toast, and crackers.

Fluids: Weak tea and coflFee (without cream, and a little
sugar), orange and lemonade, mineral waters, water,
skimmed milk, whey.

Eggs: (except hard-cooked or fried).

Desserts: Fruit gelatin, fruit whips, raw or stewed fruit.

Avoid the following foods: Fats, oils, mutton, liver,
brains, sardines, and caviar, oily fish, rich gravies and sauces,
sweet fruit, peas, carrots, condiments and spices, pastry and
confectionery, pickles, alcoholic beverages. Restrict carbo-



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DISEASES OF THE LIVER 411

hydrates, yolks of eggs, milk (cream must be skimmed off
if too rich).

DAILY DIET SHEETS

I

Breakfast — Baked apple with milk

Cream of wheat with milk

Weak coffee or tea

Dry toast
11:30 a.m. — 6 oz. orange juice, 1 egg white

Dinner — Beef broth (well skimmed) with crackers
Rice

.Stewed pears
Weak tea
Toast or rolls

3:30 p.m. — Albumenized fruit juice with crackers

Supper — Wheatena with milk
Milk toast
Stewed prunes
Toast and tea

9 p.m. — Well-skimmed chicken broth with crackers

II

Breakfast — Stewed apples with milk
Milk toast
Coffee without cream

10:30 a.m. — Well-skimmed broth with crackers

Dinner — Tomato bouillon with crackers
Baked potato — 1 small potato
Puree of spinach
Orange gelatin
Toast



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412 DIETETICS FOR NURSES

3 P.M. -T- Albumenized lemonade

Supper — Oatmeal or cream of wheat with milk
Toast
Tea
Stewed fruit

9 p.m. — Well-skimmed broth with crackers

III
Breakfast — Grapefruit

Oatmeal with milk

Toast

Weak coffee

10:30 a.m. — Orangeade with graham crackers

Dinner — Cream of spinach soup (skimmed milk)
Small piece of the breast of chicken
Mashed or boiled potatoes
Asparagus on toast
Sliced oranges

3:30 p.m. — Well-skinmied broth with crackers

Supper — Farina or cream of wheat or wheatena, with
milk
Baked potato
Baked apple with milk
Toast and tea

9 P.M. — Albumenized orange juice

IV

Breakfast — Sliced oranges
Oatmeal
Toast
Coffee



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DISEASES OF THE LIVER 413

10:30 a.m. — Beef gruel, 6 oz.

Dinner — Cream of asparagus soup, skimmed milk
Thin slice of roast beef or whitefish
Rice or potatoes
Tender string beans
PVuit
Toast
Buttermilk

3:30 P.M. — Orangeade

Supper — Stewed fruit with puffed wheat or rice
Milk toast
Tea

9 P.M. — Broth

SUMMARY

Functions of Liver. — To transform fuel foods into
available energy; to detoxify those poisonous substances
produced as the result of metabolism of body tissue or
brought in in food, and to select those available for use; to
secrete bile.

Factors Influencing Disorder of Liver. — Errors in
diet: (a) overeating; (b) excessive drinking; and (c) un-
balanced diet, especially as regards the amount of fats
and carbohydrates in the diet.

The Bowels, in most of the disturbances affecting the
liver, become constipated, thus causing much additional
work on the part of the liver in handling the products pro-
duced as the result of putrefactive bacteria upon the ac-
cumulated mass in the colon.

Tissue Changes in the liver have been caused by the
taking of alcohol, which should therefore be avoided by all
individuals having any disease involving the liver and by
tiiose with a predisposition to liver disturbances.



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414 DIETETICS FOE NURSES

Exercise and Lack of Exercise are potent factors in
the treatment of conditions involving the liver. First, be-
cause the liver requires exercise to enable it to empty itself
more completely and assure a free flow of bile; second, be-
cause exercise directly affects the energy output of the body,
causing an increased rate of metabolism and a better utili-
zation of the food ingested. Lack of exercise acts in
exactly the opposite direction, and it has been found that
with the majority of patients suffering from diseases of the
liver too little exercise and too much food are at the bottom
of the trouble.

Dietetic Treatment in the majority of diseases affecting
the liver is much the same. The keynote in each is a bal-
anced diet. Constant overeating and excessive drinking
have proved the foundation of the majority of such dis-
eases, especially of the bilious type, while an excess of fat
and carbohydrates in the diet lead to the more serious dis-
orders.

Biliousness requires abstinence from food for a short
period and a cleansing of the entire gastro-intestinal tract,
the measures being directed by the physician. After the
bilious symptoms have subsided, a simple, well-regulated
diet should be established, in which no rich foods of any
sort are allowed. All condiments and spices which have an
astringent effect upon the bowels are strictly prohibited, and
alcoholic beverages had best be eliminated from the diet.

Cirrhosis of the liver is apt to be insidious in its develop-
ment, taking a firm hold before the character of the disorder
is discovered. Dietetic treatment of this disturbance is
most important and should be directed toward overcoming
not only the liver symptoms but other symptoms as well.

Gastro-intestinal Disturbances, manifested in cirrhosis
of the liver, are treated by the diet used in chronic gastritis
(see p. 250).

Heart Sjrmptoms sometimes occur during the course of



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DISEASES OF THE LIVER 415

the disease and require especial attention to the diet. The
fluids at times must be restricted, in which case a modifica-
tion of the Karell Cure will prove valuable (see p. 342).

Kidney Complications develop in a certain percentage
of cases, and it then becomes necessary to institute one of
the various diets devised to meet the needs of those special
conditions (see Chapter XVIII).

Restricting the Diet will be found to be necessary for
those individuals showing a tendency to cirrhosis, also for
those in whose family diseases of the liver are of frequent
occurrence. Such individuals should be warned of the dan-
gers arising from overindulgence in food or alcoholic bev-
erages.

Prohibited Foods are those which by reason of their
astringent qualities favor the development of constipation,
such as condiments and spices; those foods which exert a
stimulating and irritating effect upon the liver and bile
passages, such as alcohol, malt extractives, etc.; and fats
and carbohydrates in excessive quantities, on account of the
extra amount of work required of the liver in order to make
them available in the body.

Gallstones develop as the result of inflammation or
clogging of the bile passages.

Treatment is dietetic in character and is directed toward
relieving or preventing inflammation in the bile passages,
also in stimulating the flow of bile in order that it may not
become sluggish and thus give rise to the development of
the gallstones.

The Fats, therefore must be restricted in the diet, as
they, more than any of the other food constituents, favor
the above conditions.

Peristalsis in the intestinal tract must be stimulated to
facilitate a free flow of bile, which will not occur where
the movements are sluggish. Stasis of the bile must be
prevented or stones will be apt to form.



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416 DIETETICS FOR NURSES

Dietetic Treatment for gallstones is therefore directed
to increase the flow of bile and to avoid the inflammation
of tiie gall bladder and bile passages which may result from
the product of intestinal putrefaction.

The Diet consists of foods simple in character, low in
fats, but abundant in quantity, in order to prevent consti-
pation. It must be selected carefully that digestional dis-
turbances may not develop.

The Meals should be frequent, from four to six a day, in
order to encourage a free flow of bile.

Breakfast should be ample in order that the bile secreted
and accumulated during the ni^t may be utilized as soon
as possible.

Constipation must be avoided, and tiie foods par-
ticularly adapted to prevent or overcome this condition
should have a prominent place in the diet. Any accumula-
tion of unabsorbed food in the lower intestines becomes a
breeding ground for putrefactive bacteria, the product of
whose activity imposes a serious tax upon an already over-
worked organ.

PROBLEMS

(a) Formulate a diet for a patient suffering from gall stones.
Outhne method of administration.

(b) List available foods for diets used in disturbances of the
liver. List the foods to be avoided in such cases.



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CHAPTER XXII
GOUT, OBESITY, EMACIATION

Gout is a constitutional disease characterized by an in-
flammatory condition of the joints. It is caused by or
associated with a retention of uric acid in the blood. Gout
is also characterized by the deposit of uric acid or sodium
salts which occurs in different parts of the body, the joints,
the lobe of the ear, the knee and the elbow being common
points where . the deposit of these salts ordinarily occurs.
The amount of uric acid is lessened in the urine in cases of
true gout, except in acute attacks, and in this way it is
distinguished from the so-called goutiness in which a urinal-
ysis shows an excess of uric acid. According to Strouse, this
excess of uric acid in the urine "means a physical-chemical
change in the urine and is quite different from the small
amount usually excreted." *

Source of Uric Acid. — In man the uric acid which is
eliminated in the urine is derived from two sources. It may
be taken with the body as purins in food, in which case it
is spoken of as being an "exogenous" product, or it may be
formed in the body from the breaking down of the nucleo-
proteins (the highly nucleated cells of the glandular organs
particularly). When the uric acid is formed in this man-
ner as the result of the metabolism of the body tissues, it
is known as "endogenous." In the normal body approxi-
mately one-half of the uric acid formed is oxidized, while
the remaining half is eliminated from the body by way of
the urine.

Elimination of Uric Acid. — In gout such is not the
case, ihe body loses to a certain extent the ability to elimi-

*"Food for the Sick," p. 97, by Strouse and Perry.
417



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418 DIETETICS FOR NURSES

nate the uric acid, hence it is retained within the body,
causing an excess in the blood stream, and it is this excess
uric acid in the blood which causes the acute attacks and
general pain and discomfort which inevitably occur in
chronic gout.

Purin-bearing Foods as Sources of Uric Acid. —
Formerly no difference was made in food ; all were supposed
to cause uric acid formation, but with the exhaustive inves-
tigation of food materials this sweeping condemnation has
been to a great extent removed or narrowed down to a few
foods, those rich in purins being the chief offenders.

Chief Causes of Gout. — Without a doubt, overeating,
overindulgence in alcoholic stimulation, lack 9f exercise, etc.,
are chiefly to blame for the large percentage of the cases,
but upon investigation it will be seen that those individuals
are as a rule large protein eaters and that their mode of
living is not such as to assist the body in throwing off the
poisons which form as the result of their self-indulgence.

Rules to Combat Gout. — To successfully combat the
retention of a large percentage of uric acid in the blood
there are certain definite rules to be observed: (1) The gen-
eral diet must be reduced not only in amount but also in
purin-bearing foods; (2) All foods which are liable to cause
digestional disturbances, with the attending evils of intes-
tinal putrefaction and constipation, must be avoided.

Alcohol in Gout. — If the patient is accustomed to
alcoholic stimulants and has been in the habit of taking
them constantly for years, the amount of alcohol consumed
daily must be radically reduced and only the amount pre-
scribed by the physician taken. Alcohol without a doubt
assists in the retention and increases the difficulty of uric
acid elimination by the body. In view of the present
knowledge of the cause and effect of uric acid in the body,
the treatment of gout is directed with the object of reliev-
ing the condition (1) by facilitating the elimination of uric



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GOUT, OBESITY, EMACIATION 419

acid from the body, and (2) by so regulating the diet as to
exclude as far as possible those purin-bearing foods which,
by reason of their chemical composition, augment the gen-
eral amount of uric acid formed within the organism.

In gout, as in other abnormal conditions, no set rule
can be laid down to cover the treatment of every case. The
individual must be taken into consideration, his daily habits
studied and the extent and character of the disease known
before it is possible to prescribe a treatment or formulate a
diet which would adequately meet his needs under the
existing conditions.

Obesity and Glycosuria. — Gouty individuals often be-
come obese and show evidences of glycosuria. Consequently
it is important to regulate the carbohydrates as well as the
purin-bearing foods in the diet. Only the simplest foods
are permissible. In acute attacks it has been found that
milk and alcohol cause less disturbance than meat and al-
cohol. While the acute symptoms exist all meat should be
avoided and the daily allowance of alcohol cut down. Tea
and coffee both contain purins and should be avoided while
the acute stage of the disease continues. Cereal coffee, hot
water, tea or hot milk or buttermilk may be substituted.

Purin-free Diet. — A purin-free diet is advisable during
the acute attack. The following is a sample menu of such
a diet:

Breakfast — Banana, apple, grapefruit, orange or

peach, etc.
Cereals: farina, hominy, or cream of

wheat with cream and sugar
1 egg, soft cooked
Buttered toast
Cereal coffee with sugar and cream or

hot-water tea (milk and hot water)

with cream and sugar



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420 DIETETICS FOR NURSES

Lunch or Dinner — Poached egg on toast, 1 large baked po-
tato with butter, 1 mold of fruit jelly
with cream
Supper — Rice and butter, bread or toast with hot
milk
Apple sauce with cream

Purin Per Cent,

Cocoa contains . . . 1.00 per pint
Tea " ... 1.20 per pint

Coffee " ... 1.70 per pint

Purins are soluble in water, hence those foods that are
boiled contain less than those prepared by other methods
of cookery.

Foods More or Liess Condemned. — Salt has a tendency
to bring about a deposit of sodium urates in the body, and
for this reason should be sparingly used in the preparation
of the diet. Alkaline waters are inclined to produce a like
result, consequently should be avoided by the gouty indi-
vidual. Condiments and spices are conducive to constipa-
tion, a condition to be avoided if possible under the cir-
cumstances. Certain physicians prohibit the use of oranges
in the diet of gout, while others do not. Strawberries are
likewise condemned and should be eliminated from the diet
for both chronic and acute gout.

Diet in Chronic Gout. — In chronic gout it is necessary
to maintain the general health of the patient by a well-
balanced diet. This is not difficult even if the dietary is
so regulated as to be well within the limits of his energy
requirements. It is necessary to limit the purin-bearing
foods. Meats are used sparingly and these should be boiled
rather than roasted or broiled. Eggs and cheese and milk
should be substituted for at least part of the regular allow-
ance of meat.

Exercise and Massage. — The patient should be recom-
mended to take a certain amount of mild exercise in the



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GOUT, OBESITY, EMACIATION 421

open air, or massage if he is accustomed to living an indoor
life or is confined to office work. He must be warned against
over-indulgences of all kinds, especially of overeating and
drinking. A glass or two of hot water before breakfast is
recommended.

Treatment of Obesity. — The treatment of obesity
when occurring in gouty patients is much like that used in
other conditions. Ebstein regards obesity under such cir-
cumstances as an unfavorable symptom. He advises a re-
duction in the carbohydrates to the smallest possible
amount and allows meat and fats in the diet.

Allowable Foods. — The following foods are practically
purin-free and may be used in the diet of gout: ^ Milk,
cheese, butter, eggs, nuts, gelatin, fruits, sugar, breads made
with white flour, cereals, cream of wheat, farina, rice, hom-
iny, tapioca, cornstarch, potatoes and other root vegetables,
green vegetables, except asparagus, spinach, and all fats.

Avoidable Foods. — The following foods are rich in
purins and should be avoided in the diet for gout: Sweet-
breads, liver, kidneys, beef, mutton, veal, pork, turkey,
chicken, goose, rabbit, duck and other game, fish, with the
exception of cod, sardines, and anchovies, tea, coffee, and
cocoa.

The following list shows the purin content of some of
the above-mentioned foods. The purins are computed by
Hall as follows: 1 kilogram contains,

Qrams Purin Orama Purin

Milk Flour

Butter Bread

Eggs Cauliflower

Cheese Eggplant

Farina Cabbage

Rice Lettuce

Hominy Sugar

Potato 0.02 Peas .... 0.89

'The amount of food must be limited, since overeating will precipitate
an acute attack. It is best to limit the amount to about a maintenance
allowance or a little more, temporarily.



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422 DIETETICS FOR NURSES

Orams Purin Grams Pwin

Aspara^s 0.21 Oatmeal . . . 0.53

Lentils 0.38 Beans .... 0.63

Halibut 1.00 Chicken ... 1.20

Cod 05 Sherry

Salmon 1.00 Claret

Mutton 0.96 Whisky

Beef 1.10-2.00 Brandy

Veal 1.10 Beer .... 0.12

Ham 1.10 Porter .... 0.14

Pork 1.20 Ale 0.14

Chocolate . . . 0.70 per pint

To keep the body in good condition and to help rid it of
accumulated poisons, the following diet lists are recom-
mended:

Daily Dietaries:

7 A.M. — Hot water, 8 oz.

8 a.m.

Breakfast — Stewed prunes, wheatena and cream
2 eggs

2 slices of buttered toast
1 cup of milk flavored with cocoa or coflfee or 1
cup of cereal coffee with cream

Dinner — Cream of pea soup

Boiled codfish with cream sauce
Mashed potatoes
Cauliflower
Rice pudding

Supper — Cream toast

Baked potatoes
Egg nest
Apple sauce

Hot milk flavored with coffee, cocoa, or 1 cup
of cereal coffee

7 A.M. — Hot water, 8 oz,



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GOUT, OBESITY, EMACIATION 423

8 a.m.
Breakfast — Grapefruit

Cereal and cream

Soft scrambled eggs

Cereal coffee, or milk and coffee

Buttered toast

12:30

Lunch — Cream of tomato soup

Cottage cheese and cream

Baked potato

Baked apple

Bread and butter

6 p.m.
Dinner — Chicken, small piece, no gravy or rich dressin^:
Candied sweet potatoes
Baked eggplant

Lettuce salad (lemon juice instead of vinegar)
Bread and butter
Orange or wine jelly
Milk

Breakfast — Cereal and cream

Baked apple with cream

1 slice of bacon

1 soft-cooked egg

Toast — butter

Cereal coffee, or milk flavored with coffee

Lunch — Vegetable soup

Scalloped potatoes
Cream cheese
Bread, butter
Stewed pears



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424 DIETETICS FOR NURSES

Dinner — Halibut steak

Creamed potatoes

String beans

Fruit salad

Sponge cake, orange sauce

Small coffee

OBESITY

Probably no one problem affecting the human family is
more widely discussed than that of obesity. There are
numberless "cures" suggested, most of which contain some
good, but they are as a rule more strenuous than the aver-
age fat person cares to attempt, or, if attempted, persist in.

Causes of Obesity. — It is stated that at least fifty per
cent, of the obesity is of hereditary origin, while the rest
may be due to overeating and drinking, unbalanced diets,
metabolic changes due to the approach of menopause in
women, and diseases such as gout in which there is a cer-
tain amount of. disturbance in the blood and excretory
organs and in which the diet or the disease may be account-
able for the gain of surplus adipose tissue. Women ap-
proaching menopause may not change their diet in the
least and there may still be the noticeable increase of fat.

Obesity Cures. — A great number of the "cures" are
undertaken not from a health standpoint but from the
esthetic point entirely. It makes no difference what reason
is brought forward for instituting the treatment, it is the
results which count. Of the cures undertaken which are in
themselves good, but which are too strenuous for the aver-
age "fat person" to stick to may be mentioned some of the
early cures instituted and recommended by Banting, Oertel,
and Ebstein. Obesity, then, may be said to be due to (1)
heredity, (2) overeating and drinking, (3) lack of exercise
(sedentary life), (4) a combination of the above causes.
Whether the obesity is due to the lack of exercise or the



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GOUT, OBESITY, EMACIATION 425

lack of exercise is due to the accumulation of fat which
causes a disinclination to move on the part of the indi-
vidual, can only be judged when a thorough examination
into the life and habits of the patient is made.

Comparison of Food Intake and Energy Output. —
Many fat people who claim to be small eaters in reality
constantly consume more food than their age, weight, or
mode of living would necessitate. If such patients could
be prevailed upon to keep a correct chart of their daily
intake of food and the amount of exercise taken, they would
be astounded to find how much greater was the intake in
comparison to the output of energy, in otiier words, how
much more food they ate than they required to keep them
in health. A glance at the first tables in this text will show
which foods are utilized by the body chiefly as a source of
energy.

Uses of Food in Body. — Physiological chemistry
proves that when more food is taken than is needed for
the internal and external work of the body, the surplus is
stored for future use, first, in the liver and muscles as gly-
cogen for the general expenditures, and, second, as adipose
tissue for future use. Thus it is seen that when the intake
is constantly greater than the energy expenditure there
must necessarily be some way in which the body can store
up the surplus fuel, and so long as the digestion remains
good and the amount of exercise limited there is no reason
why there should not be a constant and steady accumula-
tion of surplus fat which inevitably terminates in obesity.

Water as a Fat Maker. — That water is in itself fatten-
ing is of course untrue. A chemical analysis of this fluid
shows that it is inorganic in character and cannot alone
either produce energy or build tissue. However, this food
constituent plays a most important part in all the functions
of the body. In the first place the body cannot utilize food
unless it is in solution ; water is also one of the best known



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426 DIETETICS FOR NUKSES

stimuli to the flow of gastric juice, and for this reason is an
important factor in the preparation of the food for its ab-
sorption and utilization; since water forms the bulk of the
blood, it acts as a distributor or carrier of food to the differ-
ent parts of the body.

Limiting the Fluids in Obesity. — Thus it is seen that
when the intake of fluids is limited, the body will call upon
that surplus which is stored in every nerve, tissue, and fluid
throughout the entire organism to assist in the necessary
work of the organs, thus reducing the body weight just that
much.

Exercise. — The athlete who is overwei^t, due to
adipose tissue, increases his exercise at times, even adding
to the weight of his clothing, causing an increased energy
output, profuse perspiration, etc., all of which causes the
body to use its surplus fuel in the form of the stored fat.
Exercise does not break down a muscle, it builds it up.
Thus many individuals who increase the strenuousness of
their exercise complain that their weight is increased even
when they observe a noticeable improvement in their gen-
eral feelings and appearance.

The Appetite. — The great trouble with most women
who undertake an obesity cure which calls for an increased
amount of energy is that they will develop an increased
appetite thereby which they appease with food instead of
forcing the body to use the store in hand, thus entirely doing
away with any good the treatment might have accom-
plished. No amount of exercise without a proper regulation
of the diet will prove satisfactory as far as the reduction of
fat is concerned. The following methods recommended by
Banting, Oertel, and Ebstein are included here.