essential part of the tuberculous regime. The patient should
sleep from eight to ten hours out of every twenty-four, and
if this sleep is taken in the open, that is, in a tent or on a
sleeping porch, the benefits derived therefrom are inesti-
mable.

The Bowels. — The bowels should move every day,
even if some gentle laxative or an enema has to be used to
bring about the desired result. In a majority of cases, min-
eral oil or bran muflBns, prunes, raisins, and figs prepared
with senna will be entirely suflBcient, however, and these
substances are much less harmful than drugs, for the habit
of taking purgatives becomes a fixed one in a short time,
and is especially liable to become so when the patient is
forced, by reason of the sedentary life, to depend on some
such measures.

Massage. — Massage has been found beneficial in many
cases, giving the needed exercise to the body, which it is
otherwise unable to obtain.

CHRONIC TUBERCULOSIS

In chronic tuberculosis, the patient should be instructed
in the care necessary for his protection. He should be ad-
vised to report to the physician any symptoms occurring
during the course of the disease, especially any hemorrhage.
He must be reassured of the chances of recovery, even after
hemorrhage has occurred. It is not well to encourage the
habit of taking the temperature or weighing daily, since the
knowledge of the fluctuations which inevitably occur in



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306 DIETETICS FOR NURSES

these conditions may worry the patient to such an extent
as to interfere with his final recovery.

Rest, Sleep, and Fresh Air. — Moderation in physical
exertion, wholesome food at regular intervals, plenty of rest
and sleep, preferably in the open, and an effort made to
look forward to a complete recovery will go far toward
bringing about the desired result. The tuberculous patient
who sets his mind on recovery, refusing to be discouraged
by the numerous setbacks which may from time to time
occur, has a much greater chance of living a long and useful
life than the patient who makes no effort in this direction.

Reinforcing the Diet. — The following reenforced foods
have been found valuable in the diet for tuberculosis, espe-
cially in those cases which are confined to bed and in which
the effort to eat causes more or less gastric distress:

Milk, whole milk, milk and cream, milk diluted with
Apollinaris water, peptonized, modified milk, reenforced
with egg or egg white or reenforced with one to four table-
spoonfuls of lactose, malted milk, buttermilk, cream, egg,
and vichy, milk shake, milk punch, malted milk shake,
chocolate or cocoa malted milk, albumenized fruit juices,
egg and orange, egg and wine, reenforced, if desired, with
lactose, albumenized broths, proprietary infant foods, such
as Eskay's Food, Nestle's Food, Mellin's Food, Racahout,
cream soups reenforced with lactose or egg, junkets, and ice
cream.

Pneumonia

The diet in pneumonia is of considerable importance,
since in this condition the strength of the patient is taxed
by reason of the character of the disease, and the only means
of attaining endurance to carry him through this trying
period is by providing proper nourishment.

Dietetic Treatment. — The same general outline of diet
is used as in acute infectious fevers, milk forming the basis
of the diet. The patient is given an abundance of water and



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DISEASES OF THE RESPIRATORY TRACT 307

other beverages in addition to the other fluid foods to relieve
the thirst which is so often a common symptom in this
disease.

It is sometimes found advisable, however, on account of
the vomiting which may occur, to give a more concentrated
form of nourishment, in which case liquid peptonoids, tro-
phonine, and panopepton furnish a form of nourishment
which is both streng^ening and stimulating in character,
and for these reasons particularly desirable. Freidenwald
and Ruhrah advise against the use of starches and sugars
in most cases of pneumonia.

Daily Diet Schedule. — The same fluid diets used in
acute fevers and administered at two-hour intervals are
advisable here. The following regime is used in pneu-
monia:
6 a.m. 6oz. malted milk.
8 A.M. 6 oz. cocoa.

10 a.m. 4oz. oatmeal or commeal gruel with 2 oz. cream.
12 M. 6 oz. chicken broth reenforced with 1 egg white.
2 P.M. 6 oz. malted milk chocolate.
4 P.M. 6 oz. albumenized orange juice.
6 P.M. 6oz. chicken or beef broth, reenforced with egg

white.
8 P.M. 6 oz. hot milk.

Night feeding consisting of milk, malted milk, or reen-
forced broth may be given at 12 m. and 4 a.m. if patient is
awake.

The above diet may be varied by adding some of the
beverages mentioned in the diet for tuberculosis or fevers.

Convalescent Diet Schedule. — As the acute symptoms
subside and convalescence advances, the following diet may
be instituted:

I

Breakfast 3 to 4 oz. cereal gruel with 2 oz. cream.
1 soft-cooked egg.



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308 DIETETICS FOR NURSES

10:30 A.M. 6 oz. chicken broth, reenforced with egg, or 6 oz.
albumenized orange or grape juice.
1 P.M. 6 oz. oyster soup with rolled crackers.
1/4 cup wine jelly with 1 tbs. cream.
1 glass (6 oz.) milk — 2 parts milk, 1 part cream.
3 P.M. Milk shake (4 oz. milk, 1 egg white).
Supper 4 oz. farina with 1 oz. cream.

6 oz. cocoa.
9 P.M. 6 oz. malted milk.

Hot milk, broth, or malted milk may be given during the
night at 12 or 4 a.m. if patient is awake.

II

Breakfast 4 oz. orange juice on cracked ice.

3 or 4 oz. strained oatmeal with cream or butter.

1 slice soft toast.
6 oz. cocoa.

10 A.M. 1 soft-cooked egg on toast.

6 oz. milk.
Dinner 6 oz. cream of celery soup.

2 oz. rice.

4 oz. custard (soft or baked).
6 oz. milk or cocoa.

3 P.M. 5 oz. cream, egg, and vichy.
Supper 1 soft-cooked egg.

1 small baked potato.

6 oz. cocoa or malted milk.

Ill
Breakfast Stewed prunes.

3 or 4 oz. cream of wheat with 1 oz. cream.
1 soft-cooked egg.

1 slice of toast with butter.
6 oz. cocoa or milk.



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DISEASES OF THE RESPIRATORY TRACT 309

10:30 A,M. Eggnog (1 egg, 4 oz. milk, 2 oz. cream, 1 tbs.
whisky or sherry wine).
Dinner Cream of spinach soup.
2 oz. mashed potatoes.
2 oz. green peas.

1 slice toast with butter.

2 oz. rice or tapioca custard.
3 P.M. 6 oz. albumenized fruit juice.

Supper 1 slice toast.

1 poached egg.

6 oz. cocoa or hot milk.

2 or 3 oz. stewed fruit or prune whip.

The diet may be reenforced with lactose and meat added
only when convalescence is well established.

Tuberculosis Nursing. — The nurse must keep in mind
that the lungs are in a condition more or less out of com-
mission, and their work of excretion is forced upon the kid-
neys. For this reason, as well as on account of the increased
strain upon the heart, it is necessary to keep the diet light
and avoid all foods which may in any way exert an unfav-
orable influence upon either the kidneys or the heart.

Milk Diet. — A strict milk diet has been found neces-
sary in certain cases of pneumonia, but this is used only
while the febrile condition lasts, after which the diet is
gradually increased, as in the case of acute nephritis and in
diseases of the heart, to meet the needs of the individual.

TONSILLITIS

Dietetic Treatment. — The diet in this condition is
much the same as that used in other acute febrile conditions,
that is, a fluid diet, the basis of which is, as a rule, milk.

The development of nephritis and certain cardiac symp-
toms at times follow attacks of tonsillitis, and for this rea-
son the urine must be examined frequently and the diet



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310 DIETETICS FOR NURSES

carefully adjusted to avert, if possible, this danger. When
acute nephritis does follow the attack of toijsillitis, the diet
must necessarily be adjusted to meet that condition rather
than that of the original disease.

Special Diets. — The Mosenthal diet, and at times the
Karell Cure, is used with more or less success. This, how-
ever, is adjusted by the physician. It remains for the nurse
to report any unfavorable symptoms as soon as they occur,
and to carry out the line of dietetic treatment deemed ad-
visable by the physician.

SUMMARY
TUBERCULOSIS

Form. — Acute and chronic in character. The chief
aim of the treatment in the former is to prevent its develop-
ment into a chronic form.

Rest. — Sleep, preferably in the open air, in a tent or
on a sleeping porch.

Proper Surroundings should be striven for. The pa-
tient should be kept tranquil in mind and body, free from
disturbing worries and assured of the possibility of recovery
with proper care.

Diet should be adequate without being too abundant;
stufl^g the patient is no longer considered necessary, in fact
it is believed that forcing the eating of large quantities of
eggs, etc., defeats its own ends, upsetting the digestion and
causing a disgust for food almost impossible to overcome.

Gastro-intestinal Disturbances are apt to develop as the
disease progresses. These are treated as in other conditions
so complicated, except that the period of starvation must
necessarily be limited on account of the metabolic waste
already taking place from the disease itself.



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DISEASES OF THE RESPIRATORY TRACT 311

PNEUMONIA

The Lungs, as in pulmonary tuberculosis, are the seat
of infection and are temporarily hampered in their work of
excretion.

The Kidneys bear the brunt of the extra work caused by
the impairment of the lungs, consequently all unnecessary
work must be spared these organs if they are to be pre-
vented from being overtaxed.

Nephritis is one of the complications apt to develop when
the kidneys are not sufficiently strong to carry on their
own work and that generally done by the lungs.

The Heart. — Cardiac symptoms are also likely to de-
velop during attacks of pneumonia and make the disease
one to be dreaded and guarded against.

The Diet. — The dietetic treatment in pneumonia is
like that used in acute infectious diseases, fevers in general,
fluids constituting the form of diet and milk the chief food,
as long as there is an elevation of temperature.

TONSILLITIS

The Heart. — As in pneumonia, the development of
cardiac symptoms must be guarded against. These symp-
toms may not develop at oru;e but show later during or after
convalescence.

The Kidneys. — Nephritis also develops in some pa-
tients and the treatment is directed as far as possible to
prevent its developing into a chronic form.

Dietetic Treatment is the same as used in acute infec-
tious conditions, fevers of short duration, taking care to
institute the diet for acute nephritis should the patient
show evidences of this disease.

PROBLEM

Write a diet order for a tuberculous patient weighing 135
pounds, allowing 3000 calories and fifty per cent, of the
protein to be derived from animal sources.



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CHAPTER XVI

DIETETIC TREATMENT BEFORE AND AFTER
OPERATION

PREOPERATIVE FEEDING

The dietetic treatment which is essential before and after
operations is deserving of attention here, since it constitutes
one of the points so frequently overlooked or slighted. As
a rule the treatment depends (1) upon the character of the
disease for which surgical intervention is necessary, and (2)
upon the general health and physical condition of the pa-
tient in question.

Preparatory Treatment. — In many cases it is found to
be advisable to build up the patient before subjecting her to
the shock of an operation, and the more serious the opera-
tion the more necessary this "building-up" process.

The character of the disease also has much to do with
the preliminary diet. In certain pathological conditions in-
volving the gastro-intestinal tract, for example, the patient
comes to the surgeon after medical treatment has failed to
give relief and surgical intervention is necessary to save
life. The body is found to be in a condition bordering on
starvation, anemic and exhausted from insufficient nourish-
ment. The functions of the blood-making organs have be-
come out of gear, as it were, and the blood consequently is
deficient in one or more of its essential elements. For such
patients it is wise to attempt to reenforce and strengthen
their bodies before operation, that they may have more
endurance to withstand the shock which is more or less
unavoidable.

312



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TREATMENT BEFORE AND AFTER OPERATION 313

Adjusting the Diet. — In any case where preliminary
diet is prescribed the condition for which the operation is
necessary determines the nature of the diet; for example,
if the operation is to be upon the kidney, the diet before-
hand would naturally be in the nature of a nephritic one
to save the diseased organ unnecessary work. If the
stomach or intestinal tract required surgical care, the diet
would necessarily be formulated to meet the particular
needs of the organ in question, an analysis of the stomach
content furnishing the keynote of the diet. In any case
the food must be simple in character and well prepared.
All food in any way liable to bring about indigestion diould
be studiously avoided.

Habits. — The habits of the patient must be regulated
so that she may not "overdo"; at the same time, gentle
exercise may be the very thing needed to give an impetus
to the appetite and thus assist in the adding of strength
for the approaching ordeal. Many patients respond readily
to a change of air and scene and frequent small meals instead
of a few large ones, — a lunch in the mid-morning and mid-
afternoon hours, consisting of a glass of milk and a cracker
or malted milk chocolate or reenforced fruit juices. A cup
of warm milk before retiring induces the much-needed
sleep, hence is advisable under the circumstances.

The Bowels. — The bowels must be kept open. Coarse
bread such as that made from bran or graham flour is ad-
visable. Prunes and figs cooked with senna leaves are like-
wise simple laxatives which are both palatable and effec-
tive. For stubborn cases of constipation it is often found
that a teaspoonful of a conserve made with a third of a
pound each of raisins, prunes, and figs ground fine, with an
ounce of senna leaves added, taken at bedtime and before
breakfast, will overcome the condition and make the patient
more comfortable and the general health better.

Preliminary Light Diet. — The day before the opern,-



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314 DIETETICS FOR NURSES

tion the diet must be light; the intestinal tract must not
be filled with a food mass which is difficult to get rid of.
On the morning of the operation the patient is given no
food if the operation is to be performed at an early hour,
otherwise a cup of tea, coffee, weak cocoa, or broth with a
cracker is given. Some physicians give a glass of milk at
this time, while others do not. It is the physician who must
decide the question if there is any doubt about it. The
stomach must be empty before administering the anes-
thetic.

In certain emergency operations when it has been im-
possible to prepare the patient ahead, the diflficulties attend-
ing the administering of the ether are sometimes greatly
increased. The cleansing of the stomach and intestinal
tract oftentimes eliminates or materially decreases the
nausea and vomiting which so often forms one of the most
dreaded sequences of the operation. For this reason many
surgeons require the patient to be given lavage before leav-
ing the operating room.

Total Abstinence. — No food is given for twenty-four
hours following the operation (1) on account of the nausea
and vomiting which so often follows the giving of an anes-
thetic — ether particularly — and (2) because the entire
organism is better for a complete rest.

Routine Treatment. — The routine treatment in un-
complicated cases is rest, then water, very hot or iced, or
carbonated, or vichy in spoonful doses, then albumen water,
broth, etc., then milk, buttermilk, koumiss, etc., after which
the semi-solids, etc., until a normal diet is reached. After
a week or more the character of the operation certainly
determines the dietetic treatment. To quote Dr. Thomas
S. Brown,* "To give the same diet after pyloroplasty, gas-
tro-enterostomy, gall-bladder operation, or gastric resection

*"Some Gastro-intestinal Notes," "The Medical Clinics of North
America," Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns Hopkins
Hospital.



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TREATMENT BEFORE AND AFTER OPERATION 315

as we would after operations for fracture of the thigh or can-
cer of the breast shows a basic ignorance of the pathologic
physiology of the former group of cases." "We should
remember that hyperacidity remains long after the underly-
ing cause has been removed and it is tempting providence,
to say the least, to ply these patients with tomato soup,
salad dressing, and coarse food in the early stages of their
convalescence."

Character of Diet. — It must be kept in mind that the
character of the diet is of vital importance, especially in the
after-treatment of operations upon the stomach. In gastro-
enterostomy, for example, the food mass passes from the
stomach directly into the upper part of the small intestine
through the new opening. Thus the semi-liquid food highly
acid in character comes in direct contact with the delicate
intestinal walls which are accustomed, not to the acid, but
to a neutral or alkaline medium.

Adjusting Diet to Disease. — Thus it is demonstrated
that unless care is used in selecting the diet this portion of
the intestinal tract will be injured; hence the nurse must
understand which foods are liable to stimulate an excess
flow of acid in the stomach and avoid them. She must
also keep in mind that the foods given must be in a semi-
liquid or very finely divided condition, since the mechanical
efforts made by the musculature of the gastric organ act as
a direct stimulant to the secretory cells of that organ.

Much of the responsibility thus rests upon the nurse
whose business jt is to administer the diet. The efforts of
the best surgeon in the world may be entirely overcome by
a careless, thoughtless, or ignorant nurse.

Rectal Feeding. — In some cases it is found necessary
to nourish the patient more than is possible by mouth.
This is especially so with emaciated and very weak patients
and for those who have undergone operations upon the



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316 DIETETICS FOR NURSES

mouth or throat and m some of the above-mentioned
stomach cases when the passage of any food over the newly-
operated-upon surfaces is inadvisable. In these cases rectal
feeding is resorted to and from two to three nutrient
enemas ^ alternated with saline enemas are given daily.

Under ordinary conditions when the patient has not
been operated upon for gastro-intestinal disorders, gall-
bladder or kidney diseases, the dietetic regime is as follows:

Postoperative Feeding. — First day: starvation, a little
hot or cold water or carbonated water may be given if there
is no nausea or vomiting. If nausea or vomiting persists, a
few spoonfuls of champagne or clam broth or juice will
often check or relieve it entirely. Fluids alone must be
given during the first forty-eight hours after the operation.
When stimulation is necessary, albumen water or coflfee
containing a spoonful of brandy^ will be found useful.
When nausea entirely disappears, well-skimmed broth
milk, clam or oyster broth, buttermilk, koumiss, malted
milk, may be given. A gradual return to the normal diet is
made, adding soft toast, soft-cooked eggs, junket, ice cream,
meat, wine, or fruit jellies before solid food is introduced
into the dietary.

After-care in Feeding. — Care must be observed to pre-
vent indigestion after almost any operation, but especially
after abdominal operations there is a great tendency to form
gas, hence anything which in any way increases the tend-
ency may bring about a condition of extreme discomfort
and even acute pain to the patient. For this reason it is
unwise to follow too closely the desires of the patient as
to the food to be eaten ; for example, corned beef and cab-
bage may be the thing of all others desired by the patient,
but it would be the height of folly to risk such a meal until
all danger of digestional disturbances is at an end. It

'See Formulas for Nutrient Enemas, p. 145.
'Se^ Albumen Water with Brandy, p. 141,



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TREATMENT BEFORE AND AFTER OPERATION 317

is wiser to avoid such disturbances than to trust to relieving
them after they occur. The digestion of even a perfectly
normal individual is at a disadvantage when that individual
is deprived of outdoor exercise. How much more so will
it be when the entire organism is taxed by the ordeal
through which it has just passed. Convalescence is never
hastened by imprudent eating, and a condition as bad as
the original may be brought on by lack of care on the part
of the one whose business it is to feed the patient.

CONDITIONS REQUIRING SPECIAL DIETS

Diet After Appendicitis. — After a simple operation for
appendicitis the same regime is carried out as in stomach
and intestinal operations: fluids on the second day, soft diet
on tiie third, and solid food of the simplest character and
prepared in the simplest way may be given on the fifth and
sixth days. When, however, the operation has been of a
more serious character, for example, when there was pus
formation or a gangrenous appendix, the feeding by mouth
must not be instituted for five days or more, nutrient
enemas being used instead. Patients have been known to
die from exhaustion after operations upon the stomach and
intestines, not on account of the operation but on account
of the lack of reserve power and endurance to carry them
through the ordeal without a sustaining diet to overcome it.
Under the circumstances Dr. F. Ehrlich ** advises the follow-
ing routine method : "So soon as the nausea from the anes- .
thetic has worn off the patient gets tea, red wine, and gruel ;
on the day after the operation he is given sweetbreads in
bouillon even if it nauseates him; if the nausea is persist-
ent, his stomach is washed. On the second day finely
chopped cooked squab, chicken, or veal, is added; on the
third day, beef, potato puree and cakes; on the fourth,
chopped (raw) ham, soft zwieback, and soft-boiled eggs.

*"Diet in Health and Disease," p. 555, by Friedenwald and Ruhriih.



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318 DIETETICS FOR NURSES

On the fifth, white bread and spinach. After the seventh
day the meat is not chopped, and the patient returns gradu-
ally to normal diet. The bowels are regulated by oil
enemas."

Diet After Operation upon Gall Bladder or Liver. —
The dietetic treatment in these cases is like that of any
other abdominal operation except for the character of the
food. Fats are not well handled by the body of such indi-
viduals and should be eliminated as far as possible from the
diet. Broths must be skimmed carefully to remove fat, and
milk when given should be skimmed or given in the form
of buttermilk or koumiss.

Diet After Operations upon the Kidneys. — The diet
administered after operations upon these organs is logically
one in which those foods which are entirely dependent upon
the kidneys for their elimination are restricted. In a former
chapter the fate of the foods in metabolism was explained;
the protein foods were seen to be the ones leaving the body
chiefly by way of the kidneys and for this reason in the
diet after operations upon these organs, as well as in that
administered in disturbances affecting their functioning
powers, this food constituent, the protein of meat in par-
ticular, must necessarily be restricted. The upsetting of the
nitrogen equilibrium is for so short a period after kidney
operations that this feature need not be considered here.
The diet under the circumstances is essentially the same as
that given during acute attacks of nephritis.

SUMMARY

Factors AflFecting Diet before and after operations must
be considered under two heads, namely, the character of the
disease for which the operation is considered necessary and
the general physical condition of the patient at the time.

Emaciation and Anemia are often encountered in pa-



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TREATMENT BEFORE AND AFTER OPERATION 319

tients having certain gastro-intestinal disturbances for which
surgical intervention was found to be necessary. At times
a preliminary up-building treatment is required before it is