on a sleeping porch instead of in a poorly ventilated bed-
room.
The patient must be urged to eat, regardless of appetite,
for in this way only can the body weight be increased. The
dietary must be made up largely of the fat-forming foods,
but not to such an extent as to upset the nitrogen equilib-
rium.
The following diet sheet is given to be used as a guide
in the treatment of emaciation. Other foods of a similar
composition and fuel value may be substituted for those
given here, to vary the diet.
Emaciation Diet Sheet
Approximately 5106 calories
Material
Breakfast :
Stewed prunes
Sugar .
Oatmeal . .
with cream and
sugar . .
Poached egg .
loast .
Butter . .
Coffee . . .
with cream and
sugar
Milk and cream
Amount
6 prunes
Itbs.
1 tbs. (dry)
2 tbs. cream
1 tbs. sugar
legg
3 slices
Itbs.
1 cup
1 tbs. cream
2t8p.
8 cup milk
J cup cream
}
Protein
Gm.
1.02
3.2
5.35
7.9
.40
Carbo-
hydrate
Om.
35.26
14.7
25.0
44.7
.40
9.45
Fat
Gm.
6.6
4.16
13.0
2.8
Total
Calories
145.
56.6
172.2
58.8
328.
53.9
389
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GOUT, OBESITY, EMACIATION
Emaciation Diet Sheet — Continued
443
Material
Amount
Protein
Om.
Carbo-
hydrate
Om,
Fat
Om.
Total
Calories
11 A.M.
Cereal milk gruel
with cream
Lunch, 1 P.M.:
Cream of pea soup
Potato salad . .
Bread • . . •
Butter
Cocoa made with
milk . . .
Sug^r . . .
Milk ....
Cream . . .
3:30 P.M.
Cream, egg, vichy
Dinner :
Tomato bouillon
with whipped
cream . . .
Beefsteak . . .
Mashed potatoes
Cauliflower . .
Asparagus salad
with mayonnaise
Bread ....
Butter . . .
Charlotte russe .
Milk ....
and cream .
Black coffee if de-
sired
At bed time:
Malted milk . .
made with milk
and reenforced
with lactose .
8 oz. (1 cu;
1 ounce
ip)|
8 oz. (1 cup)
3.5 oz. (1 seiT-
ing)
3 slices
Itbs.
Icup
2tsp.
icup
J cup
8oz.
Icup
Itbs.
1 serving (8
oz.)
J cup
1 serving
6 stalks
2tsp.
2 slices
2tbs.
1 serving
icup
icup
}cup
}
1 cup
1 ounce
6.
1.76
7.8
.8
27.
4.9
.30
18.6
1.16
1.53
2.00
.01
5.2
.28
2.3
8.4
17.66
15.6
44.7
1.4
27.6
12.4
.42
7.5
2.99
3.72
1.45
29.8
11.1
41.
7.66
15.33
1.04\
5.6 J
41.4
36.
5.67
17.34
3.5
.42
.241
9.00 f
.68
24.09
22.6
10.2
248.
185.9
210.
328.
661.
38.
53.9
230.6
66.5
21.8
111.8
419.
257.
389.
288.5
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444 DIETETICS FOR NURSES
Methods of Increasing the Diet. — The above diet fur-
nishes three times as much food as is needed to maintain
the body living a sedentary Ufe, or about as much as would
be needed to maintain a lumberman at hard outdoor labor
in the Maine woods. It would be impossible for an ordi-
nary individual to handle such an abundant diet without
making the increase in the diet gradually. This is best
done by adding the milk and cream at the end of each meal
and a glass of milk between meals and at bedtime, then
gradually adding the fattening foods already mentioned until
the diet approximates the diet sheet here computed.
SUMMARY
GOUT
Gout is a constitutional disease characterized by an in-
flammatory condition of the joints.
The Joints are the seat of chalky deposits of iiric acid or
sodium salts.
Metabolism in gout is disturbed, with a consequent re-
tention instead of elimination of uric acid by the body.
The Blood contains an excess of uric acid which increases
greatly during an acute attack.
The Urine in true gout does not contain an excess of
uric acid except during an acute attack, whereas in the so-
called goutiness there is a constant excess of this acid.
Uric Acid is produced as the result of the metabolism in
the human body of the nucleoproteins and in food of the
purin bodies.
Alcohol undoubtedly assists in the retention and in-
creases the difficulty of uric acid elimination by the body.
Chief Causes of Gout. — Overeating, excessive alcohol-
ism, and too little exercise, especially in the open air.
Treatment consists in regulating the diet both as to the
quantity and type of food eaten; reducing or eliminating
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GOUT, OBESITY, EMACIATION 445
the alcohol in the: dietary, and increasing the amount of
outdoor exercise.
Dietetic Treatment. — The best results are obtained by
reducing the size of the meals and avoiding the purin-bear-
ing foods as far as possible. Eggs are purin-free and may
be substituted for much of the meat in the diet. In chronic
gout it is impossible to eliminate meat entirely from the
diet, but the quantity can be materially reduced and that
which is eaten may be rendered less harmful if it is boiled
instead of roasted or broiled, as in this way much of the
purin is dissolved out. Highly spiced and seasoned foods,
rich gravies, etc., are apt to cause an acute attack and
should be omitted. Excesses of all kinds must be avoided
to enable the patient to live a fairly comfortable life, free
from frequent painful attacks of gout.
OBESITY
Causes. — Heredity, overeating, unbalianced diet, chronic
alcoholism, and disturbed metabolism, as manifested in gout
and other pathological conditions.
Cures are more or less of a risk, except when under-
taken upon the advice and under the care of a competent
physician. As a rule they are too strenuous to be carried
out alone and are of no good unless persisted in. Among
the best known obesity cures may be mentioned those for-
mulated by Banting, Oertel and Ebstein.
Most physicians have their own methods of treating
obesity, but all are based primarily on diet and exercise.
Food is the chief cause of obesity and since some foods
are more readily converted into adipose tissue than others,
it is necessary to understand the behavior and functions
of the various food combinations in the body before it is
possible to say which are the offending articles of diet.
Water has no fattening properties of its own. This is
proved by a glance at its chemical composition, but as it
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446 DIETETICS FOR NURSES
acts as a distributor and carrier of food to the various parts
of the body and since the bulk of all the secretions is com-
posed of water and every tissue in the body stores this
fluid, thus adding to the wei^t, a consideration of the
intake of water for obesity patients is most essential.
Appetite requires attention. The majority of obese
patients eat more than their energy output calls for, conse-
quently it is necessary to curb the appetite and increase the
energy output in order to utilize the material on hand in
the form of adipose tissue.
Exercise is absolutely essential in order to force the body
to bum up its surplus fat as fuel. The best form of exercise
is that which is taken out of doors. The well-worked muscle
is heavier than one which is unaccustomed to exercise. The
latter is infiltrated with fat and weighs less than muscular
tissue, but a muscular body can endure more than one which
is covered with adipose tissue.
The Heart of obese patients becomes more or less
affected as obesity advances and it becomes absolutely nec-
essary in many cases to get rid of some of the surplus fat
in order that the patient may live. This is best accom-
plished by dietetic treatment.
Circulatory Changes likewise occur as the heart becomes
affected, making it necessary to institute some dietary meas-
ures at once.
Glycosuria in obese patients suffering from gout is not
at all unusual and to relieve this condition the carbohy-
drates in the diet must be at once reduced.
Dietetic Treatment is most important. It constitutes
the only rational method of ridding the body of its surplus
fat. To do this it is necessary to regulate the diet both as
to quantity and type. Fat-forming foods are those which
the body utilizes most easily for the production and storage
of fat. Any food, no matter whether it is fat-forming or
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GOUT, OBESITY, EMACIATION 447
not, if taken greatly in excess of the needs of the body, will
be stored as adipose tissue.
Chief Points to be remembered in formulating a diet
and instituting an obesity treatment are the necessity for
small meaU and dry media, no fluid given at all during the
meal except perhaps one or two small cups of coffee per
day, without sugar or cream, the avoidance of fat-forming
foods, sugars and starches in all forms, milk, cream, butter
and oil, potatoes, bananas, fat meats of all descriptions,
especially pork, soups of every description and alcoholic or
malted beverages. It is necessary to limit the amount of
sleep, prohibiting naps during the day, and to increase the
amount of outdoor exercise.
Massage is advisable, especially in those patients who
are unable, on account of their excessive weight or heart
S3anptoms, to take the requisite amount of exercise neces-
sary for their future welfare. Massage likewise makes the
muscles firmer, often preventing the disfiguring sagging of
the skin caused by depriving it of its padding of fat.
EMACIATION
Causes. — Errors in diet, overwork, over-exercise,
heredity, nervousness, worry, malformation of the mouth,
throat, or stomach, heredity and certain pathological con-
ditions, such as typhoid fever, tuberculosis, anemia, dysen-
tery, etc., in which the breaking down of the tissues occurs
more rapidly than they can be rebuilt.
Children are often emaciated on account of their unbal-
anced diet. They receive an insufficient amount of building
food to cover their growth and development requirements.
Parents are often to blame for allowing the child to overeat
of some of the food constituents at the expense of others.
Sugar, for example, is very necessary in the diet of a grow-
ing active child, but all sugar and very little milk and eggs
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448 DIETETICS FOR NURSES
will lead to an unbalanced diet which may bring about a
condition of extreme thinness later on.
In Adults the constant eating of the wrong foods, over-
working and persistent worrying, all contribute to the break-
ing down of the tissues which ends in emaciation.
Weight is an index to health. Any persistent loss of
weight on the part of an adult or loss or even failure to
gain in a growing child, are indications that all is not ri^t
and immediate measures must be taken to locate and relieve
the trouble.
Loss of Weight due to pathological conditions can only
be relieved by removing the cause, after which the diet may
be adjusted to suit the condition.
Dietetic Treatment is practically the only means of
combating and overcoming emaciation, since it is by food
alone that the body is built.
Fat-forming foods, which in obesity were prohibited,
have a prominent place in the diet for emaciation. Padding
the nerves and organs with a layer or covering of fat pro-
tects them from the jars and shocks incidental to daily life,
besides lending grace and contour to the body.
Foods Which Produce Fat are nutrient beverages of all
sorts; milk, malted milk and cream are especially valuable;
water, because of its particular properties and functions in
the body; and fruit beverages, which are made chiefly of
water and sugar, are always included in the dietary. Milk
and cream, soups and milk gruels, as well as all dishes made
with milk or cream, add materially to the fat-forming
quality of the diet. Butter, olive and other salad oils, as
well as cereals, potatoes, bread and simple desserts are ad-
vised. The diet must be bountiful, the meals frequent, and
lunches consisting of milk or cream with crackers will hasten
the gain in weight.
Rest, preferably lying down, is absolutely essential. A
period of relaxation covering from fifteen to thirty minutes
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GOUT, OBESITY, EMACIATION 449
should be taken before or after each meal. The body de-
rives the use of the food for the storage of fat which would
otherwise be required to cover its energy expenditures.
Sleep is essential to gain, consequently the patient
should retire early and take one or two naps during the day.
Baths should be warm, not hot, followed by a cold
shower or sponge.
Exercise must be mild in character; over-exertion pre-
cludes a gain in weight and exhaustion undermines the
forces which make it possible for the body to store fat as
adipose tissue.
Nervous Excitement and Worry must be avoided.
Gastro-intestinal Disturbances should be guarded
against, since all the pounds gained through months of
treatment may be quickly lost during one acute attack of
diarrhea or auto-intoxication.
Massage is advised. The kneading and gentle manipu-
lation of the muscles stimulates them to utilize more food
material, besides enabling the patient to eat more by rea-
son of an increased appetite.
The Milk Cure has been used extensively in overcoming
extreme emaciation. It consists in the taking of large quan-
tities, ranging from one to two gallons per day. It is given
every hour or oftener for a period of one month to six
weeks.
Reenforcing the Diet with eggs and lactose is often
foimd of great value in increasing the weight quickly, as is
the giving of one-third of a glass of cream and two-thirds
of a glass of milk after each meal and at bedtime. The
whole scheme of putting on pounds resolves itself into the
giving of proper food in larger quantities than are ordinarily
given, but dividing it up into frequent meals in order not
to upset the digestion and do away with the good already
accomplished.
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450 DIETETICS FOR NURSES
PROBLEMS
(a) Formulate a diet order for a patient with gout in which
the purin foods are eliminated.
(6) Formulate a diet order for an obese patient whose heart
is more or less affected.
(c) List the foods of special value in the diet for emaciation.
Write a diet order for day suitable for a patient
(woman) weighing 110 pounds, whose normal weight
is 135 pounds.
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CHAPTER XXIII
OTHER CONDITIONS MORE OR LESS AFFECTED
BY DIET
PTOMAINE POISONING, ACIDOSIS AND PELLAGRA
PTOMAINE POISONING
The poisoning due to ptomaine is very similar to that
brought about by overeating and other dietetic errors.
However, it is not so easy to avoid being poisoned by pto-
maines as it is to observe moderation in the quantity of
food eaten.
Origin. — These substances are believed to be of an
infective bacterial origin and may be present in foods which
are otherwise seemingly fresh and good. The fact that they
cannot be detected in food without an analysis makes them
more of a menace than they would otherwise be, for any
substance which is not discernible to our senses, the taste,
sight, or smell, and which exerts a baleful influence, such
as ptomaine, cannot be anything but a menace to humanity.
Infected Food Materials. — We may congratulate our-
selves in the knowledge that these substances are not pres-
ent in many foods, and if we avoid eating nitrogenous ma-
terials, which may have become polluted, either through
imperfect canning or by standing in unclean vessels, we
may avoid much of the poisoning which may otherwise be
due to the action of ptomaines.
Chicken Salad and Ice Cream Poisoning. — Certain
violent attacks of so-called ptomaine poisoning may be
traced to chicken salad which has been allowed to stand
overnight in tin receptacles or to ice cream which has melted
451
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452 DIETETICS FOR NURSES
and been re-frozen. In any case the treatment remains the
same.
Treatment. — The patient is put to bed and the intes-
tinal tract cleansed by means of enemas and in many cases
purgatives (salts, castor oil, etc.) as directed by physician.
The symptoms usually present in those suffering from
ptomaine poisoning are nausea, vomiting, dizziness, pain
more or less violent in character, and prostration which is
at times alarming.
Dietetic Treatment — The treatment instituted under
the circumstances is very much the same as that used in
other forms of acute poisoning. All food is withheld for a
period; the duration of this starvation must necessarily
depend upon the condition of the patient, the violence of
the poison and the extent of the prostration.
Rectal Feeding. — When the prostration is great, it is
sometimes necessary to give saline enemas and even rectal
alimentation to prevent collapse.
Fluid Diet. — After the violent attack subsides, the pa-
tient is placed upon a fluid diet similar to that used in auto-
intoxication and practically the same as the diet for acute
infectious diseases. The diet must be gradually increased
until it becomes normal and the nurse must remember that
the patient is in a condition to suffer a relapse with the least
indiscretion. It is advisable to have a thorough investiga-
tion made to ascertain the source of the original attack,
that the patient may be able to avoid future trouble from
partaking of the same food.
Personal Idiosyncrasies. — It may be that there is a
personal idiosyncrasy against one particular food, and in
this case it becomes more or less of a simple matter to pre-
vent future attacks. Certain individuals are, for example,
invariably poisoned by eating shellfish, others manifest a
similar idiosyncrasy against strawb^ries. Thus is the old
proverb demonstrated: "What is one man's meat is an-
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CONDITIONS AFFECTED BY DIET 453
other man's poison." And he who wantonly flies in the
face of the danger signals Nature provides for his guidance
must necessarily sufiFer the consequences of his folly.
It has been proved with certain individuals that the
foods that at one time cause an attack of poison at another
time may be eaten with impunity. Thus it would seem to
remain a question not so much of the t3T)e of poison, pto-
maines, etc., as the amount of resistance manifested at the
time by the individual partaking of the infected food.
Aanosis
Metabolism of Fats. — Acidosis is a condition believed
to be due primarily to some impairment in the metabolism
of fat in the body, in consequence of which there is an
accumulation of substances more or less irritating and at
times toxic in character in the blood. These substances,
known as acetone bodies, are especially apt to appear in
the urine of individuals suffering from diabetes, likewise in
those undergoing starvation, whether as a result of treat-
ment to overcome a definite pathological condition, as in
diabetes, or as the result of disease itself.
Malnutrition as a Source. — Certain individuals, chil-
dren especially, develop symptoms of acidosis under many
different circumstances; for example, in many cases of mal-
nutrition the evidences of acidosis are almost invariable.
The treatment in these cases must be, of course, prompt in
order that the condition may not assume a serious aspect.
Dietetic Treatment. — The diet is adjusted in order to
neutralize the effect of the acid in the blood. This is done
in two ways: first, by reducing the fat, and second, by in-
creasing the amount of base-forming foods in the diet.
The following table * illustrates the foods in which the
acid-forming elements and base-forming elements predomi-
nate:
* "Chemistry of Food and Nutrition" (revised), by Henry Sherman.
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454 DIETETICS FOR NURSES
Foods in Which Acid-Fobmino Elements Predominate
Estimated Excess Acid-forming Elements Equivalent to C.C. Normal
Acid per 100 Calories
Beef, free from visible fat 10
Eggs 9
Round steak 6.7
Oatmeal 3.2
Wheat flour . 2.7
Wheat, entire grain 2.6
Rice 2.4
Bacon 1
Com, entire grain (high protein) 1
Foods in Which Base-Forming Elements Predominate
Estimated Excess Base-forming Elements Equivalent to C.C. Normal
AlkcUi per 100 Calories
Celery 40
Cabbage 10-13.6
Potatoes 9-12
Prunes 7.9
Turnips 6.e-12.5
Apples 5
Milk 3.3
Beans 2.9- 6.8
Peas 1.9
Com, entire grain (low protein) .8
The fruits likewise show a predominance of base-forming
elements over acid-forming elements and for this reason
may be used to balance the diet.
Diabetic Acidosis. — The acidosis during diabetes has
been already discussed in the chapter devoted to that dis-
ease.
It has been found advisable in the majority of cases of
acidosis to restrict the fat in the diet of all patients who,
during the course of a disease, have given evidence of this
condition ; at the same time it is well to remember that fat
is one of the essential food constituents and absolutely nec-
essary to the welfare of the individual, consequently it is
impossible to eliminate it from the diet entirely. The only
feasible method, then, to pursue under the circumstances
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CONDITIONS AFFECTED BY DIET 455
is to restrict the fats in the diet so long as there are symp-
toms of acidosis and to add them gradually and in very small
amounts until the individual's tolerance for fats is deter-
mined.
Balancing the Diet. — In many cases of acidosis due to
starvation, no matter what the cause, the diet must be nec-
essarily regulated and properly balanced. It would be
decidedly unwise to attempt to build up the body by giving
building foods alone, without due consideration to the foods
containing the agents provided by Nature to neutralize the
acid formed during the process of their metabolism. It is
readily seen in the table just given that meat and eggs
show a marked excess of acid-forming elements, whereas
vegetables and fruits yield an excess of base-forming ele-
ments. With these data, it becomes more simple to balance
the diet and to avoid the acidosis which may arise from im-
pairment of the fat metabolism of the body.
PELLAGRA
The enormous increase in the number of cases of pel-
lagra in America during the last twenty years makes it nec-
essary for something to be done to arrest its progress. The
cause of this disease is still under discussion, but much has
been done to find out definitely the reason for the tremend-
ous increase in the number of cases, especially in the
Southern States, where the increase has been most notice-
able.
Cause. — This disease has been the subject of much
study and discussion in this country in recent years.
Voegtlin, in an article published in a Report of the United
States Pubhc Health Service (Reprint 597 of Public Health
Report), summarizes the current findings on pellagra as
follows:
"1. The hjrpothesis that there is a causal relation be-
tween pellagra and a restricted vegetable diet has been sub-
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456 DIETETICS FOR NURSES
stantiated by direct proof to this effect and has led to results
of considerable practical and scientific value.
"2. The metabolism in pellagra shows certain definite
changes from the normal, which point to decreased gastric
secretion and increased intestinal putrefaction.
"3. In the treatment and prevention of pellagra, diet is
the essential factor. The disease can be prevented by an
appropriate change in the diet without changing oth^ sani-
tary conditions.
"4. A diet of the composition used by the pellagrins
prior to their attack by the disease leads to malnutrition
and certain pathological changes in animals, resembling
those found in pellagra. A typical pellagrous dermatitis
has not been observed in animals. Pellagrous symptoms
have been produced in man by the continued consumption
of a restricted vegetable diet.
"5. The nature of the dietary effect has not been dis-
covered, although certain observations point to a combined
deficiency in some of the recognized dietary factors as the
cause of the pellagrous syndrome."
Dietetic Treatment. — The diet in pellagra is one which
is well balanced in all its particulars, and one in which the
proteins are carefully adjusted as to tjrpe. The best results
have been observed on diets in which the complete proteins
(milk, meat and eggs) have a prominent place. As a rule,
in the diet of an adult suffering from pellagra, at least forty
grams of the necessary proteins should be in this form. The
diet for pellagra must necessarily be such as to ovw^come
as far as possible the progressive emaciation which is an
important symptom in the disease. Howevw, it must be
kept in mind that gastro-intestinal disturbances are likewise
prominent and that diarrhea is often most diflScult to over-
come. For these reasons it is essential to formulate a diet
which will not interfere with the treatment for the disease,