinglass which has been 
 dissolved, and let the mixture cool. When cool add half a pint of 
 good cream whisked to a froth, mix together, and set it for a time 
 in a very cool place, or on ice ; when used, turn it out of the basin 
 into a dish, and pour fruit juice around it, or some stewed apple or 
 pear may be served with it. 
 
 Rice Cream (from Food, January, 1894). — Two tablespoonfuls of 
 rice. Two cups of milk. One saltspoonful of salt. Two table- 
 spoonfuls of sugar. Two eggs. 
 
 Cleanse the rice by washing it several times in cold water ; cook 
 it in a double boiler with the milk until the grains will mash. Three 
 hours will generally be required to do this. Should the milk evap- 
 orate, restore the amount lost. When the rice is perfectly soft, 
 press it through a coarse soup strainer or colander into a saucepan, 
 return it to the fire, and while it is heating beat the eggs, sugar, 
 and salt together until very light. When the rice boils, pour the 
 eggs in rather slowly, stirring lightly with a spoon for three or four 
 minutes, or until it coagulates, and the whole is like a thick, soft 
 pudding; then remove from the fire, and pour it into a dish. By 
 omitting the yolks and using the whites of the eggs only, a delicate 
 cream is obtained. 
 
 Malt (Ground) and Rice Pudding (Yeo). — Stir an ounce of ground 
 malt into a pint of boiling milk, strain through a sieve, and add 
 the milk to two ounces of well-soaked rice. Mix well, and stand 
 for ten minutes in a warm place, then bake for an hour. 
 
 Cracker Gruel (from Food, January, 1894). — Two tablespoonfuls 
 of cracker crumbs. One scant saltspoonful of salt. One scant tea- 
 spoonful of sugar. One cup of boiling water. One cup of milk. 
 
812 APPENDIX 
 
 To make the cracker crumbs, roll some crackers on a board until' 
 they are fine. Water crackers are good, cream crackers are better ; 
 mix the salt and sugar with the crumbs, pour on the boiling water, 
 put in the milk, and simmer it for two minutes. The gruel does 
 not need long cooking, for the cracker crumbs are already thor- 
 oughly cooked. Do not strain. 
 
 Indian-meal Gruel (from Food, January, 1894). — Two teaspoon- 
 fuls of cornmeal. One tablespoonful of flour. One teaspoonful of 
 salt. One teaspoonful of sugar. One quart of boiling water. One 
 cup of milk. 
 
 Mix the cornmeal, flour, salt, and sugar into a thin paste with 
 cold water, and pour into it the boiling water. Cook it in a double 
 boiler for three hours. No less time than that will cook the corn- 
 meal thoroughly. Then add the milk, and it is ready to serve. 
 
 Hard-bread Gruel (U. S. Army Hospitals). — Toast hard bread 
 thoroughly and grind it into a powder. To one pint of boiling water, 
 to which one half teaspoonful of salt has been added, add two 
 tablespoonfuls of hard-bread powder. Boil ten minutes and then 
 strain. Flavour with one teaspoonful of sugar and one teaspoonful 
 of condensed milk to each cupful of the gruel. 
 
 Bread Jelly (Chrystie). — Pour boiling water on stale bread, and 
 let it soak for an hour. Pour off the water, add fresh water, and 
 boil down until a thick mass is obtained which becomes jellylike 
 on cooling, and may be eaten with milk or cream and sugar. 
 
 Milk Porridge (U. S. Army Hospital Receipt for Ttvelve Men). — 
 Milk, eight pints ; flour, twelve ounces ; water, three pints. 
 
 Directions. — The flour to be used for milk porridge should be 
 previously prepared by being tied up closely in a bag and boiled 
 four or five hours. It can then be grated to powder, which should 
 be mixed into a smooth paste with cold water. Add to the milk 
 the prescribed quantity of water, and stir in the flour, with a little 
 salt. Let it boil ten minutes, stirring all the time. 
 
 Fothergill's Amylaceous Food. — Of rice, well washed, of arrow- 
 root, tapioca, and pearl barley, take each an ounce, add two quarts 
 of water, and boil down to a quart ; then flavour with candied eringo. 
 
 Barley Jelly (Eustace Smith). — Put two tablespoonfuls of washed 
 pearl barley into a pint and a half of water, and slowly boil down 
 to a pint; strain, and let the liquid settle into a jelly. Two tea- 
 spoonfuls of this, dissolved in eight ounces of warmed and sweet- 
 ened milk, are enough for a single feeding, and such a meal may be 
 allowed twice a day. 
 
 Panada (Ringer). — Take the crumb of a penny roll and soak 
 it in milk for half an hour, then squeeze the milk from it ; have 
 ready an equal quantity of chicken or veal, scraped very fine with 
 a knife ; pound the bread crumb and meat together in a mortar. 
 It may be cooked either mixed with veal or chicken broth, or 
 
GELATIN PREPARATIONS 813 
 
 poached like an egg. By taking it up in two spoons, in pieces 
 the shape of an egg, after seasoning, it may be served with mashed 
 potato. 
 
 Another Caudle (Ringer). — Mix well together one pint of cold 
 gruel with a wineglassful each of good cream and sherry and a 
 tablespoonful of noyau, and sweeten with sugar candy. 
 
 Almond Cakes for Diabetics (See gen). — Take of blanched, sweet 
 almonds a quarter of a pound, beat them as fine as possible in a 
 stone mortar; remove the sugar contained in this meal by putting 
 it into a linen bag and steeping it for a quarter of an hour in boiling 
 water acidulated with vinegar ; mix this paste thoroughly with three 
 ounces of butter and two eggs. Next add the yolks of three eggs 
 and a little salt, and stir well for some time. Whip up the whites 
 of three eggs and stir in. Put the dough thus obtained into greased 
 moulds, and dry by a slow fire. 
 
 Macaroni Boiled (U. S. Army Hospital Receipt for Twelve Men). 
 — Macaroni, one pound ; salt, a quarter of an ounce ; boiling water, 
 six pints. 
 
 Directions. — Wipe the macaroni carefully. Break into four-inch 
 lengths. Put with the salt into cold water and boil until tender, but 
 not until it bursts or becomes a pulp. Drain off the water at once, 
 and season with butter. The liquor from the macaroni makes a 
 good broth. 
 
 GELATIN PREPARATIONS 
 
 Port-wine Jelly (Ringer). — Put into a jar one pint of port wine, 
 two ounces of gum arabic, two ounces of isinglass, two ounces of 
 powdered white sugar candy, a quarter of a nutmeg grated fine, 
 and a small piece of cinnamon. Let this stand closely covered all 
 night. The next day put the jar into boiling water and let it simmer 
 until all is dissolved, then strain, let stand till cold, and then cut into 
 small pieces for use. 
 
 Milk, Rum, and Isinglass (Ringer). — Dissolve in a little hot water 
 over the fire a pinch of the best isinglass ; let it cool, and mix a 
 dessertspoonful of rum with it in a tumbler, and fill up the glass 
 with new milk. 
 
 Nutritious Coffee (Ringer). — Dissolve a little isinglass in water, 
 then put half an ounce of freshly ground coffee into a saucepan with 
 one pint of new milk, which should be nearly boiling before the 
 coffee is added ; boil both together for three minutes ; clear it by 
 pouring some of it into a cup and dashing it back again, add the 
 isinglass, and leave it to settle on the hob for a few minutes. Beat 
 up an egg in a breakfast cup, and pour the coffee upon it ; if pre- 
 ferred, drink it without the egg. 
 
 Lemon Jelly (U. S. Army Hospitals). — One fourth box of gelatin 
 (one half ounce). One fourth cup of cold water. One fourth cup 
 
8 14 APPENDIX 
 
 of fresh lemon juice (about the amount yielded by two lemons). 
 Three tablespoonfuls of sugar. One and one fourth cups of boiling 
 water. Put the gelatin to soak in the cold water, about twenty 
 minutes being required for this process. When dissolved, pour on 
 the boiling water. Add the lemon juice and sugar. Stir thoroughly 
 and strain through a fine-meshed cloth into a china or granite-ware 
 mould, cooling in a refrigerator or by placing in a pan of cold water. 
 Never use tin moulds for lemon jelly. 
 
 Coffee Jelly (U. S. Army Hospitals). — One fourth box of gela- 
 tin (one half ounce). One fourth cup of cold water. One cup of 
 boiling water. One half cup of strong coffee. Two tablespoonfuls 
 of sugar. Soak the gelatin in the cold water for half an hour. Pour 
 on the boiling water, then put in the sugar and coffee. Strain it 
 through a cloth into a mould or dish in which it may be cooled, 
 either in a pan of iced water or in a refrigerator. Coffee jelly may 
 be served with cream and sugar. 
 
 Have the coffee strong, two tablespoonfuls of coffee to each cup 
 of water. Where vanilla extract is available, one half teaspoonful 
 will be advantageously added to the above recipe. 
 
 Wine Jelly (U. S. Army Hospitals). — One fourth box of gelatin 
 (one half ounce). One fourth cup of cold water. One half cup of 
 sugar. One half cup of sherry wine. One and one fourth cup of 
 boiling water. One small piece of cinnamon. Put the gelatin and 
 cold water together in a dish large enough to hold the whole mix- 
 ture. Let it soak for half an hour, then pour the boiling water (in 
 which the piece of cinnamon has been simmering) over the softened 
 gelatin. Add the sugar and wine, strain through a clean cloth into a 
 china or granite-ware mould, and cool in a refrigerator or a pan 
 of cold water. 
 
INDEX 
 
 Abnormal cravings, 328. 
 
 Abnormalities of digestion, 349. 
 
 Abscess of liver, 588. 
 
 Absinthe, 252. 
 
 Absorption of food, 358. 
 
 Absorptive power of stomach, 521. 
 
 Acid, hydrochloric, 517; lactic, 54; 
 salicylic, in food, 281; salts, 518. 
 
 Acids, 174; fatty, in cod-liver oil, 
 200; in fruits, 174; vegetable, 48. 
 
 Acidulous waters, 210. 
 
 Acne, 616. 
 
 Adams's dietary for young children, 
 768. 
 
 Addison's disease, 692. 
 
 Adult life, food for, 307. 
 
 Adulteration of cocoa, 223; of coffee, 
 219; of food, 381; of liquors, 251; 
 of milk, 61-63; of wines, 251. 
 
 Aerated bread, 140. 
 
 Age and food, 15, 284, 306. 
 
 Albumin, 23; of egg, 102, 103; of 
 milk, 54; vegetable, 349. 
 
 Albuminoids, 349. 
 
 Albuminuria, 492; functional, 493. 
 
 Albumoses, 345, 349. 
 
 Alcohol, 225; absorption, 232; action 
 upon circulation, 229; action upon 
 gastric digestion, 231; action upon 
 mucous membranes, 231; action 
 upon muscles, 230; action upon 
 temperature, 230; and tuberculosis, 
 460; antipyretic action, 236; as a 
 diuretic, 231; as food, 9, 228; as a 
 heart stimulant, 235; as a stimulant, 
 229; as a tonic, 234; climate and, 
 233; clinical uses, 234; consump- 
 tion of, 239; elimination, 233; do- 
 sage, 233; force value of, 226; in 
 fevers, 236, 421-423, 431; in gout, 
 650; hypodermic use, 233; in ner- 
 vous diseases, 236; physiological 
 action, 228; poisoning, 392; in ty- 
 phoid fever, 431; value of, 225-228. 
 
 Alcoholic beverages, 238. 
 
 Alcoholism, 392. 
 
 Ale, 241. 
 
 Alimentary canal, 507; pastes, 152. 
 
 Alkaline purges, 208. 
 
 Allspice, 256. 
 
 Almond cakes, 678; oil, 198. 
 
 Almonds, 190. 
 
 Alum and food, 281. 
 
 Amphoper tones, 355. 
 
 Amylaceous food, 812. 
 
 Anaemia, 484; alcohol in, 237; bone 
 marrow for, 196; pernicious, 489. 
 
 Anaesthetics and food, 695. 
 
 Analysis, chemical, of a man, 2; of 
 liqueurs, 252; of milk, 58. 
 
 Aneurism, 482; Tufnell's diet for, 483. 
 
 Angina pectoris, 482. 
 
 Angiocholitis, 584. 
 
 Angostura, 252. 
 
 Animal food, 4; force production 
 and, 32; muscular labour and. 33; 
 urea and, 32; vegetable and, com- 
 pared, 29-35; viscera, 121. 
 
 Anise, 252. 
 
 " Anti-fat," 637. 
 
 Antiseptic preservatives, 281. 
 
 Apollinaris, 208. 
 
 Apoplexy, 609. 
 
 Appendicitis, 578. 
 
 Appetite, 327, 397. 
 
 Apple sauce, 181. 
 
 Apples, 180. 
 
 Apricots, 181. 
 
 Arabs, diet of, 321. 
 
 Arctic diet, 293-296, 318. 
 
 Argol. 243. 
 
 Army hospital dietaries, 793. 
 
 Army prison dietaries, 713. 
 
 Army ration, 14, 700; Austrian, 707. 
 708; British, 707, 708; foreign, 707: 
 French, 707, 709; German, 707, 709; 
 Italian, 709; Russian, 709; Spanish, 
 708; United States, 705. 
 815 
 
8i6 
 
 INDEX 
 
 Aromatic herbs, 254. 
 Arrack, 250. 
 Arrowroot, 157, 809. 
 Arterio-sclerosis, 482. 
 Arthritis deformans, 640. 
 Artichokes, 171; Jerusalem, 167. 
 Artificial digestion, 352. 
 Ascaris, 369. 
 Ascites, 585. 
 Asitia, 297. 
 Asparagus, 172. 
 Asses' milk, 58. 
 Asthma, 470. 
 
 Atheroma and vegetarianism, 36. 
 Athletes, diet for, 727. 
 Atwater's calorimeter, 10. 
 Austrian army ration, 707. 
 
 Bacillus acidi lactici, 67. 
 
 Bacon, 120. 
 
 Bacteria in diarrhceal stools, 556. 
 
 Bacterium cyanogenum, 67. 
 
 Bacterium synxanthum, 67. 
 
 Baking, 268; powders, 139. 
 
 Balfour's diet for senile heart, 480. 
 
 Banana flour, 183, 184; meal, 183. 
 
 Bananas, 182. 
 
 Banting system, 626. 
 
 Barley, 155; water, 155. 
 
 Bauer's standard diet, 286. 
 
 Bavarian beer, 241. 
 
 Beans, 164; kidney, 164; red, 164; 
 soy, 164; vanilla, 257. 
 
 Beaujolais, 249. 
 
 Beechnuts. 191. 
 
 Beef, 109; blood, 112: broth, 116; 
 chipped, no; concentrated, no; 
 corned. 276; embalmed, 282; es- 
 sence. 803; extracts, no, in, 802; 
 fat, 196; jelly, in; juice, 114; meal, 
 in; peptones, 117; peptonoids, 
 113; powdered, 112; preparations, 
 fluids, 801 ; preparations for the 
 sick, no; preservation, 276; refrig- 
 eration, 276; smoked, 275; tea, 114- 
 116, 801, 802; tongue, 119. 
 
 Beer, 239; brewing, 240; composi- 
 tion of, 239. 
 
 Beet, 167; sugar, 129. 
 
 Bellevue Hospital dietaries, 781. 
 
 Benger's food, 149; peptonised beef 
 jelly, in. 
 
 Beri-beri, 608. 
 
 Berries, 186. 
 
 Beverages, 205; demulcent, 799; diu- 
 retic, 800; in fevers, 420; nutritive, 
 
 799; receipts for, 799; refrigerant, 
 800. 
 
 Bicycle-racers' diet, 734. 
 
 Bicycling and digestion, 337. 
 
 Bile, 351. 
 
 Biliousness, 366, 367, 580. 
 
 Birds' nests, 123. 
 
 Biscuits, 146; meat, 805; pilot, 151; 
 ship, 151. 
 
 Blackberries, 187. 
 
 Blair's wheat food, 146. 
 
 Blancmange, 809. 
 
 Blood, 122; for rectal feeding, 409. 
 
 Blueberries, 187. 
 
 Boas's test, 517. 
 
 Boat-crew dietary, 729, 731. 
 
 Boiled beef, 261; fish, 263; milk, 75. 
 
 Boiling, 261-263. 
 
 Bone marrow, 196. 
 
 Borax and food, 281. 
 
 Bordeaux wine, 248. 
 
 Boric acid and food, 281; in milk, 
 63- 
 
 Bottle feeding, 751. 
 
 Bouchard's system, 635. 
 
 Bouillon, 116, 804. 
 
 Bourbon whisky, 250. 
 
 Bovinine. 117. 
 
 Boys' school diet, 773. 
 
 Brain food, 330. 
 
 Brains, 122. 
 
 Brainworkers, diet for, 737-741. 
 
 Braising, 269. 
 
 Bran, 136; bread, 677. 
 
 Brandy, 250. 
 
 Brazil nuts, 191. 
 
 Bread, aerated, 140; baking, 137; 
 bran, 677; composition of, 137, 142; 
 compressed, 271; dried, 271; dia- 
 betic, 676; gluten, 145; Graham, 
 144; inulin, 678; jelly, 150; making, 
 135, I37-I4I; rice, 154; rye, 145; 
 spoiled, 141; soya, 152, 679; stuffs, 
 141; substitutes for, 675; whole 
 meal, 143. 
 
 Breast milk. See Human Milk, 55. 
 
 Brie, 99. 
 
 Bright's disease and milk, 73; acute, 
 490; chronic, 496. 
 
 British Army Hospital dietaries, 797. 
 
 British army ration, 707. 
 
 Broccoli, 170. 
 
 Broiling, 264. 
 
 Bronchitis, capillary, 469; chronic, 
 470. 
 
 Broncho-pneumonia, 474. 
 
INDEX 
 
 8l 7 
 
 Broth, chicken, 803; clam, 126; diet, 
 779; mutton, 119; veal, 119. 
 
 Broths, 803. 
 
 Buckwheat, 152. 
 
 Bulimia, 328, 526. 
 
 Burgundy, 248. 
 
 Butter, 96; adulterated, 96; analysis, 
 96; cocoa, 198, 222. 
 
 Butterine, 196. 
 
 Buttermilk, 97, 682; cure, 97. 
 
 Butternuts, 191. 
 
 Cabbages, 169. 
 
 Cacao butter, 198, 222. 
 
 Calcium, 47. 
 
 Calculi, biliary, 193; renal, 502; ves- 
 ical, 502. 
 
 Calorie, 12. 
 
 Calories of carbohydrates, 12; of fats, 
 12; of protein, 12. 
 
 Calorimeter, 9. 
 
 Calfs-foot jelly, 123. 
 
 Camembert, 99. 
 
 Cancer of the stomach, 550. 
 
 Candy, 130, 774. 
 
 Cane sugar, 129. 
 
 Canning, 278-281. 
 
 Capers, 256. 
 
 Capillary bronchitis, 469. 
 
 Capon, 121. 
 
 Capsicum, 255. 
 
 Caramel, 130. 
 
 Carbohydrates, 19, 21. 
 
 Carbon in food, 11, 16. 
 
 Carbonic-acid gas in bread, 137; wa- 
 ters, 208. 
 
 Carcinoma of oesophagus, 509; of 
 stomach, 550. 
 
 Carnrick's food, 150; soluble food, 92. 
 
 Caroid, 358. 
 
 Carrots, 168. 
 
 Casein, 54; vegetable, 163, 349. 
 
 Cassava, 157. 
 
 Catsup, 257. 
 
 Caudle, 813. 
 
 Cauliflower, 170. 
 
 Caviare, 125, 311. 
 
 Cayenne pepper, 255. 
 
 Celery, 171. 
 
 Cellulose, 13. 
 
 Centrifugal cream, 95. 
 
 Cepe, 189. 
 
 Cereals, 133. 
 
 Cerebro-spinal meningitis, 444. 
 
 Certified milk, 68. 
 
 Cetraria, 158. 
 
 Chalybeate waters, 210. 
 
 Chambers's system, '636. 
 
 Champagne, 247; Chartreuse, 252. 
 
 Cheddar, 100. 
 
 Cheese, 97; Brie, 99; Camembert, 
 99; cream, 98; Roquefort, 99; 
 Gorgonzola, 100; poisoning, 377. 
 
 Chervil, 171. 
 
 Chestnuts, 191. 
 
 Chicken, 121; broth, 803; jelly, 805. 
 
 Chicory, 171, 219. 
 
 Childhood and food, 306. 
 
 Children, dietaries for, 761-768; 
 starchy foods for, 158. 
 
 Children's hospital dietaries, 793. 
 
 Chilies, 255. 
 
 Chloride of sodium, 45. 
 
 Chlorosis, 484. 
 
 Chocolate, 223; habit, 223; prepara- 
 tion, 223. 
 
 Cholera, 446. 
 
 Cholera infantum, 558; infection and 
 food, 388; morbus, 560. 
 
 Chorea, 606. 
 
 Cider, 253. 
 
 Circulation and diabetes, 661 ; and di- 
 gestion, 332. 
 
 Circulatory system, 476. 
 
 Cirrhosis, 584. 
 
 Clams, 126. 
 
 Claret, 244, 248. 
 
 Classes of foods, 37. 
 
 Climate and alcohol, 2^3', and food, 
 284, 320. 
 
 Clothing and food, 284. 
 
 Clotted cream, 95. 
 
 Clouty cream, 67. 
 
 Cocoa, 221; adulteration of, 223; 
 composition of, 221. 
 
 Cocoanut oil, 198. 
 
 Cocoanuts, 191. 
 
 Codfish, 125. 
 
 Cod-liver oil, 199, 459; dosage, 200; 
 inunctions, 204; methods of ad- 
 ministration, 201; properties, 199; 
 substitutes for, 203; uses, 203; tu- 
 berculosis and, 459. 
 
 Coefficiency of foods, 25. 
 
 Coffee, 215; adulteration of, 219; and 
 tea compared, 220; composition of, 
 215; habit, 218; ill effects of, 218; 
 physiological action of, 217; prep- 
 aration of, 216; substitutes for, 220. 
 
 Cognac, 250. 
 
 Cole, 170. 
 
 Colitis, chronic, 561. 
 
8i8 
 
 INDEX 
 
 Colostrum, 64; human, 57. 
 Commercial life, diet in, 741. 
 Concentrated food, 270. 
 Condensed cream, 95; food, 270; 
 
 milk, 93. 
 Condiments, 253. 
 Confectionery, 130, 774. 
 Consomme, 804. 
 
 Constipation, chronic, 568; in chil- 
 dren, 576; in infants, 576; fruits for, 
 
 177. 
 Convalescence, diet in, 423, 799; in 
 
 typhoid fever, 434. 
 Cook County Hospital dietaries, 788. 
 Cooking, 259; varieties of, 260. 
 Corn, 153. 
 Cornaro's diet, 299. 
 Cornmeal, 154. 
 Cornstarch, 154. 
 Corpulency, 621. 
 Cost of foods, 26-28, 319. 
 Cottolene, 196. 
 Cottonseed oil, 198. 
 Crabs, 125. 
 Crackers, 142, 151. 
 Cranberries, 173. 
 Cream, 52, 94; centrifugal, 95; cheese, 
 
 98; clotted, 95; condensed, 95; 
 
 Devonshire, 95; estimation of, 60; 
 
 evaporated, 95; ice, 96; poisoning 
 
 by, 377; separator, 95. 
 Cream-of-tartar drink, 800. 
 Creamometer, 60. 
 Cress, 170. 
 Crimping, 125. 
 Crustaceans, 125. 
 Crystalose, 679. 
 Cucumbers, 171. 
 Cuisine, 196. 
 Curagoa, 252. 
 Cure, buttermilk, 97; dry, 726; fruit, 
 
 723; grape, 185, 724; koumiss, 82; 
 
 milk, 51, 719; rest, 600; whey, 101, 
 
 721. 
 Currants, 187; dried, 178. 
 Curry, 253. 
 Custard, 105. 
 
 Dahi, 388. 
 
 Dandelion roots, 170. 
 Darby's fluid meat, 112. 
 Dates, 188. 
 
 Decorticated flour, 145. 
 Delirium tremens, 395. 
 De Long expedition, 293. 
 Dementia, 610. 
 
 Demulcent beverages, 799. 
 
 Dentition, 507. 
 
 Dermatitis exfoliative, 620. 
 
 Desiccation, 270. 
 
 Deutero-albumose, 349. 
 
 Devonshire cream, 95. 
 
 Dextrin, 127. 
 
 Diabetes mellitus, 654; beverages in, 
 680; and circulation, 661; course, 
 666; diagnosis of, 667; dietetic 
 treatment, 668-684; During's diet, 
 683; Ebstein's diet, 682; gout and, 
 656; hygienic treatment, 684; na- 
 ture of, 654; and nervous system, 
 661; Naunyn's diet, 683; and other 
 diseases, 656; and pancreas, 660; 
 physiological experiments, 657; 
 prognosis, 667; prophylaxis, 668; 
 substitutes for sugar in, 679; 
 skimmed milk in, 682; symptoms 
 of, 663; theories of, 661. 
 
 Diabetic diets, 682; urine, 663. 
 
 Diabetin, 679. 
 
 Diarrhoea, 552; chronic, in children, 
 554, 563; in infants, 554; summer, 
 557- 
 
 Diastase, 148, 159. 
 
 Diathesis, gouty, 647. 
 
 Diet, alimentary-canal diseases and, 
 507; anaesthetics and, 695; arctic 
 expedition, 293-296; for athletes, 
 727; for brainworkers, 737-741; 
 average daily, for adult, 288; in 
 commercial life, 741 ; of concen- 
 trated foods, 272; in convalescence, 
 423; Cornaro's, 299; in disease, 415; 
 in fever, 415; in infectious disease, 
 415; of football team, 26; improp- 
 erly balanced, 304; kitchen outfit, 
 414; leanness and, 638; and lapa- 
 rotomy, 698; liver diseases and, 580; 
 milk, 49; mixed, 33; nervous dis- 
 eases and, 591; and occupation, 
 734; in pregnancy, 744; in prisons, 
 712; in puerperal women, 744; race 
 and, 314; for school-children, 769- 
 776; respiratory system, diseases in, 
 467; of soldiers, 26; for starvation, 
 297, 298; surgical patients, 695; in 
 travel, 743; Tufnell's, 483; urinary 
 system diseases and, 489; variety 
 in, 329; vegetarian, 35. 
 
 Dietaries, standard, 15, 287. 
 
 Dietetic complications in associated 
 diseases, 694. 
 
 Diets, diabetic, 682. 
 
INDEX 
 
 819 
 
 Digestibility of foods, 25; compara- 
 tive, of meats, 109; of nutrients, 25. 
 
 Digestion, 323; alcohol and gastric, 
 231; artificial, 352; abnormalities 
 of, 349; circulation and, 332; dura- 
 tion of, 346-348; exercise and, 336; 
 external heat and, 333; of fats, 351; 
 in the intestine, 350; mental emo- 
 tion and, 340; in the mouth, 340; 
 and nervous system, 331; and rest, 
 337; in the stomach, 341; salivary, 
 341; and temperature, 333; sleep 
 and rest and, 337; and wines, 249. 
 
 Digestive ferments, 353. 
 
 Dilatation of the stomach, 536; lav- 
 age, 535- 
 
 Diphtheria, 442; feeding in, 339; and 
 milk, 66, 390; paralysis in, 444. 
 
 Diseases due to dietetic errors, 365; 
 especially influenced by diet, 621; 
 miscellaneous, 692. 
 
 Disinfection of utensils, 401. 
 
 Distilled water, 40. 
 
 Diuretic beverages, 800. 
 
 Donkin's diet for diabetics, 682. 
 
 Dough, 137. 
 
 Doura, 153. 
 
 Dried dates, 178; fruits, 178; vege- 
 tables, 271. 
 
 Drinks, effervescing, 207. 
 
 Drugs in human milk, 57. 
 
 Dry cure, 726; Tufnell's, 483. 
 
 Drying of food, 270. 
 
 Duck, 121. 
 
 Dujardin-Beaumetz system, 634. 
 
 Diiring's diabetic diet, 683. 
 
 Dysentery, 566; chronic, 567. 
 
 Dyspepsia, 511, 521-527; alcohol in, 
 238; atonic, 526; dietetic treatment 
 of, 521; in children, 526; flatulent, 
 525; foods forbidden in all cases, 
 521; foods allowable, 522; gout and, 
 526; hyperacidity, 527; irritation, 
 526; nervous, 526. 
 
 Dyspeptics, rules for, 525. 
 
 Dysphagia, 508. 
 
 Ebstein diabetic diet, 682; system, 
 
 626. 
 Economic value of food, 24. 
 Eczema, 616. 
 Eczema, in children, 619; in infants, 
 
 619. 
 Eels, 124. 
 
 Egg albumin, 102; preparations, 807. 
 Eggnog, 103, 807. 
 
 Egg plant, 171. 
 
 Eggs, 101; boiled, 104; cooked, 104; 
 composition of, 101 ; desiccated, 
 106; dried, 271; evaporated, 106; in 
 fever, 419; plover's, 197; preserva- 
 tion of, 105; preserved, 278; raw, 
 103; for rectal feeding, 409; tuber- 
 culosis and, 458. 
 
 Elements, chemical, 1 ; quantity of, 
 in standard diets, 19. 
 
 Elimination of food, 359. 
 
 Embalmed beef, 282. 
 
 Embryomine, 677. 
 
 Emergency ration, 706. 
 
 Emphysema, 471. 
 
 Empyema, 476. 
 
 Enemata, milk, 70; nutrient, 403. 
 
 Energy from foods, 7; and foot tons, 
 18; potential, in foods, 26. 
 
 English walnuts, 190. 
 
 Enteralgia, 591, 595. 
 
 Enteritis, acute catarrhal, 560; chron- 
 ic, 561 ; membranous, 565. 
 
 Entero-colitis, 557; chronic, 563. 
 
 Epilepsy, 583. 
 
 Equivalents, food, 285. 
 
 Erbswurst, 163. 
 
 Ergotism, 380. 
 
 Erysipelas, 445. 
 
 Erythema, 615. 
 
 Eskay's albuminised food, 150; food, 
 114. 
 
 Eskimo diet, 315-318. 
 
 Ewald's test breakfast, 515. 
 
 Exercise, digestion and, 336; food 
 and, 15, 284, 336. 
 
 Exophthalmic goitre, 693. 
 
 Extracts, 270; of beef, 113; of pan- 
 creas, 79, 356. 
 
 Extractum carnis, 116. 
 
 Famine, 304. 
 
 Farina, 150; gruels, 429. 
 
 Farinaceous diet in hospitals, 777; 
 
 foods, 146, 809. 
 Fasting, 298. 
 Fat of milk, 52; beef, 196; diarrhoeal 
 
 stools and, 555; of pork, 196. 
 Fats, 19, 192; animal, 195; dietetic 
 
 uses of, 198; digestibility of, 194; 
 
 digestion of, 351; tuberculosis and, 
 
 459; uses of, 192; vegetable, 197. 
 Feces and food, 12. 
 Feeding, forced, 465, 610; of helpless 
 
 patients, 400; hypodermic, 411; of 
 
 infants, 749; intravascular, 411; rec- 
 
820 
 
 INDEX 
 
 tal, 403, 408; the sick, 397; of un- 
 conscious patients, 402; young chil- 
 dren, 764. 
 
 Ferments, 353; in foods, 274. 
 
 Fever, alcohol in, 236, 421-423, 431 ; 
 beverages in, 420; diet in, 415; di- 
 etetic treatment of, 417-420; pathol- 
 ogy of, 415; remittent, 453; thirst 
 in, 430; typhoid, 425; typhus, 437. 
 
 Figs, 188. 
 
 Fig wine, 251. 
 
 Filbert, 172. 
 
 Filtered water, 40. 
 
 Finkler's proteid feed, 112. 
 
 Fish, 124; cooking of, 269; desic- 
 cated, 125; diet, 778; digestibility 
 of, 125; fat, 197; oils, 197; poison- 
 ing by, 378; smoked, 275. 
 
 Fistula, gastric, 510. 
 
 Flatulency, 525. 
 
 Flaxseed tea, 800. 
 
 Flies and food infection, 390. 
 
 Flour, 133; ball, 147; banana, 183; 
 decorticated, 145; wheaten, 142. 
 
 Food, absorption, 358; age and, 15, 
 284, 306; adulteration, 381; anaes- 
 thetics and, 675; animal, 4, 48; an- 
 tiseptics and, 281; body weight and, 
 312; canned, 278-281; carbon in, 
 16; childhood and, 306; cholera in- 
 fection and, 388; classes of, 37; cli- 
 mate and, 284; clothing and, 284; 
 combustion, 9, 12; "complete," 4; 
 composition of, 3, 4, 6; concen- 
 trated, 272; concentration, 270; 
 condensed, 270; cost of, 26-28; 
 desiccation of, 270; digestion, 323; 
 digestibility of, 25; dried, 270, 274; 
 economic value of, 24; elementary 
 composition of, 1; elimination of, 
 359; enemata, 408-412; energy 
 from, 7; equivalents, 285, 361; ex- 
 ercise and, 15, 284, 336; extracts, 
 270; farinaceous, 146; force pro- 
 ducing, 7, 18, 28; frozen, 276; fuels, 
 9; heat-producing, 8; heredity and, 
 314; hydrogen in, 16; idiosyncrasy 
 and, 391; infants', 146, 748; malted, 
 354; medicines and, 411-414; mi- 
 cro-organisms, 385; nitrogen in, 16, 
 20; nitrogenous, 5; non-nitrogen- 
 ous, 5; nutrition percentage of, 25; 
 in old age, 308; oxygen in, 16; 
 parasites and, 368; poisoning, 375; 
 potential energy in, 26; prepara- 
 tion, 259; preservation, 259, 274; 
 
 ptomaines and, 374; purveyors, 414; 
 quantity of, 398; quantity required, 
 28, 283; race and, 314; refrigera- 
 tion, 276; relative to special dis- 
 eases, 363; respiration, 16; respira- 
 tory, 5; salted, 275; sex and, 285, 
 313; starchy, 133; serving the sick, 
 398; size of body and, 311; sleep 
 and, 430; special conditions for, 
 306; sterilisation, 277; stimulating, 
 23; substitutes for, 282; supposi- 
 tories, 410; temperature and, 284, 
 333S36', tobacco and, 360; typhoid 
 infection, 388; urine and, 360, 489; 
 vegetable, 5, 160; vegetable and 
 animal, compared, 29-35; work 
 and, 15; for young children, 761. 
 
 Foot-and-mouth disease, 390; and 
 milk, 65. 
 
 Football dietary, 733. 
 
 Foot pounds and work, 12. 
 
 Foot tons and food energy, 18. 
 
 Forced feeding, 465, 610. 
 
 Force-producing value of foods, 18. 
 
 Force production, 7. 
 
 Foreign bodies swallowed, 510. 
 
 Formaldehyde and food, 281, 282; in 
 milk, 63. 
 
 Fowl, 121. 
 
 French Army Hospital dietaries, 798. 
 
 Frijole, 164. 
 
 Fromentine, 677. 
 
 Fruit in constipation, 572; cures, 723; 
 poisoning, 177; sirups, 208; soups, 
 178. 
 
 Fruits, 174; composition of, 175; dia- 
 betes in, 674; digestibility of, 178; 
 dried, 178; ripening, 177; uses and 
 properties, 176; varieties, 179. 
 
 Frying, 267. 
 
 Fuel value, 9, 12; of foods, 28. 
 
 Functional albuminuria, 493. 
 
 Fungi, 188; in milk, 67. 
 
 Furunculosis, 621. 
 
 Fusel oil, 250, 252. 
 
 Gaduin, 200. 
 
 Gaertner's Mother Milk, 93. 
 
 Gall ducts, 584. 
 
 Gallstones, 588. 
 
 Game, 121; high, 267; poisoning, 
 
 375- 
 Garlic, 172. 
 Garrison ration, 705. 
 Gases of stomach, 512. 
 Gastralgia, 591, 594. 
 
INDEX 
 
 821 
 
 Gastrectasia, 536. 
 
 Gastric catarrh, acute, 527; chronic, 
 530; in children, 536. 
 
 Gastric digestion, 341; juice, 342; 
 total acidity of, 516; fever in chil- 
 dren, 529. 
 
 Gastritis, acute, 527; chronic, 530. 
 
 Gastro-intestinal catarrh, chronic, 
 
 563. 
 
 Gavage, 754. 
 
 Gelatin, 122, 349; preparations of, 
 814. 
 
 Gerber's food, 149. 
 
 Germain See system, 632. 
 
 German army ration, 707. 
 
 Germs in food, 274, 282. 
 
 Gin, 251. 
 
 Ginger, 256; ale, 208. 
 
 Glucose, 132. 
 
 Gluten, 136; bread, 145, 676; flour, 
 676; vegetable, 161. 
 
 Glutenin, 136. 
 
 Gluttony, 366. 
 
 Glycerin, 199. 
 
 Glycogen, 23. 
 
 Goat's milk, 57. 
 
 Goitre, exophthalmic, 693. 
 
 Gonorrhoea, 506. 
 
 Goose, 121, 
 
 Gooseberries, 187. 
 
 Gorgonzola, 100. 
 
 Gout, 641; alcohol in, 650; chronic, 
 647; saline waters in, 653. 
 
 Gouty diathesis, 647. 
 
 Graham bread, 144. 
 
 Grain poisoning, 379, 380. 
 
 Granola, 151. 
 
 Granose, 151. 
 
 Granum, 147. 
 
 Grape cure, 724; " food," 185. 
 
 Grapes, 184. 
 
 Gravel, 504. 
 
 Greengages, 185; tea, 211; vegeta- 
 bles, 161. 
 
 Greens, 161, 170. 
 
 Grilling, 264-267. 
 
 Groats, Scotch, 156. 
 
 Grocer's itch, 130. 
 
 Grog de la poudre de viande, 112. 
 
 Ground pear, 167. 
 
 Grouse, 121. 
 
 Gruels, 809-811; farinaceous, 429. 
 
 Gruyere, 99. 
 
 Guinea-worm disease, 369. 
 
 Gum in fruits, 175. 
 
 Giinzberg's test, 517. 
 
 Haemoptysis, 468. 
 
 Haemorrhage of lungs, 468. 
 
 Haemorrhoids, 578. 
 
 Ham, 120. 
 
 Hard labour prison diet, 284. 
 
 Hard-tack, 151. 
 
 Haricots, 164. 
 
 Harvard boat crew dietary, 731. 
 
 Hasheesh and fasting, 283. 
 
 Heart, 122; diseases of, 476; senile, 
 
 479- 
 Heat, external, and digestion, 333. 
 Heat-producing foods, 8. 
 Heat unit. See Calorie, 12, 15. 
 Herb teas, 207. 
 Heredity and food, 314. 
 Hetero-albumose, 349. 
 Hindu, diet of the, 320. 
 Hock, 249. 
 
 Hoff's malt extract, 160. 
 Holt's table for infant feeding, 757. 
 Honey, 132. 
 Horlick's food, 148. 
 Horseflesh, 120. 
 Horseradish, 258. 
 Hospital dietaries, 776. 
 Hot-water cure and meat, 726. 
 Hours for meals, 323-327. 
 House diet, 777. 
 Huckleberries, 187. 
 Humanised milk, 88. 
 Human milk, 55; artificial, 88; drugs 
 
 in, 57- 
 Hunger, 302, 339, 404. 
 Hydrochloric acid, 343, 517; gastritis 
 
 and, 535. 
 Hydrogen in food, 16. 
 Hyperacidity, 349, 525. 
 Hypersecretion, 349, 519. 
 Hypodermic feeding, 411. 
 
 Ice, 45. 
 
 Ice cream, 96; poisoning by, 377. 
 
 Iced fluids, 334. 
 
 Iceland moss, 190, 158. 
 
 Idiosyncrasy and food, 391. 
 
 Imperial Granum, 147. 
 
 Inanition, 297. 
 
 Indian meal, 154. 
 
 Indigestion, 511. 
 
 Infancy food required, 757. 
 
 Infant foods, 146, 748; artificial, 759. 
 
 Infantile scurvy, 690. 
 
 Infants, premature, 761. 
 
 Infectious diseases, diet in, 415. 
 
 Influenza, 440. 
 
822 
 
 INDEX 
 
 Insanity, acute, 610; dietaries, 791. 
 
 Insomnia, 605. 
 
 Intermittent fevers, 453. 
 
 Intestinal antisepsis, 432; gases, 352; 
 digestion in children, 562; obstruc- 
 tion, acute, 567; putrefaction, 560; 
 worms, 369. . 
 
 Intravascular feeding, 411. 
 
 Intubation, 442. 
 
 Inulin biscuit, 678. 
 
 Inunction foods, 410. 
 
 Iron, 48. 
 
 " Iron ration," 164. 
 
 Isinglass, 122. 
 
 Italian pastes, 152. 
 
 Jam, 187. 
 
 Jaundice, 584. 
 
 Jellies, 123. 
 
 Jelly, 812, 813, 814. 
 
 Jerusalem artichoke, 167. 
 
 Jockey's diet, 734. 
 
 Johannis water, 208. 
 
 Johns Hopkins Hospital dietaries, 
 
 787. 
 Johnson's fluid beef, 116. 
 Junket, 806. 
 
 Kava, 225. 
 
 Keating's diet, 603. 
 
 Kefir, 83. 
 
 Kepler's extract of malt, 160. 
 
 Kidney beans, 164. 
 
 Kidneys, 122. 
 
 Kindermilch, 357. 
 
 Kirsch, 250. 
 
 Kneipp system, 723. 
 
 Kohl rabi, 168. 
 
 Kola, 224. 
 
 Koumiss, 80, 807; composition of, 
 
 81; cure, 82; properties of, 81. 
 Koumys. See Koumiss. 
 Koumysgen, 82. 
 Kummel, 252. 
 Kumyss. See Koumiss. 
 
 Laboratories, milk, 88. 
 Lactalbumin, 54. 
 Lactated food, 92, 149. 
 Lactic acid, 54. 
 Lactometer, 59. 
 Lactone, 83. 
 Lacto-preparata, 92. 
 Lactose, 53, 132. 
 Lamb, 119. 
 Laparotomy and diet, 698. 
 
 Lard, 195. 
 
 Laryngismus stridulus, 467. 
 
 Laryngitis, tubercular, 468. 
 
 Lathyrism, 380. 
 
 Lavage, 535, 538. 
 
 Lead poisoning, 384, 693; and milk, 
 70. 
 
 Leanness, 638. 
 
 Leaven, 138. 
 
 Lebert's milk cure, 463. 
 
 Leeks, 172. 
 
 Legumes, 162. 
 
 Legumin, 80, 6jJ. 
 
 Lemonade, 179, 207, 800; efferves- 
 cing, 800; in fever, 420; substitutes 
 for, 207. 
 
 Lemons, 179. 
 
 Lentils, 165. 
 
 Lettuce, 170. 
 
 Levulose, 132. 
 
 Leyden's diet, 603. 
 
 Lichen, 190. 
 
 Liebig's extract of meat, 116; foods, 
 148. 
 
 Lima beans, 164. 
 
 Lime, 46, 47; saccharated, 78; water, 
 807; juice, 179; biscuit, 46. 
 
 Limes, 179. 
 
 Linseed oil, 198. 
 
 Lipanin, 203. 
 
 Liqueurs, 252. 
 
 Liquor, consumption of, 239; adul- 
 teration of, 251; malt, 239; thera- 
 peutic uses of, 251. 
 
 Liquors, 250. 
 
 Liver, 122; abscess of, 588; amyloid, 
 587; diseases, diet in, 580; fatty, 
 586. 
 
 Liverpool Infirmary dietaries, 787. 
 
 Lithsemia, 504. 
 
 Lobsters, 125. 
 
 Locomotor ataxia, 608. 
 
 Loeflund's cream emulsion, 149; malt 
 extract, 160. 
 
 Macaroni, 152. 
 
 Macaroons, 190. 
 
 Mace, 256. 
 
 Madeira, 252. 
 
 Maize, 153. 
 
 Malaga, 246. 
 
 Malaria, 453. 
 
 Malmsey, 246. 
 
 Malt, 240; extracts, 159; liquors, 239. 
 
 Malted milk, 92, 149. 
 
 Maltine, 160. 
 
INDEX 
 
 823 
 
 Maltose, 132, 159, 353. 
 
 Mangoes, 181. 
 
 Mania, 610. 
 
 Manioc, 157. 
 
 Mannite, 132. 
 
 Maple sugar, 129. 
 
 Marasmus, 564. 
 
 Mare's milk, 58. 
 
 Marrow, bone, 196; vegetable, 173. 
 
 Mash, sour, 250. 
 
 Massage, constipation in, 574; of 
 stomach, 541. 
 
 Mate, 220. 
 
 Matzoon, 83. 
 
 Meal, banana, 183; corn, 154; Indian, 
 153; pea, 164; peanut, 165. 
 
 " Measles," 370. 
 
 Measles, 439. 
 
 Meat, 106; composition of, 107; con- 
 sumption of, 106; digestibility of, 
 108; dried, 271; extracts, composi- 
 tion of, 118; frozen, 276; hot-water 
 cure and, 726; lozenges, 113; poi- 
 soning, 375; preparations, fluid, 
 117; solid, 804; preservation, 281; 
 raw, 108; quantity eaten, 106; 
 smoked, 275; sterilised, 277; tu- 
 berculosis and, 386, 457. 
 
 Mechanics, diet of, 28, 29. 
 
 Medicines and food, 411-414. 
 
 Melancholia, 610. 
 
 Mellin's food, 148. 
 
 Melons, 187. 
 
 Meningitis, cerebro-spinal, 444. 
 
 Mental emotion and digestion, 340. 
 
 Metabolism, 9. 
 
 Meteil, 153. 
 
 Micro-organisms and food, 385. 
 
 Migraine, 595. 
 
 Milk, 48-93; absorbent power of, 67; 
 adaptation of, for the sick, 72,; 
 adulteration, 61-63; albumin of, 54; 
 albuminoid, 61; alkalies with, 77; 
 amylaceous foods, 77; analysis, 52, 
 58; analysis of human, 55, 60; arti- 
 ficial human, 753; asses', 58; bac- 
 teria in, 66, 67, 87; boiled, 75; bot- 
 tles, 87; chemical composition of, 
 52; contamination, 63; colour of, 
 58, 63; cure, 51, 719; Lebert's, 463; 
 diet, 49; Bright's disease in, 497; 
 gastritis, 532; diet in tuberculosis, 
 463; digestion, 71; dilution of, 76; 
 diphtheria and, 66, 390; derivatives, 
 93; dried, 270; enemata, 70; fat, 52; 
 fat, estimation of, 60; improving 
 54 
 
 the digestibility of, 75; impurities, 
 61; indigestion, 72; infant feeding, 
 and, 751; infection, 64, 68, 385; 
 acute, 558; "foods," 92; foot-and- 
 mouth disease and, 65; fever in, 
 417; gelatin and, 78; goat's, 57 
 human, 55; human drugs in, 57 
 humanised, 88; laboratories, 88 
 lead poisoning, 70; legal stand- 
 ards of, 62; malted, 149; methods 
 of altering the taste of, 74; modi- 
 fied, 88, 92; odour, 58; other foods 
 compared and, 53; pancreatinised, 
 79; pasteurised, 86; peptonised, 78; 
 poisoning by, 377; predigestion of, 
 78; preparations, 806; prescrip- 
 tions, 89-91; preservation, 84; re- 
 action, 58; scalded, 76; scarlatina 
 and, 66, 390; skimmed, 75; 
 skimmed, in diabetes, 682; steril- 
 ised, 84; substitutes for, 428, 753; 
 total solids, 59; tuberculosis and, 
 64, 386; typhoid fever and, 66, 426; 
 uses of, 69; varieties of, 54. 
 
 Millet, 153. 
 
 Mineral waters, 207. 
 
 Mint, 171, 258. 
 
 Molasses, 131. 
 
 Morel, 189. 
 
 Mosquera's beef jelly, in; beef meal, 
 in. 
 
 Mother Milk, 93. 
 
 Moulds in cheese, 100. 
 
 Mouth, cleansing of, 401 ; care of, 
 
 433- 
 Mucous diarrhoea, 565. 
 Mulberries, 187. 
 Mulled wine, 801. 
 Mumps, 440. 
 Muscarin, 189. 
 Mush, 154. 
 Mushrooms, 188. 
 Muskmelon, 187. 
 Mussels, 126. 
 " Must " of wines, 245. 
 Mustard, 255. 
 Mutton, 119. 
 Mytilotoxin, 378. 
 
 Naunyn's diabetic diet, 683. 
 
 Navy rations, 710. 
 
 Nectarines, 181. 
 
 Negro diets, 319. 
 
 Nephritis, acute, 490; in children, 
 
 492; chronic, 496. 
 Nervous diseases, alcohol in, 236. 
 
824 
 
 INDEX 
 
 Nervous system, 591; diabetes and, 
 661; digestion and, 331. 
 
 Nestle's food. 150; milk food, 92. 
 
 Neuchatel, 100. 
 
 Neuralgia, 591. 
 
 Neurasthenia, 597. 
 
 Neutrose, 100. 
 
 New York Hospital dietaries, 779. 
 
 New York Infirmary for Women and 
 Children, 788-791. 
 
 New York State Reformatory diet- 
 ary, 716-718. 
 
 Nitrogen balance, 20; in food, 11, 16, 
 20; lag, 21. 
 
 North Eastern Hospital for Children, 
 
 793- 
 Nursing bottles, 760; mother. 747. 
 Nut flour, 678. 
 Nutmeg. 256. 
 Nutrient enemata, 403. 
 Nutrition, 29; percentage of foods, 
 
 25- 
 Nuts, 190; in diabetes, 674; in consti- 
 pation. 573. 
 
 Oatmeal. 155. 
 
 Oats. 155. 
 
 Obesity, 621. 
 
 Occupations and diet, 734. 
 
 Oertel system, 628-632. 
 
 (Esophagus, carcinoma of, 509; stric- 
 ture of, 509. 
 
 Oidium lactis, 67. 
 
 Oil, almond, 198; cod-liver, 199; cot- 
 ton-seed, 198; linseed, 198; olive, 
 197; peanut, 198; theobroma. 198. 
 
 Oils, 192; vegetable, 197. 
 
 Okra, 171. 
 
 Oleomargarine, 196. 
 
 Olive oil and biliary calculi, 193; in- 
 unction, 193. 
 
 Olives, 186. 
 
 Omelette, 105. 
 
 Onions, 172. 
 
 Operations and diet, 696. 
 
 Orangeade, 180. 
 
 Oranges, 180. 
 
 Osteomalacia. 692. 
 
 Overdrinking, 367. 
 
 Overeating, 366. 
 
 Overfeeding, 778. 
 
 Oxaluria, 501. 
 
 Oxygen in food. 16. 
 
 Oyster plant, 168. 
 
 Oysters, 126; typhoid fever and, 
 388. 
 
 Palpitation, 482. 
 
 Panada, 812. 
 
 Pancreas, diabetes and, 660; diseases 
 of the, 591. 
 
 Pancreatic extract of malt, 160. 
 
 Pancreatin, 356. 
 
 Pancreatinised meat for rectal feed- 
 ing, 408; milk, 79. 
 
 Panopeptone. 118. 
 
 Papoid. 357. 
 
 Paralysis, post-diphtheritic, 444; and 
 food, 368. 
 
 Parsley, 171. 
 
 Parsnips, 168. 
 
 Pasteurised milk, 86. 
 
 Pastry, 146. 
 
 Peaches, 181. 
 
 Pea meal. 164; soup. 164. 
 
 Peanut oil, 198. 
 
 Peanuts, 165. 
 
 Pearl tapioca, 157. 
 
 Pears, 181. 
 
 Peas, 162. 
 
 Pea soup, 164. 
 
 Pecan nuts, 191. 
 
 Pectin, 174. 
 
 Pellagra, 381. 
 
 Pemmican, 196, 271, 293. 
 
 Pepper, cayenne. 255; black, 255; 
 white, 255. 
 
 Peppermint, 255. 
 
 Pepsin, 344, 354. 519- 
 
 Peptic ulcer, 546. 
 
 Peptones, 345, 349, 355- 
 
 Peptonoids. 113. 
 
 Peptonised milk, 78. 
 
 Peristalsis, 346. 
 
 Peritonitis, acute, 579; chronic, 
 580. 
 
 Pernicious anaemia, 489. 
 
 Pertussis, 440. 
 
 Phosphates. 47. 48. 
 
 Phosphorus. 48. 
 
 Phthisis, 456. 
 
 Pickles, 257, 281. 
 
 Pie plant, 172. 
 
 Pigeon, 121. 
 
 Pigments in food, 383. 
 
 Pilot biscuits, 151. 
 
 Pineapples, 181. 
 
 Pistachio, 191. 
 
 Plasmon. 100. 
 
 Playfair's diet, 602. 
 
 Pleurisy, 474. 
 
 Plums, 185. 
 
 Pneumonia, 472. 
 
INDEX 
 
 825 
 
 Poisoning, alcohol, 392; by cheese, 
 377', by cream, 378; by fish, 378; 
 by fungi, 189; by grain, 380; by ice 
 cream, 377; by lead, 384, 693; by 
 meat, 375; by milk, 377; by shell- 
 fish, 378; by tin, 384. 
 
 Poland water, 208. 
 
 Polenta, 154. 
 
 Poluboskos, 145, 677. 
 
 Polysarcia, 621. 
 
 Pomegranate, 181. 
 
 Pomelo, 180. 
 
 Pork, 120, 196. 
 
 Porridge, 812. 
 
 Porter, 241. 
 
 Port wine, 245, 252. 
 
 Potassium salts, 47. 
 
 Potatoes, 165; sweet, 167. 
 
 Pot cheese, 99. 
 
 Powder, baking, 139. 
 
 Predigestion of milk, 78; of proteids, 
 354; of starch, 353. 
 
 Pregnancy, diet in, 744; vomiting of, 
 
 543- 
 Premature infants, 761. 
 Presbyterian Hospital dietaries, 781- 
 
 784. 
 
 Prisons, diet in, 712. 
 
 Professional men's diet, 325. 
 
 Proprietary foods, 759. 
 
 Proteids, 7, 19; digestion of, 348; pre- 
 digestion of, 354; vegetable, 161. 
 
 Protein, 7; daily income and outgo 
 of, 11; required per diem, 13. 
 
 Proteoses, 349. 
 
 Protogen, 104. 
 
 Prunelles, 186. 
 
 Prunes, 186. 
 
 Pruritus, 621. 
 
 Prussian Army Hospital dietaries, 
 798. 
 
 Psoriasis, 620. 
 
 Ptomaines and food, 374. 
 
 Ptyalin, 341. 
 
 Puddings, 146. 
 
 Puerperal women, diet for, 744. 
 
 Pugilists' diet, 734. 
 
 Pulled bread, 150. 
 
 Pulmonary haemorrhage, 468. 
 
 Pulque, 205. 
 
 Pumpernickel, 144. 
 
 Pumpkin, 172. 
 
 Purees, 418. 
 
 Purpura, 692. 
 
 Purveyors of food, 414. 
 
 Pyaemia, 452. 
 
 Pyelitis, 501. 
 Pyrosis, 349. 
 
 Quantity of food, 398; for children, 
 
 757- 
 Quinces, 181. 
 Quinsy, 508. 
 
 Rabbit, 121. 
 
 Rabies, 454. 
 
 Race and food, 314. 
 
 Radishes, 168. 
 
 Rain water, 39. 
 
 Raisin wine, 249. 
 
 Raisins, 185. 
 
 Raspberries, 187. 
 
 Ration, bare sustenance, 17; emer- 
 gency, 706; garrison, 14, 705; ideal, 
 17; liquid, 287; solid, 287; work, 17. 
 
 Rations, 700; army, 14, 700; navy, 
 710. 
 
 Raw meat, 804. 
 
 Receipts for invalid foods, 799. 
 
 Rectal feeding, 403-408. 
 
 Rectum, care of, 406. 
 
 Refrigeration, 276. 
 
 Reindeer milk. 58. 
 
 Rennet ferment, 519. 
 
 Rennin, 71. 
 
 Respiration and food, 16. 
 
 Respiratory foods, 5; system, 467. 
 
 Rest cure, 600; digestion and, 337. 
 
 Revalenta, 157, 165. 
 
 Rhachitis, 685. 
 
 Rheumatism, acute, 639; chronic, 
 640. 
 
 Rhine wines, 246. 
 
 Rhubarb, 172. 
 
 Rice, 154; flour, 140. 
 
 Rickets, 685. 
 
 Ridge's food, 146. 
 
 Riegel and Leube's test dinner, 515. 
 
 River water, 40. 
 
 Roasting, 264. . 
 
 Robinson's patent barley. 146. 
 
 Roe, 125. 
 
 Roosevelt Hospital dietaries, 786. 
 
 Root beer, 207. 
 
 Roots, 165. 
 
 Roquefort. 99. 
 
 Rosacea. 620. 
 
 Rotch's modified milk, 88; table for 
 infant feeding, 757. 
 
 Roundworm, 369. 
 
 Rubeola, 439. 
 
 Rudisch's beef peptone, 113. 
 
826 
 
 INDEX 
 
 Rum, 251. 
 
 Rye, 153; bread, 145; whisky, 250. 
 
 Saccharin, 133, 679. 
 
 Saccharose. 128. 
 
 Sago, 158. 
 
 Sake, 250. 
 
 Salcify, 168. 
 
 Salep, 157. 
 
 Salicylic acid, food in, 384: milk in, 
 
 63. 
 
 Saline waters in gout, 653. 
 
 Saliva, 341. 
 
 Salmon, 124. 
 
 Salt, celery, 171 ; habit. 46. 
 
 Salts, 18, 45; calcium, 47; deprivation, 
 46; excess of, 45; potassium, 47; 
 sodium, 46, 47; uses of, 45; vari- 
 eties of, 45. 
 
 Samp, 154. 
 
 Sanose, 100. 
 
 Sarcopeptone, 113. 
 
 Sauces, 257. 
 
 Sauerkraut, 170. 
 
 Savory & Moore's Infant Food, 148. 
 
 Scalded milk, 76. 
 
 Scarlatina and milk, 66. 390. 
 
 Scarlet fever, 438. 
 
 Schleicher's diet, 632. 
 
 School children, diet for, 769-776. 
 
 Schroth's method, 727. 
 
 Schumacher's food, 146. 
 
 Schweniger system. 632. 
 
 Sclerosis, 482. 
 
 Scotch groats, 156. 
 
 Scraped beef, 805: meat, m. 
 
 Scurvy, 48, 688; in infants. 690. 
 
 Seakale, 170. 
 
 Seasickness, 544. 
 
 Season and food, 320. 
 
 Seegen's almond flour. 678. 
 
 Seltzer, 208. 
 
 Semolino, 151. 
 
 Senile heart, 479. 
 
 Separated cream, 95. 
 
 Septicaemia, 452. 
 
 Sex and food, 285. 313. 
 
 Shaddocks, 180. 
 
 Shallots, 172. 
 
 Shellfish, 126; poisoning by, 378. 
 
 Sherry, 246, 252. 
 
 Ship biscuits, 151. 
 
 Shredded wheat, 150. 
 
 Shrimp, 125. 
 
 Shrub, 187. 
 
 Sirup, 131; maple, 129. 
 
 Skimmed milk, 75. 
 
 Skin diseases, 614. 
 
 Sleep, digestion and, 338; feeding 
 and, 401, 769; food and, 430. 
 
 Smallpox, 438. 
 
 Smalt, 96. 
 
 Smoking, 275. 
 
 Soda water, 208. 
 
 Sodium, 45; chloride, 46. 
 
 Soldier's diet, 26. 
 
 Somatose, 113. 
 
 Sorghum, 130. 
 
 Sorrel, 170. 
 
 Soups, 268, 803; fruit, 178. 
 
 Sour mash, 250. 
 
 Soused fish, 281. 
 
 South American beef extract, 113. 
 
 Soya, bean, 164; bread, 152. 
 
 Spaghetti, 152. 
 
 Spices, 253, 256. 
 
 Spinach, 170. 
 
 Spirits, 252. 
 
 Squab, 121. 
 
 Squash, 172. 
 
 Standard dietaries, 15, 286. 
 
 Standards of digestibility of foods, 
 25- 
 
 Starch in vegetable foods, 135. 
 
 Starches, predigestion of, 353. 
 
 Starchy foods, 133; for children, 
 158. 
 
 Starr's table for infant feeding, 757. 
 
 Starvation. 297; symptoms, 300; 
 treatment, 303. 
 
 Steaks, 266. 
 
 Steaming. 268. 
 
 Stearin, 196. 
 
 Sterilised milk, 84. 
 
 Stewing, 263. 
 
 Stilton, 100. 
 
 Stimulants, 205. 
 
 Stimulating foods, 23. 
 
 Stomach, absorption, 521 ; cancer of, 
 550; digestion in, 341; dilatation of, 
 536: acute catarrh of, 527; chronic 
 catarrh of, 530; examination of 
 contents, 515; motility, 520; ulcer 
 of, 546. 
 
 Stomatitis, catarrhal, 507. 
 
 Stools, examinations of, 555; of in- 
 fants. 759- 
 
 Stout, 241. 
 
 Strawberries, 186. 
 
 Stricture of oesophagus, 509. 
 
 Strippings. 54. 
 
 Substitutes for foods, 282. 
 
INDEX 
 
 82/ 
 
 Sucrose, 129. 
 
 Suet, 196. 
 
 Sugar, 22, 127; beet, 129: cane. 129; 
 in fruits, 175; maple. 129: milk, 
 131; substitutes for, 679: urine and, 
 128. 
 
 Sulphates, 48. 
 
 Sulphur, 48; waters, 209. 
 
 Summer diarrhoea, 557. 
 
 Superalimentation, 464, 613. 
 
 Suppositories, food, 410. 
 
 Suralimentation, 464, 613. 
 
 Surgical patients, diet for, 695. 
 
 Sweet bread, 121. 
 
 Sweet potatoes, 167. 
 
 Swiss cheese, 100. 
 
 Swiss milk. 94. 
 
 Syntonin, 349. 
 
 Tabasco. 257. 
 
 Taenia, 369. 
 
 Taka-diastase, 353. 
 
 Tamarinds, 181. 
 
 Tannin, 210. 
 
 Tapeworm. 369. 
 
 Tapioca, 157. 
 
 Tea, 211; adulteration. 215: black, 
 211; beef, 802; coffee compared 
 and, 220: good effects of, 212; 
 green, 211; habit, 214; ill effects, 
 214; infusion, 212; properties, 212. 
 
 Teething and food, 768. 
 
 Temperature and digestion, 333; food 
 and, 284, 333-336. 
 
 Test meals, 515. 
 
 Tetanus, 453. 
 
 Theobromine. 222. 
 
 Thirst, 43. 404; in fever. 430. 
 
 Thyroid gland. 121. 
 
 Tin poisoning. 384. 
 
 Toast, 143. 
 
 Tobacco, 575: food and. 360. 
 
 Tomatoes, 171. 
 
 Tongue, 119. 
 
 Tonsilitis, 508. 
 
 Tous-les-mois, 157. 
 
 Tracheotomy, 444. 
 
 Training, 727, 734. 
 
 Travel, diet in, 743. 
 
 Treacle. 131. 
 
 Trichina spiralis, 370. 
 
 Trichinosis, 370; symptoms. 372. 
 
 Tripe, 122. 
 
 Trommer's diastatic extract of malt. 
 160. 
 
 Tropon, 112. 
 
 Truffles, 189. 
 
 Tubercular laryngitis, 468. 
 
 Tuberculosis, 455; aids to dietetic 
 treatment, 466; diet in advanced 
 cases, 462; diet in mild cases, 460; 
 forced feeding and. 464; milk and, 
 64, 386; meat and, 386. 
 
 Tubers. 165, 168. 
 
 Tufnell's diet, 483. 
 
 Turkey, 121. 
 
 Turnips, 168. 
 
 Typhoid fever, 425; children in, 437: 
 convalescent diet, 435; milk diet in, 
 426; and milk, 66; milk infection 
 and, 388; oysters and, 388: pathol- 
 ogy. 425- 
 
 Typhus fever, 437. 
 
 Tyrotoxicon, 378. 
 
 Ulcer of the stomach. 546. 
 
 United States Army Hospital dieta- 
 ries, 793-797; prison diet, 713; ra- 
 tions, 701-707; navy ration. 710. 
 
 Uric-acid diathesis, 504. 
 
 Urine and food, 360-489: and fruits. 
 176; diabetic, 663. 
 
 Urinary system, 489. 
 
 Urticaria, 615. 
 
 Utica State Hospital dietaries, 791. 
 
 Valentine's meat juice, 117. 
 
 Valvular heart disease, 477; in chil- 
 dren, 478. 
 
 A^anilla, 257. 
 
 Variola, 438. 
 
 Veal, 119. 
 
 Vegetable and animal food compared. 
 29-35: acids, 48; fats, 197; food. 5, 
 160; marrow, 173; oils, 197. 
 
 Vegetables, composition of, 173; 
 cooking of, 269; dried. 211: green, 
 169. 
 
 Vegetarianism. 30. 31. 35-37. 
 
 Venison. 119. 
 
 Vermicelli, 152. 
 
 Vertigo. 605. 
 
 Vichy, 209. 
 
 Vinegar. 257. 
 
 Viscera. 121. 
 
 Vomiting. 543; of pregnancy, 546. 
 
 Walnuts. 190. 
 
 Water, 18. 37; acidulous, 210; boiled, 
 
 41: chalybeate. 210; in constipation. 
 
 573: in diabetes, 680; distilled. 40; 
 
828 
 
 INDEX 
 
 excess of, 42; in fevers, 420; fil- 
 tered, 40; in gout, 650; hard, 39; 
 lime, 807; mineral, 207; quantity 
 required, 37, 292; purity of, 38; 
 rain, 39; river, 40; soft, 39; starva- 
 tion, 43; thermal, 208; uses, in 
 
 . body, 38; varieties of, 39. 
 
 Watermelons, 187. 
 
 Waters, alkaline, 207, 209; efferves- 
 cing, 207; purgative, 210; sulphur, 
 209. 
 
 Weaning, 755. 
 
 Weight and food, 312. 
 
 Weir Mitchell's system, 632. 
 
 Welsh rarebit, 100. 
 
 Wet nurse, 746-748. 
 
 Wheatena, 150. 
 
 Wheaten flour, 142. 
 
 Wheat kernel, structure of, 135. 
 
 Whey, 99. 101; cure, 721. 
 
 Whisky, 250. 
 
 White pepper, 255. 
 
 Whooping-cough, 440. 
 
 Wine, 241; cocoa, 246; composition 
 of, 241; fig, 251; properties of, 242; 
 raisin, 249. 
 
 Wines, adulteration of, 251; acid, 
 246; aromatic, 246; digestion and, 
 249; dry, 245; "perfect," 248; red, 
 244; Rhine, 246; rough, 249; spark- 
 ling, 246; sweet, 246; white, 243; 
 varieties of, 245. 
 
 Woodcock, 121. 
 
 Work, food and, 15; foot pounds 
 and, 12; ration, 17. 
 
 Worms, intestinal, 369. 
 
 Yale boat crew dietary, 729; football 
 
 dietary, 733. 
 Yam, 167. 
 Yeast, 138. 
 
 Yellow fever, 449-452. 
 Yeo system, 633. 
 
 Zoolak, 83. 
 Zwieback, 144. 
 
 (1) 
 
 THE END 
 
 3VT7 
 X-262J. 
 

 
 * o n o ' A ^ . , r 
 
 ^ .V, <<". .<V . 
 
 
 ,V 
 
 •£, 
 
 
 
 
 o cr ; • 
 
 
 # 
 
 
 » 1 | v -A 
 
 ^; 
 
 
 A A 
 
 ; .\ A ■' 
 
 . ■ , A ' '-- ^> A l » * **b 
 
 
 > V 
 
 o o' 
 
 ^ ^ 
 
 A 
 
 > * 8 
 
 <T A s s A A/. ' 
 
 A 
 
 A/ A A 
 
 V 
 
 \ 
 
 
 o, 
 
 • 
 
 
 
 " * 
 
 
 
 
 
 
 
 
 
 
 
 *o 
 
 0^ 
 
 
 
 ■> 
 
 ^ 5 
 
 -r r 
 
 
 
 
 £ . n 
 
 c» 
 
 
 -V 
 
 
 
 -A 
 
 
 
 f-2. 
 
 
 H> 
 
 A 
 
 * 
 
 
 
 Kt° * A° ^> 
 
 ,0o 
 
 v 5 -*>. -; 
 
 <£ 
 
 ** ^ 
 
 : ' .: .a ■ 
 
 A 
 
 ^ 
 
 
 x° 
 
 <<> 
 
 
 cP 
 
 
 7 8 1 \ N 
 
 
 
 cy 
 
 N v 
 
 
 > .,**' 
 
 
 
 *3> ^ 
 
 
 
 A' «/> 
 
 
 
 W 
 
 ^ ^ 
 
 
 v 5 ^ : ^ 
 
 
 G x ° 
 
 A x , ll, < ' 7 o 
 
 ^ c o K( - , ;<e. ■ 
 
 
 ^ 
 
 
 a : %^ 
 
 > -v' - s 
 
 .^'% v- 
 
 
 ,0o. 
 
 
 V * & 
 
 "* ,A V 
 
 \> , 
 
 
 % 'o« ^ J 
 
 ^ f ' ^ «s^ 
 
 * . <*> 
 
 PO 
 
 ^ ^ 
 x 00 ^. 
 
 
 \^' r ^> 
 
 
 
 •\ 
 
 A ./> 
 
 k V tP: 
 
 . 
 
 0' « 
 
 '-- 
 
 u 
 
 
 0" 
 
 
 '^ = 
 
 
 
 A- 
 
 
 
 V 
 
 s> , 
 
 * r0 
 
 - 
 
 — .