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DIETETICS FOR
NURSES

BY

FAIRFAX T. PROUDFIT

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

SECOND EDITION
Completely Revised

NEW YORK
THE MACMILLAN COMPANY
1923

All rights reserved

PRINTED IN THE UNITED STATES OF AMERICA

Copyright, 1918 and 1922,
By THE MACMILLAN COMPANY.

———

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

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

Dedicated
to the
Great Army of Nurses
in the Service

[Pg vii]

PREFACE TO SECOND REVISED EDITION

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

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

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

F. T. P.

[Pg ix]

PREFACE TO FIRST EDITION

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

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

[Pg xi]

CONTENTS

APPENDIX

SECTION I

FOOD AND ITS SIGNIFICANCE

Preliminary Course of Lectures and Laboratory Work

[Pg 1]

CHAPTER I

FOOD

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

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

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

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

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

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

[Pg 2] The dividing line between health and disease is frequently almost imperceptible, and without a knowledge of the normal body, it is, at times, impossible to tell where the normal leaves off and the abnormal begins. For this reason a nurse must understand normal nutrition, that is, the behavior of food in the healthy body, before undertaking the task of ministering to the body attacked by disease.

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

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

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

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

COMPOSITION OF THE FOODSTUFFS

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

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

Neither water nor mineral salts alone can be burned to produce heat; nevertheless, they enter into the composition and take part in every function performed by the carbohydrates, fats and proteins; therefore one foodstuff cannot be said to be of greater importance than another, since the needs of nature are best met by a judicious combination of all. However, the wear and tear of life can be more [Pg 4] efficiently accounted for, and the strain upon the organism reduced more nearly to a minimum when the various foodstuffs are furnished in amounts which science is proving to be necessary for the health and well-being of the organism.

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

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

THE INDIVIDUAL FOODSTUFFS AND VITAMINE FACTORS

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

CARBOHYDRATES

In the ordinary mixed diet of man, the carbohydrates predominate, being not only the most abundant, but also the most economical source of energy. The term carbohydrate covers all of the simple sugars and those substances which can be converted into simple sugars by hydrolysis; the ones of special interest in this study are divided into three groups, known as, Monosaccharides (C₆H₁₂O₆); Disaccharides (C₁₂H₂₂O₁₁) and Polysaccharides (C₆H₁₀O₁₅).

Monosaccharides.—Glucose, Fructose and Galactose are substances whose monosaccharide molecules contain one sugar radical; hence they cannot be hydrolized to simpler sugars (sugars of lower molecular weight). Those constituting this group of sugars are all soluble, crystallizable and diffusible substances, which do not undergo changes from the action of the digestive enzymes, consequently these sugars will enter the blood stream in their original form, unless attacked by the bacteria which inhabit the stomach [Pg 8] and intestinal tract. The monosaccharides are all susceptible to alcoholic fermentation. Each member of the group is utilized in the body for the production of glycogen and for the maintenance of the normal glucose of the blood.

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

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

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

Glucose, which is abundant in the juice of plants and fruits, and to a more or less degree in the blood of all animals (usually about 0.1%) occurs free in nature. This sugar is likewise obtained from many carbohydrates, either through the action of acids, or as the result of the digestive enzymes, and as such becomes the principal form in which the animal body utilizes the carbohydrates ingested. Under normal conditions the glucose in the blood is constantly being burned and replaced; it is only when the body loses to a greater or less degree the ability to burn the glucose that [Pg 9] it accumulates in the blood, from which it must escape by way of the urine. There are times, such as when very large quantities of carbohydrates are eaten at once, when glucose will also appear in the urine; but under such circumstances it is generally found to be merely temporary, and for this reason, the condition is known as temporary glycosuria. As a rule, however, the surplus of glucose absorbed, whether it be eaten as such, or is found as the result of enzymic action upon the other carbohydrates, is converted into glycogen and stored in the liver and to a less extent in the muscles. Glycogen is readily reconverted into glucose, which is used by the body for the production of energy. It has been estimated that over half the energy manifested in the human body is derived from glucose, and it is in this form that the tissues of the body will ultimately make use of most of the carbohydrates in food. Practically all of the fruits, and many of the vegetables, are rich in this form of carbohydrate, but grapes contain more than any of the other fruits, while sweet corn, onions, and unripe potatoes contain appreciable amounts.

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

Honey is the most abundant source of fructose in nature.

Galactose.—This sugar, unlike the other members of this group, is not found free in nature, but it is produced as the result of hydrolysis of milk sugar, either by enzymes or by acids. Like glucose and fructose, galactose seems to promote the production of glycogen in the body. [Pg 10] Certain substances known as galactosides, which are combinations of galactose and some substances other than carbohydrates, are found in the nerve and brain tissues of the animal body.

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

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

Maltose (Malt sugar) is an important constituent of germinating grains—malt and malt products being [Pg 11] formed as the result of enzymic action (amylases) on starch. A similar action takes place in the mouth as the result of the ptyalin in the salivary juices and in the intestines from the action of the starch-splitting enzyme, amylopsin, in the pancreatic juice. The maltose thus formed is further converted into glucose by the sugar-splitting enzyme in the intestinal juice, and in this form it is chiefly absorbed. Maltose is also an intermediate product formed during the manufacture of commercial glucose as the result of the boiling of starch with dilute acids.

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

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

Starch is the form in which the plant stores her supply of carbohydrates. It is found in this form in roots and [Pg 12] (mature) tubers, three-fourths of the bulk of which is made up of this material. From one-half to three-quarters of the solids of grains is made up of starch also. Pure starch is a fine white powder, odorless and almost tasteless. It is insoluble in cold water and alcohol, but changes from an insoluble substance to a more soluble one upon the application of heat. Upon hydrolysis starch gives first a mixture of dextrin and maltose, then glucose alone as an end-product. This hydrolysis may be the result of enzymic action, as occurs upon bringing starch in contact with the ptyalin in the saliva, or with the amylopsin in the pancreatic juice; or it may be the result of boiling starch with acid, as is seen in the manufacture of commercial glucose.

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

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

Cellulose is a woody, fibrous material insoluble in water and to a certain extent impervious to the action of the digestive enzymes. This carbohydrate constitutes the skeleton of plants just as the bones constitute that of the animal body. It is probable that owing to the length of time required for this carbohydrate to be broken down in digestion, much of it escapes oxidation entirely. Hence, it passes down the digestive tract lending bulk to the food mass and [Pg 13] thus promoting peristalsis throughout the whole of the digestive tract.

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

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

[Pg 14] The Effect of Heat upon Carbohydrates.—The changes wrought in the carbohydrates as a result of heat have already been discussed to a certain extent. It is seen that the sucrose (cane sugar) is soluble alike in hot and cold water; the same is true of maltose; but lactose is much more soluble in hot water than it is in water which has not been heated. So far as their digestibility is concerned, the application of heat (boiling) neither increases nor decreases the utilization of these sugars by the body.

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

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

FATS

The second member of the organic food group, and one which is almost as widely distributed throughout animal and vegetable life as the carbohydrates, is found in the fats. This foodstuff, while composed of the same chemical elements that go to make up the carbohydrates, contains these [Pg 15] elements in different proportions; that is, fats contain less oxygen and more hydrogen than carbohydrates.

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

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

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

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

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

Definition of Fat.—The fats are all glycerides; that is, they are substances made up of combinations of fatty acids and glycerine, which constitute a definite group of chemical compounds, certain members of which are liquid in form, while others are solid, or semi-solid. The liquid fats are known as fatty oils. The fatty acids in which we are chiefly concerned in this study are: Butyric, Stearic, Oleic, and Palmitic. Most of the common fats owe their form and flavor to the type and amount of the various fatty acids of [Pg 16] which they are composed. For example, butter is made up of ten fatty acids; but its soft, solid form is due to the olein and palmitin (glycerides of oleic and palmitic acids) which it contains; and its characteristic flavor, as well as its name, to its butyric acid content (about 5 to 6%). It is evident that the degree of softness or hardness of a fat may be determined chiefly by the amount of oleic acid in its composition. Most of the common oils with which we are familiar in food are composed chiefly of olein. Stearin (the glyceride of stearic acid) is the hardest of the fatty acids, while palmitin, although classed with the solid fats, is not so hard as stearin. Lard and butter are higher in olein and palmitin and are consequently semi-solid, while suet and tallow, consisting chiefly of stearin, are much harder than the other food fats.

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

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

Effect of Heat upon Fat.—When fats are brought to a high temperature, the glycerine which they contain decomposes with the production of a substance known as acrolein, which has an irritating effect upon the mucous membranes. It is possible that the over-heated fatty acids add their quota to the production of irritating fumes. As [Pg 17] a rule, it is inadvisable to use frying as a method of preparing food for the sick or for children. Doubtless, if every cook understood the exact degree of heat to apply in frying, and knew just how moist to have the food mixture which she intended to cook in this manner, better results would be obtained; but since the average cook knows little about the scientific application of heat to fat or the changes brought about thereby, it is safer to make use of other methods of food preparation under the circumstances.

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

PROTEINS

Upon investigation it was found that neither the fats nor carbohydrates were the chief constituents of the active tissues. It was found, in fact, that the carbohydrates [Pg 18] occurred in very small quantities only in the muscles, and that frequently the quantity of fat was likewise limited. Other substances, containing nitrogen and sulphur in addition to carbon, oxygen, and hydrogen, which were invariably present, and which are essential constituents of all tissues and cells, both in animals and in plants, must be necessary to all known life. To these substances, believed at the time to be the fundamental constituents of all tissues, Mulder gave the name Protein, from the Greek, meaning “to take first place.” Later investigations proved that, while the proteins were essential to the building and repairing of the tissues and cells in general, they were not the only factors concerned in the work; that certain mineral salts were necessary constituents of all tissues, and must be present in order for any normal growth and development to occur.[4]

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

Construction of Proteins.—In plant structure the building up of the proteins is accomplished by the plants from inorganic substances existing in the soil and air; but in the animal body this is not possible, because the construction of the tissues requires the use of other proteins—the most available ones being found in food. Each animal [Pg 19] (or species) forms the proteins characteristic of its own tissues,—while the proteins of food are similar to those found in the body, they cannot be utilized in their original form, but must be split into simpler substances from which the cells of the various tissues throughout the body may select those particularly adapted for their purpose. These transformed substances are known as amino acids, the production of which is a result of digestion in the digestive tract. There are about seventeen of these acids entering into the construction of the common proteins. One scientist has likened these units to letters of the alphabet, which, being combined, spell many proteins. When a protein contains all of the essential units, it may be said to be “complete,” the best example of which may be seen in milk, eggs, and meat. When a protein lacks some of the essential elements, or letters of the protein alphabet, it is said to be incomplete. Gelatin is the best example of this type of protein, but the cereals and beans must likewise be supplemented by other substances; milk being the one most generally used for this purpose. For the purpose of building young tissues, and maintaining those already mature, it is logical to use foods containing the foodstuffs in their best form; that is, those that not only contain the complete protein, but also the requisite mineral salts and vitamines. Foods lacking in some of these respects become adequate when supplemented by these foods which can supply the missing constituents; hence, the use of such incomplete protein foods need not necessarily be abandoned, for, as in the case of cereals, the foods are both economical and palatable, and, when used in addition to milk, furnish valuable adjuncts to the dietary.

Classification of Proteins.—A brief description of some of the more important proteins with which we are chiefly concerned will serve to simplify the formulation of a diet. Those assuming the most important position in nutrition [Pg 20] and food are globulins, albumens, nucleoproteins, phosphoproteins, hemoglobins, and derived proteins such as proteoses and peptones. The albumens and globulins associated together occur in the tissues of both animals and plants. The albumens are richer in sulphur than the globulins and are found more abundantly in the animal fluids, such as the blood, while the globulins predominate in the more solid tissues of animals and in plants. The close association of these two proteins is particularly noticeable in the blood and cells. They have different characteristics, however.

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

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

Globulins.—Simple proteins, insoluble in pure water, [Pg 21] but soluble in neutral salt solutions; examples, muscle globulin, serum globulin (blood), edestin (wheat), physelin (beans), legumin (beans and peas), tuberin (potatoes), amandin (almonds), arachin, and conarachin (peanuts).

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

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

Conjugated Proteins:—Nucleoproteins, Phosphoproteins and Hemoglobin.

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

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

[Pg 22] (c) Hemoglobin.—Much of the greater part of the iron existing in the body occurs as a constituent of the hemoglobin of the red blood cells. When the intake of iron is not sufficient to cover the output, there must be a consequent diminution in the hemoglobin of the blood with a corresponding development of anemia.

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

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

The Effect of Heat upon Proteins.—The fact that certain proteins are most susceptible to heat has already been stated, but the application of this knowledge in the preparation of protein foods is important. In milk, for example, whole raw milk forms a large hard curd; whereas boiled milk curdles in a much finer and softer form. Pasteurized [Pg 23] milk shows smaller curds than raw whole milk, but larger than the boiled whole milk.[8]

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

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

Functions of Protein in the Body.—The proteins serve two distinct uses in the body; first, that of building and repairing tissues and furnishing, in conjunction with other [Pg 24] substances, material for growth; second, that of producing energy for the internal and external work of the body. For this latter function a large percentage of the proteins ingested is used; consequently, since the carbohydrates and fats are primarily the energy furnishing material most readily used by the organism, it is clearly demonstrated that the average individual takes more protein into the body than is necessary for its maintenance. Except during the period when an allowance for growth must be made, it is probable that a much smaller daily consumption of protein could be made without disadvantage to the organism, leaving the bulk of the work, in so far as the running of the engine is concerned, to the other organic foodstuffs.

WATER

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

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

Function of Water.—The uses of water in the body are many, and the advantage arising from a sufficient amount of this foodstuff in the dietary cannot be overestimated. It is no longer considered an error in diet to drink a moderate amount of water with the meals, so long as it is not used as a substitute for mastication, and as a means [Pg 25] of washing the food into the stomach. In the diet, both as a beverage and as a part of most of the food materials ingested, water serves to moisten the tissues; to furnish the fluid medium for all of the secretions and excretions of the body; to carry food materials in solution to all parts of the organism; to stimulate secretory cells producing the digestive juices, thereby aiding in the processes of digestion, absorption and excretion; to promote circulation; to furnish material for free diuresis, thus preventing to a great extent the retention of injurious substances by the body, which might otherwise take place.

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

MINERAL SALTS

Ash.—The eight remaining chemical elements, i.e., calcium, magnesium, sulphur, iron, sodium, potassium, [Pg 26] phosphorus, chlorine, constituting the mineral salts or ash, are likewise classed as food on account of the work which they perform in the body. Some of these elements enter the body as essential constituents of the organic compounds, and are metabolized in the body as such, becoming inorganic only upon oxidation of the organic materials of which they form a part.

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

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

The above outline, showing the various ways in which the mineral constituents enter and take part in the various functions, as well as in the structure of the body, make it evident that the same close attention and study which was given to the other foodstuffs must be accorded to these substances. When the student realizes that the presence of certain salts dissolved in the blood assists in the regulation of the vital processes of the body such as the digestion, circulation and respiration; that they are responsible for the contraction and relaxation of the muscles; that they assist in controlling the nerves; that they are, in a way, [Pg 27] instrumental in releasing the energy locked up in food—the value of these elements becomes very evident, and their importance in the dietary inestimable. Some of the mineral salts are more widely distributed in food than others, and the danger arising from their deficiency in the diet is not so great as is the case with others; hence attention is called to those found by investigators to be most often lacking or deficient in the average diet; i.e., calcium, phosphorus, and iron. A brief summary of the special parts played by these elements will be outlined here.

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

Phosphorus.—According to Sherman, phosphorus compounds are as widely distributed in the body, and as strictly essential to every living cell as are proteins. Science has also proved that they are important constituents in the skeleton, in milk, in glandular tissue, in sexual elements, and in the nervous system; that these compounds take part in the functions of cell multiplication, in the activation and control of enzyme actions, in the maintenance of neutrality in the body; that they exert an influence on the osmotic pressure and surface tension of the body, and upon the processes of absorption and secretion. Like calcium, phosphorus is absolutely essential to the growth and development of the body, and, as in the case of the mineral, its presence in the dietary must be accorded strict attention, in [Pg 28] order to avoid the results accruing from its deficiency. Casein, or caseinogen of milk and egg yolk (ovovitellin), are the substances richest in this mineral salt. The fact that the phosphorus existing in grains (cereals) may be removed largely in the process of milling, makes it advisable to consider the use of the breads made from the whole grains.

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

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

The newborn infant has a store of iron already on hand, derived from the mother through the placenta before birth. After the birth, and through the nursing period, the child receives a certain amount of iron from the mother’s milk. This supply is not altogether reliable, however, since any [Pg 29] disturbance of the digestion will tend to interfere with its absorption, and consequently deprive the organism of what would otherwise be used for the building up of the blood supply. Thus it is clearly indicated that the infant’s safest source of iron is from the mother during the pre-natal period. This supply must necessarily come from her diet during this time, and is made possible by regulating day by day the iron bearing foods in her dietary. After the original store of iron is reduced to that of the adult (after the child has tripled in birth-weight, generally at 12 or 13 months), and during the remainder of the growth period, it is very necessary to regulate the iron-bearing food in the diet, in order to insure the child of an adequate amount to cover the demands made by the increasing blood supply.

VITAMINES

Up to a few years ago it was believed a complete diet should contain an adequate amount of protein of a proper type, a sufficient amount of calcium, phosphorus and iron, and enough carbohydrates and fats to furnish the body with sufficient fuel to cover its energy expenditures. This belief was proved to be incorrect a number of years ago by Dr. Hopkins of England. In making certain feeding experiments with rats, Dr. Hopkins showed that some substance or substances present in milk, other than those already mentioned, was essential for the growth of the animal; that animals deprived of this material grew for a time, but gradually ceased to do so. Later on, Osborne, Mendel, McCollum and Davis discovered a like substance in butter fat; and still later Dr. McCollum found the same growth stimulating material, or one very like it, existing in the leaves of plants. These scientists found, upon investigation, that there were probably two substances in milk—one soluble in the fat, the other in the protein-free and fat-free whey—both of which were essential for normal growth. In [Pg 30] 1911 Dr. Funk discovered in rice polishings a substance which he believed to be a cure and preventive of Beri-beri; to this substance, which is now believed to be identical with the second substance found in milk, he gave the name “vitamine.” Dr. Funk’s name “Vitamine” is now accepted to cover a number of substances essential to growth, and for the prevention and cure of certain diseases. To the first two has been added a third member of the vitamine family, which has proved to be a cure and preventive of scurvy. These substances are called—on account of the substances in which they are soluble—“Fat soluble A,” “Water soluble B,” and “Water soluble C.” The table on page 496 shows the sources from which these factors may be obtained. The four plus system is used by Dr. Eddy to describe the abundance with which they occur.[11]

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

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

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

Mellanby of England believes the “A” vitamine to be a factor in the prevention of rickets. Scientists of America have recently investigated this disease, and Dr. Hess (New [Pg 31] York) has found cod liver oil to be a remedy for it. Cod liver oil is known to be rich in “Fat soluble A,” but whether the cure of rickets is due to the presence of this vitamine in the oil, or to a possible fourth vitamine, is still undetermined.

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

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

Function of the “B” Vitamine.—Like the “A” vitamine, water soluble “B” is believed to be essential to growth. [Pg 32] Funk established its value as a preventive and cure of Beri-beri, the disease common in the Orient among people living largely upon a diet of polished rice and fish. Besides being a growth-stimulating substance and an antineuritic, the “B” vitamine is highly valued for its stimulating effect upon the appetite. To this property is probably due at least part of the credit for which certain substances work for the promotion of growth in animals. This can be utilized to good advantage for children showing a disposition to refuse food, by supplementing formulas made from milk,[13] with the expressed juice of vegetables and fruits known to be rich in the “B” vitamine.

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

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

[Pg 33] “Water Soluble C.”—The third member of the vitamine family is known for its antiscorbutic property; that is, it is the best known cure and preventive of scurvy. It likewise exerts a certain amount of influence upon the growth of the animal and must be present in the diet, in order that the health and well-being of the individual may be safeguarded. The “C” vitamine, like the “B” vitamine, is soluble in water, and is present to an appreciable extent in the fresh juices of the fruits and vegetables. Some are richer in this respect than others (orange and tomato juice), while the cereals, grains, seed of plants, sugars, oils, and meats are singularly deficient. Milk (whole) does not contain a great amount of the “C” vitamine, and this amount is still further reduced under certain methods of preparation. Milk powders, made either from the whole or the skimmed milk, are found to contain only very small amounts of this essential substance. Condensed milk and cream are supposed to be free of “C,” and the same is true of eggs.

Effect of Heat on “C” Vitamine.—All authorities agree that the “C” vitamine is much more sensitive to heat than the other two; and for this reason much of the value obtained from this vitamine in uncooked material may be lost when the food containing it is subjected to long-continued heat. Hess claims that the temperature used for pasteurizing milk for some time, is more destructive to this vitamine than boiling water temperature continued for a few minutes only.[14] There is need for care in formulating the diet for children to see that they are given fresh fruit every day; or when that is not possible, to see that they are at least given tomato juice. This substance is rich in the antiscorbutic vitamine, and according to experiments made by Sherman, LeMer and Campbell, loses fifty per cent. of its antiscorbutic power when boiled one hour. Dr. Delf at the Lister Institute experimented with raw and cooked [Pg 34] cabbage, and found that when this material was cooked for one hour at temperatures ranging from 80° to 90° C the loss in antiscorbutic power amounted to 90% in the cooked leaves over the raw material. Dr. Delf also concluded from her experiments that it was advisable to add neither acid nor alkali in the cooking of vegetables if these substances were to give their maximum value of vitamines.

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

SUMMARY

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

[Pg 35] Science has gone even further than this, as has just been demonstrated, and has proven that without the substances known as vitamines the normal growth and development in the young would be arrested, and that the maintenance of the adult body would be impaired. It has also proven that certain diseases owe their development to deficiencies in the vitamine supply to the body.

PROBLEMS

[Pg 36]

CHAPTER II

THE FUEL VALUE OF FOOD

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

Amount and Type of Food.—The next point of investigation would logically be the amount and kind of food necessary to best accomplish this purpose. To be able to do this it was necessary to have some standard unit by which to measure the amount of heat each food was capable of producing when burned outside the body, after which it was more or less simple to calculate the heat production of each of the food combinations within the organism. An apparatus known as the “Bomb Calorimeter”[15] was devised by Berthelot, and adapted for the examination of food materials by Atwater and Blakesley. The food material to be tested was placed within the bomb, which was charged with a known amount of pure oxygen. The bomb was then sealed and immersed in a weighed amount of pure water, into which a very delicate thermometer was inserted. The food within the bomb was ignited by means of an electric fuse, and the heat given off by the burning of the material was communicated to the surrounding water and [Pg 37] was registered upon the thermometer. It was evident that some definite name had to be devised by which these heat units might be known. Hence the name “calorie,” which represents the amount of heat required to raise the temperature of 1 kilogram of pure water 1 degree centigrade, or about 4 pounds of water 1 degree Fahrenheit.

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

In the calorimeter it was found that the carbohydrates and fats burned to the same end products, namely, carbon dioxide and water, while the proteins, upon oxidation, produced carbon dioxide, water and nitrogen gas. In the body it was found that the carbohydrates and the fats acted in exactly the same manner as in the calorimeter, producing the same end products. But this was not the case with the proteins; the oxidation process of this chemical combination was found to be not nearly so complete within the body as in the calorimeter, and instead of the free nitrogen as produced in the apparatus there were urea and other [Pg 38] nitrogenous substances eliminated which, while combustible, represented a less complete oxidation of the proteins.

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

TABLE[16]

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

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

[Pg 39]

EFFECT OF HEAT AND COLD UPON THE FOODSTUFFS

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

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

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

This is done by multiplying the entire number of grams of food given by the amount of protein, fat and [Pg 40] carbohydrate contained in one gram, then multiplying these results by the physiological fuel factor of each. Thus 100 grams of milk would yield

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

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

[Pg 41] The Standard or 100 calorie portion of eggs would be,

100:148 :: X:100 = 68

or the number of grams required to yield 100 calories.

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

PROBLEMS

[Pg 42]

CHAPTER III

THE FOOD REQUIREMENTS OF THE BODY

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

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

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

DuBois[20] finds “Basal Metabolism above normal in exophthalmic goiter, in fevers, in lymphatic leukemia, and [Pg 43] in pernicious anemia, in severe cardiac disease, and in some cases of severe diabetes and cancer; it is lower than normal in cretinism, and in myxedema, in old age, in some wasting diseases and perhaps in some cases of obesity.” This fluctuation in the Basal Rate of metabolism furnishes a factor in the diagnosis of disease, not only recognized but coming more and more in use.

FACTORS DETERMINING THE FOOD REQUIREMENTS OF THE BODY

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

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

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

[Pg 44] Sex.—Science has proved, that there is little difference in the food requirements of men and women, provided they are alike in age, weight and size, and are doing the same amount and type of work. But women, as a rule, weigh less than men, hence their food requirements are approximately less.

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

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

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

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

[Pg 45]

TABLE[21]

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

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

[Pg 46] “Sitting at rest” includes the time spent at meals, sitting in class room, ward office, studying or reading. It does not include much walking about the room, rising frequently, or nervous restlessness.

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

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

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

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

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

Her daily food requirements would probably be approximately 2,235 calories. This estimate would be increased, [Pg 47] if she were obliged to do much heavy lifting, scrubbing of beds, or other duties requiring the expenditure of much effort. It would be decreased if the hours spent in study and class room work were increased and the hours on the ward shortened. The estimation may be made as follows,

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

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

Food Allowances for Healthy Children[23]

Calories per Pound of Body Weight per Day.[24]

Children, like adults, differ in degrees of activity; that is, one child may be very active, running and playing more strenuously than another. Hence a margin of safety must [Pg 49] be allowed to cover the energy expenditures of the more active child, to safeguard it against becoming malnourished.

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

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

Average Rate of Gain per Week, for Normal Children

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

There have been tables arranged to show the proper weight for height for boys and girls of different ages (see appendix). These are valuable since, by their use, attention is called to the child who is not up to the average. Medical examination of such children frequently shows reason [Pg 50] for their underweight, and measures may be instituted which may save the child from a lifetime of poor health.

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

PROTEIN REQUIREMENTS

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

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

MINERAL REQUIREMENTS

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

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

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

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

The following diagram illustrates this point.

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

[Pg 52] The following outline will serve as a guide in making the estimates for the food requirements of children:

The Diet of a Child Should Contain for Every 1000 Calories Furnished by the Foodstuffs,

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

Factors Affecting the Food Selection.—The estimation of the energy needs of the body, and the selection of the foods to furnish the fuel for this purpose, depend largely upon the individual. The digestion of the fats, as well as the way in which the body utilizes them, makes the use of this foodstuff more or less limited according to the ability of the individual to take care of them, the minimum [Pg 53] allowance for children being between 2 and 3 ounces per day. According to Gillett, “If boys and girls get at least this amount from butter and its substitutes, cream, bacon, fat meat and oils, additional amounts from their food will provide a margin of safety, without overtaxing the digestive system.”

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

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

The American Red Cross recommends the following method for estimating the amount of sugar in the dietary: “Add one-half the weight of such foods as jellies, jams and preserves, and three-quarters the weight of such foods as candy, honey and syrup, to the weight of sugar used.” The amount of sugar consumed, as such, by the adult each day, is not of such paramount importance as it is in the [Pg 54] case of children, but even for adults an excessive amount of carbohydrate in this form is not considered advisable from a health standpoint.

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

The Diet Each Day Should Contain:

1. Milk:

2. Cereals and Breadstuffs:

3. Meat or its Substitute:

4. Vegetables:

5. Fruit:

6. Desserts:

7. Fats:

[Pg 56] Suggestions for Serving Meals.—After reckoning the number of calories needed for the day, it is well to remember that the protein must be adequate in type and amount; that there should be an abundant supply of vitamines and iron in each day’s ration; that milk should always be included in order to make sure of having a sufficient amount of calcium in the diet; that there should be only one heavy protein dish at any one meal, and that it is unwise to serve a meal in which the fluids predominate on account of their deficiency in energy and proteins.

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

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

PROBLEMS

SECTION II

LABORATORY OR DIET KITCHEN WORK

[Pg 59]

CHAPTER IV

METHODS OF FEEDING IN NORMAL AND ABNORMAL CONDITIONS

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

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

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

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

[Pg 60] Technique of Gavage.—The apparatus used in gavage consists of a moderate sized soft rubber tube to which is attached a rubber or glass funnel and a “pinch cock.” The tube should be filled with water to prevent air entering the stomach and causing pain or discomfort. In certain cases the patient refuses to swallow the tube and it will be found necessary to use some means to force the passage if the throat is shut off. By closing the nostrils the patient will be obliged to breathe through the mouth, thus opening the passage into the throat through which the tube may be quickly slipped. In certain abnormal conditions the gastric organ is so badly impaired as to render it impossible for the patient to retain food taken in by way of the mouth. It is often found that food introduced into the stomach by means of the “stomach tube” will be retained and utilized which otherwise would be rejected. It is disagreeable, however, and should only be used when it is impossible to feed otherwise.

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

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

The method of administering nourishment through the rectum is important. A nutrient enema injected only into [Pg 61] the lower bowel not only does no good, but may actually cause a good deal of unnecessary discomfort to the patient.

Temperature of Enema.—Care must be taken not to have the temperature of the nutrient enema too hot or too cold or it will be promptly rejected. The patient is placed on the side with one knee flexed; the solution is poured into a fountain syringe bag or an enamel container (heat the container before pouring the solution into it or the latter will be chilled). The bag or container has attached to it a rubber tube with a cock adjusted so that only a small stream will flow in at a time. To the end of this tube a rubber rectal tube or catheter—1 cm. (about ½ inch)—is attached. This should be well greased (do not use glycerin as this substance is irritating to the mucous lining of the rectum). The liquid should be allowed to fill the tube before it is inserted into the rectum, to prevent any air passing in with it. The tube should be inserted with a gentle twisting movement, using very little force or the tender mucous membranes will be injured. Insert the tube twelve or more inches, since the solution is more completely absorbed if given high up in the bowel. The bag containing the solution should be held only a few inches higher than the rectum, thus allowing only a small stream to pass in and allowing an air space above the stream for the passage of gas which may be accumulated in the upper part of the rectum. The tube should be allowed to remain in the rectum for fifteen or twenty minutes, then very gently withdrawn to prevent the liquid from being rejected. A pad of gauze may be pressed against the anus to assist the patient in retaining the enema. It is well to divert the attention of the patient also, to further assist her in retaining the liquid.

Duration of Rectal Feeding.—Rectal feeding cannot be substituted for a great length of time, first, because the patient cannot absorb sufficient nourishment in this way to [Pg 62] fully cover the body requirements, and, second, because the rectum becomes more or less sensitive and will reject the liquid before it has an opportunity to be absorbed. From three to four nutrient enemas a day is about the limit for the average patient. Between the nutrient enemas it is advisable to give one of saline solution.

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

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

SPECIAL DIETS

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

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

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

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

[Pg 63] Mixed Diet.—The diet used in normal conditions and for those not affected by any special food.

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

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

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

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

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

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

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

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

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

Obesity Diets.—Those containing as few of the fat-forming foods as possible, such as cream, olive oil, potatoes, white bread, etc., pastry and desserts, candy and soda water, and containing lean meats, fish or shellfish cooked and served without butter or other fats, fresh or stewed fruit without sugar, green vegetables and salads served without oil or other fats; one egg a day two or three times a week, coffee [Pg 64] and tea without sugar or cream, toasted gluten bread (1 slice) without butter, saccharine substituted for sugar.

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

THE TRAY

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

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

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

[Pg 65] Arranging the Tray.—If the nurse will place the necessary articles upon the tray and memorize their position so that she will be able to duplicate the same at each meal, she will be able to tell at a glance if everything needed is in its proper place, thereby saving herself unnecessary steps and the patient the worry of having to wait until they can be brought. Food should not be allowed to stand in the sickroom, and glasses or plates in which food has been served should be removed from sight as soon as the patient finishes with them. Care must be taken, however, not to create the impression of hurry or the patient will be made nervous and either will lose her appetite or have indigestion.

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

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

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

3. Place service plate directly in front of patient.

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

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

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

7. Bread and butter plate on top of napkin.

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

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

[Pg 66] 10. Place salt and pepper next to cream pitcher (to the left).

11. Water glass in upper right corner of tray.

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

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

Suggestions for Serving.—Make tray as attractive as possible.

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

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

Food Poisoning.—Poison caused by decomposed eggs has manifested itself in individuals who have partaken of [Pg 67] cake in which such eggs were used. Canned meat and fish have produced the most violent types of ptomaine poisoning. As a rule in these cases the canned article has begun to decompose and while the decomposition may not have advanced sufficiently far to be discernible from the flavor or odor, it is there, and if the resistance of the individual eating this food is not great, serious danger may result. Poisoning develops in some individuals upon the eating of shellfish, strawberries, oranges, pimentos, and various other foods,—another evidence of personal idiosyncrasy against certain articles of diet. There is no way to overcome these idiosyncrasies; the only thing to do is to warn the individuals so affected to let the offending foods alone.

ADULTERATION OF FOOD

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

Tests for Adulterants.—Boric acid, borax, and formaldehyde are the preservatives more often found in milk. These chemicals are introduced to arrest the natural souring and decomposition which takes place after milk reaches a certain age. Occasionally salicylic acid and sodium carbonate are used. Formaldehyde may be detected by placing about 20 c.c. of milk in a small glass vessel or tube. Dilute with an equal amount of pure water, add commercial sulphuric acid, allowing it to flow gently down the inside of the tube. A purple ring will appear at the zone of contact [Pg 68] if formaldehyde is present. “Boric acid and borax may be detected by adding a drop or two of hydrochloric acid to a few drops of milk in a white dish and then several drops of a saturated alcoholic solution of turmeric. The dish is then heated gently for a few minutes, and, if boric acid or borax is present, a pink or dark red color will appear. A dark blue-green should appear when the dish is cooled and a drop of ammonia added.”[28]

Canned goods must be carefully examined before being used. The domestic canned goods are rarely adulterated, but imperfect sterilization and defective cans may bring about a condition of fermentation and gas formation due to bacterial action. Cans should have a concave appearance on the top. If there is a bulging of the can it may be due to gas formation, and a small hole should be made in the can to note any escape of this gas. Should there be any indication of fermentation, the contents should be discarded. It is advisable to look with suspicion on cans that appear old, rusty, and soiled; they are probably left-over stock and liable to be bad. Peas which have been imperfectly sterilized produce a type of gas which is soluble in the liquid. After decomposition has occurred there will be no apparent evidence by the escape of gas, but the liquid will be found to be excessively acid, and will present a muddy appearance. Certain foreign importations of canned goods are preserved in color by the introduction of certain color preservatives. Peas—petits pois, for example—and the very small string beans which are imported are intensely green from the copper sulphate used. Its presence may be detected by adding a few drops of hydrochloric acid to some of the colored material, then dropping in a bright steel nail, knitting needle, or knife blade. There will be a deposit of copper salts (like copper plating) upon the steel if the preservative is present in the can. Canned corn is often [Pg 69] artificially sweetened with saccharine, which may be detected by shaking several tablespoonfuls of the liquid in an equal amount of chloroform. Saccharine is soluble in chloroform, while sugar is not. Allow the mixture to stand a few minutes and remove some of the chloroform which has settled at the bottom. Place in a small dish, evaporate the chloroform by gently heating the dish; taste the residue; if sweet, saccharine is present.

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

METHODS USED IN THE PREPARATION OF FOOD

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

Certain foods, as has already been stated, require a high degree of temperature to make them wholesome, but if this temperature is applied by means of heated fat, as in frying, the food is changed from a wholesome to a more or less indigestible article. In health the organs of digestion are capable of overcoming much of the harm wrought by wrong preparation, but even in the healthy, normal individual a steady diet of fried food will eventually undermine what is [Pg 70] known as good digestion. In abnormal conditions (illness) frying is a method seldom, if ever, used.

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

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

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

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

[Pg 71] Baking and roasting are both brought about in the oven. Bread, biscuits, pies and other pastry, potatoes, cakes, etc., are baked, while meats, roast of beef, lamb, veal, mutton, as well as chicken, turkey, duck, and large fish are roasted. The heat in the oven may be intense. The outside or cut surface of the meat is seared, the soluble albumens are coagulated, thus sealing the juices within. If the meat is placed in a pan surrounded by cold water and then placed in the oven, the juices are “drawn out” in the water. These juices contain the flavoring matter or extractives. Meat so treated is not so palatable or highly flavored as that which has first been subjected to intense heat, the water for the gravy added later.

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

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

Poaching.—This term is applied chiefly to the cooking of eggs in a shallow pan of water heated just below the boiling point. To be properly poached an egg must be [Pg 72] perfectly fresh, or the white and yolks will run together and present an unappetizing, unpalatable appearance.

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

Time-Table

CARE OF ICE-BOX AND CONTENTS

The ice-box plays an important rôle in the preservation of the health and comfort of the family, as well as that of the invalid. Therefore the first consideration is the [Pg 74] cleanliness of it. The old-fashioned boxes were constructed without ventilation. This was clearly a mistake, since many foods absorb both the odor and flavor of the substances about them if allowed to stand for any great length of time in a closed compartment with them. The ice-boxes or refrigerators of to-day have a ventilation system which insures a circulation of air constantly throughout the interior of the box. The drain pipes require special attention, because no matter how clean the box itself is kept, the melting of the ice causes a slime to accumulate on the inside of the pipe which will clog it and become offensive unless it is flushed out often. This may be accomplished by pouring through it a solution made by dissolving one-half ounce of borax, washing soda, or ammonia in one gallon of boiling water. The adjustable part of the pipe can be removed and cleaned with a long brush made for the purpose. The pipe is then replaced and the boiling water poured through. In this way the entire drainage system of the box is completely cleaned. All loose bits of food which may drop from the containers to the floor and shelves should be carefully removed each day and the interior of the box and shelves thoroughly wiped out. Three times a week is sufficient to wash and flush the box and pipes unless milk, cream, or other food materials have been spilled, in which case it should be washed at once before it has an opportunity to sour or spoil and become offensive. Ice should always be washed off before being put in the box, and all milk and cream bottles should likewise be wiped with a clean wet cloth before being placed on the ice.

Hot food must never be put in the ice-box, as the heat from the food will raise the temperature of the air in it. In some cases the sudden chilling of the food itself is undesirable, but this is not so often the case. However, the best results are obtained by first allowing the food to cool, [Pg 75] and then placing it on ice. This is particularly the case with jellies made from gelatin.

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

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

RULES GOVERNING SELECTION OF FOOD

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

[Pg 76]

THE CARE OF FOODS AND UTENSILS

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

Method of Washing Dishes.—Cleanliness must be observed in the care of all food materials and the utensils in which they are to be prepared. If the nurse will observe the scientific rules governing the solubility of the foodstuffs, she will be able to save herself much time and trouble. For example, it is a known scientific fact that starch is insoluble in cold water and more or less soluble in boiling water, hence it would be a useless waste of time to try to wash a utensil in which a starchy food has been cooked in cold water. Fats solidify under the influence of cold and melt under the influence of heat, so that hot water should be used in conjunction with soap or an alkali to remove grease from dishes and silver and utensils. Albumens are soluble in cold water and are coagulated in hot, therefore to remove milk, egg white, and like protein substances from glasses, spoons, etc., it is advisable to soak first in cold water to wash out the food material, and then to wash thoroughly in hot soapsuds to cleanse and polish. The dishcloths used in the washing and drying of dishes and kitchen utensils should be washed after using in hot soapsuds, rinsed in clear water, then dried in the sun. When this is impossible, they should [Pg 77] at least be hung in the fresh air to make them sweet and clean before the next using. In contagious diseases the care of the utensils and dishes used by the patient is of the utmost importance. They should be thoroughly sterilized before being placed with those used by the rest of the family, otherwise the disease may be communicated to the unaffected members. A word about the handling of glasses and spoons used in administering medicine in the sickroom: It is advisable when possible to keep these separate from those used on the tray, as many medicines have a very lasting and disagreeable taste, which is more than apt to cling to the spoons or glasses in which they are measured and in turn be communicated to the food, making it distinctly unpalatable. This has been found to be the case with asafetida, valerian, ichthyol, etc.

METRIC MEASURE

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

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

deci.—0.100
centi.—0.010 
milli.—0.001

Units of Weight

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

[Pg 78] A liter of water weighs 1 kilogram; 1 kilogram of water = 2.2 lb.

Household Weights and Measures

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

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

The standard measuring cup holds 8 ounces or 16 tablespoonfuls.

[Pg 79] The following list shows the approximate weights and measures of the foods comprising dietaries:

Percentage Calculation

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

The method of figuring the per cent. of foodstuffs in a [Pg 80] food material is simple. Milk, for example, has a percentage composition of 3% protein, 4% fat, and 5% sugar. To find the definite amounts of these foodstuffs in 1 ounce of milk it is best to reduce the ounce to grams, since the gram is the unit of measurement generally used.

THERMOMETRY

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

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

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

[Pg 81]

CHAPTER V

FOOD MATERIALS AND THEIR PREPARATION

Dairy Products.—Milk, cream, and other dairy products form such an important part of the invalid dietary that they require especial care in their selection. “Certified Milk” is the safest. This is protected by special inspection. The methods and standards governing the production and distribution of certified milk were adopted by the American Association of Medical Milk Commissions, May 1, 1912. The sanitary condition of the dairy, the cleanliness of the vessels into which the milk is placed, the health of the milkers, and a surety that no member of their family with whom they come in contact has any kind of contagious disease, are all obligatory. The feed for the cows and the purity of the water given them to drink must be inspected and made to conform to the standard laid down for certified milk. The milk of sick cows and those having tuberculosis is absolutely condemned. The composition of certified milk is standardized as follows: the fat standard shall be 4%, with a permissible range varying from 3.5% to 4.5%. The proteins shall be 3.5%, with a permissible range varying from 3% to 4%. Certified milk shall not contain more than 10,000 bacteria to the cubic centimeter when it is delivered. This inspection and standardizing necessarily raises the price of certified milk above that of milk not so rigidly cared for, and when the additional expense makes it impossible for the patient to afford certified milk, the only thing to do is to be sure of the reliability of the dealer from whom the milk is purchased and the cleanliness of the dairy from which it is procured. Buttermilk [Pg 82] and butter are the milk products which require some attention as to selection. The former grows sour with age and the odor of advanced fermentation and decomposition is readily recognized. Sweet butter, butter without salt, is less apt to be old when purchased than the salted variety, as the flavor of rancid fat is unmistakable in butter which has not been especially treated.

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

The proteins of milk, which form the curd or larger part of the solids, according to Van Slyke[29] are in the form of casein and albumen. There are 3.6 parts casein to 1 part soluble proteins, but these figures vary somewhat at times. Casein is insoluble in pure water, but dissolves readily in water to which an alkali or calcium carbonate is added. The [Pg 83] soluble protein in the form of lactalbumen is one of the constituents of whey. This substance contains more sulphur than does casein, but no phosphorus.

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

Mineral salts, 0.7% of milk, are made up of calcium, potassium, sodium, magnesium, iron, sulphur, phosphorus, and chlorine. Milk is so rich in calcium that it requires only 400 c.c. (or about 2½ cups) to furnish 1 gram of calcium. This is the amount believed to be necessary for the welfare of man each day and this must be derived from food.[30]

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

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

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

Milk also furnishes a splendid medium for bacterial growth, and if left exposed to the air, put into unclean receptacles, or kept in a warm place, will immediately become more or less contaminated, after which it is unwise to use it. Sterilization and pasteurization will in a measure overcome the bacterial contamination, but milk purchased from a dairy which is not clean or milked under unsanitary conditions will remain dirty, hence unfit for [Pg 84] human consumption. When the morning’s milk supply is brought to the house it should be in clean, well-stoppered bottles, but before placing it in the ice-box the tops of the bottles should be carefully wiped off with a wet cloth to remove any superficial dust which may be adhering to them. Every time a portion of the milk is removed thereafter the tops should be again cleansed before the milk is poured out. This is a wise precaution, and often prevents contamination from the hands, etc.

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

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

As a rule the flavor and odor of milk are not changed by heat until the temperature reaches nearly to the boiling [Pg 85] point. A scum then forms on boiling milk, composed of casein 50.86%, fatty matter 45.42%, ash 4.72% (Rosenau). Prolonged boiling changes the color of milk from a creamy white to a yellowish brown which deepens with boiling. This is due to the caramelization of the milk sugar. Cream will not rise (or its rise will be very slow) on milk which has been subjected to a temperature of 150° F. for thirty minutes or more because the fat droplets are broken down so that they cannot hold together at that temperature and become more completely distributed throughout the fluid.[32]

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

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

Sommerfield’s[36] investigations prove that butyric acid [Pg 86] bacilli are destroyed at a temperature of 212° F. for from 1 to 2 minutes.

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

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

Selection and Care of Milk.—There are a few essential facts to keep in mind in regard to milk: (1) Be sure of the source of the milk supply, especially in the feeding [Pg 87] of the sick and of infants. Milk for such cases should always be purchased from inspected dairies when it is possible. (2) Keep the milk cold; the best milk in the world will spoil if left in a warm place. (3) Always keep the milk bottle well covered, thus eliminating the danger of contamination, flies, etc.

Albuminized Milk

135-152 calories

Have the milk thoroughly chilled.

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

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

Albuminized Milk Shake

135 calories

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

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

[Pg 88]

Milk and Ginger Ale (or Sarsaparilla)

59 calories

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

Milk Punch

298 calories

A grating of nutmeg on top. Place ingredients in shaker as directed above, and shake a few minutes to thoroughly mix ingredients. Pour over cracked ice, grate nutmeg or cinnamon over the top. The milk may be peptonized if necessary, using ½ tube of Fairchild’s peptonizing powder.

Peptonized Milk

314 calories

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

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

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

The milk may be poured from bottle into a clean saucepan and brought quickly to a boil to prevent further peptonization; this process, however, is apt to make the milk [Pg 89] very bitter and should not be used unless it is to be flavored with fruit juice.

Peptonized Milk Punch

212 calories

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

Buttermilk (Bulgarian)

627 calories

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

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

Cocoa

147-166 calories

[Pg 90] Mix cocoa and sugar together and add boiling water slowly. Boil 3 to 5 minutes; heat milk in double boiler and add cocoa mixture. Beat with Dover egg beater to distribute cocoa and prevent scum forming. Serve with or without whipped cream. Cocoa may be reinforced as directed in “broths” with albumen or the whole or yolk of one egg well beaten. If the white alone is used, care must be observed that the liquid is not hot enough to coagulate the albumen. Proprietary foods and casein preparations are used in like manner.

Plain Junket

161 calories

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

Junket Ice Cream

428 calories

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

[Pg 91]

Plain Vanilla, Lemon, or Almond Ice Cream with or without Egg White[39]

585-602 calories

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

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

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

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

Frozen Custard

289-329 calories

Prepare as soft custard, freeze.

Lactone Buttermilk

627 calories

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

[Pg 92] Dissolve tablet in cold water and stir into fresh milk (which may or may not be skimmed, according to the directions of the physician, but the finished product is more palatable using whole milk). Pour into a clean jar or wide-mouthed bottle; plug with cotton or close not tightly, allow to stand in room temperature 70°-75° F. 24 hours, shaking the bottle occasionally to keep the cream from rising. At the end of this time pour the milk out (if sufficiently fermented), and beat briskly for 5 to 6 minutes with egg beater or with churn; place on ice until ready to serve.

Malted Milk (1)

77-96 calories

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

Malted Milk (2)

107-155 calories

Proceed as above.

Malted Milk Chocolate or Cocoa

230-300 calories

Mix cocoa or chocolate with water and boil 2-3 minutes. Pour milk into a double boiler and heat, mix malted milk with a little water and stir into the hot milk, add the cocoa [Pg 93] paste, sugar, and vanilla, mix thoroughly, beat the mixture briskly to mix ingredients thoroughly, and serve with or without cream.

Milk or Cream Soups

Milk or Cream Sauce for Soups

599-1229 calories

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

Cream of Asparagus (1)

213 calories

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

Cream of Asparagus (2)

216 calories

Cut off the tips of the asparagus in 1-inch pieces, and place with the rest in a saucepan, and cover with water; [Pg 94] add salt and cook until the tips are tender; lift out and put aside to be used instead of the toast croutons. After the water in which the asparagus is cooked is of sufficiently strong flavor, strain and add the extra spoonful of flour, mixed in a tablespoonful of water; cook 15 minutes, measure ½ cupful, and proceed as directed above.

Cream of Potato

259 calories

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

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

Cream of Spinach, Celery, Peas or Carrots

224-461 calories

Proceed as in making other cream soups.

Oyster Soup

179 calories

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

[Pg 95]

Eggs

Eggs.—The table shows eggs to have a chemical composition of water 73.7%, protein 14.8%, fat 10.5%, and mineral salts (ash) 1.0%. Fuel value per pound, 672 calories. The white of the egg, constituting 57% of the entire weight, is composed chiefly of albumen and water with a small percentage of mineral salts in the form of calcium, potassium, magnesium, sodium, phosphorus, chlorin, sulphur, and iron. Typical albumens are always rich in sulphur, and in eggs the sulphur content is much greater in the egg white than it is in the yolk. The yolk of eggs contains more protein and fat than the white, and less water. The protein of the yolk is chiefly in the form of ovovitellin, while the fats occur as palmitin, olein, and stearin. There is also 5% of coloring matter in the yolk of eggs besides lecithin, nuclein, salts of iron, potassium, magnesium, and phosphorus. The latter mineral salt comprises 1.0% in yolk, while in the white there is only .03%. Eggs have a position in the invalid dietary second only to that of milk. They are nutritious, easy of digestion, and exceedingly palatable if properly selected and correctly prepared. The albumen in the white is very susceptible to the effect of heat. At a temperature of about 135° F. the clear, pale yellowish white begins to change to an opalescent tint, and, as the temperature is gradually increased, the texture changes from a viscid, sticky substance to an opaque, jelly-like mass which solidifies with an ever increasing temperature. Hard cooked white of egg, unless it is very finely divided, is considered difficult of digestion, but if the heat is applied gradually and is not raised to the boiling point (212° F.) there is no reason why the hard cooked white of the egg should not be digested. However, it is unwise to cook eggs in this manner for invalids or children. Any of the other methods, with the exception of frying, which [Pg 96] should never be used, is decidedly preferable. Egg albumen is soluble in water and fresh fruit juices, so that it may be used with great success as a reinforcing agent. In fact, the whole egg may be so used, but it is more difficult to disguise the yolk in a beverage than it is the white, and for this reason it is not so adaptable in many cases. Eggs may be cooked by the following methods in the invalid dietary: coddled, soft-cooked, poached, creamed, omelet, scrambled, or in custard. Uncooked eggs may be given in water, milk, wine, or fruit juices.

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

Fruit Beverages

Orangeade

118 calories

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

Albuminized Orangeade

152 calories

Make orangeade as directed in above recipe, without the addition of water. Break the whites of 2 eggs into a saucer [Pg 97] and with scissors cut the albumen until free from membrane and strain, stir this into the orange juice and add several pieces of cracked ice. This is both nourishing and palatable, and the taste of the egg cannot be detected.

Albuminized Lemonade

107 calories

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

Pineappleade

151 calories

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

Albuminized Grape Juice

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

[Pg 98]

Egg White and Mint

57 calories

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

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

Cream, Egg and Vichy

232 calories

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

Coffee

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

[Pg 99]

Plain Eggnog

267 calories

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

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

Coffee Eggnog

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

Panopepton or Liquid Peptonoid Eggnog

233-257 calories

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

Malted Milk Eggnog

264-316 calories

Mix milk as directed above and chill thoroughly. Beat egg yolk with sugar and whisky or wine and add to the mixture. Beat egg white stiff and stir into the rest of the [Pg 100] ingredients. Pour into shaker and shake with cracked ice until thoroughly chilled. The cream may be served on top, or beaten into the eggnog.

Foamy Omelet

130 calories

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

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

Coddled Eggs

75 calories

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

Soft-Cooked Eggs

75 calories

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

[Pg 101]

Poached Eggs

75 calories

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

Creamed Egg on Toast

With milk 131 calories
With cream 170 calories

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

Egg Nest

204 calories

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

Beat egg white stiff, and pile roughly upon the toast, leaving a slight depression in the center. Slip the unbroken yolk into the depression (take care not to break the egg yolk or the appearance and significance of the dish will be [Pg 102] ruined). Set plate in oven to brown the white (the oven must not be too hot or the white will brown before the yolk is sufficiently cooked to be palatable). Place the remaining butter on the yolk, dust with salt and pepper and serve at once.

Soft Custard

289 to 329 calories

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

Baked Custard

249 calories

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

[Pg 103] Care must be taken not to allow the oven to get hot, or the egg will coagulate, making a watery, unpalatable, and indigestible mixture.

Caramel Custard

306 calories

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

Floating Island

381 calories

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

Cereals and Breadstuffs

Corn Meal Gruel

101 calories

[Pg 104] Allow water to boil, mix corn meal with 3 or 4 teaspoonfuls of cold water. As soon as water begins to boil, stir briskly until gruel begins to thicken. Then place on a cooler part of the stove, and cook gently for 2 hours, replacing water as it evaporates. Strain through a coarse sieve if it lumps.

Farina

183 calories

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

Rice (1)

99 calories

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

Rice (2)

2-3 servings, 316 calories

[Pg 105] Wash rice and soak it in cold water for 1 hour (or overnight). Place in an earthenware baking dish, cover with the milk, water and salt. Cover and set in the oven; allow to cook until all of the moisture is absorbed (if the rice is not done by the time the moisture has evaporated, add more milk, or milk and water, and continue until the grains are tender). If the given amount of moisture is not absorbed by the time the rice is tender, drain off the surplus and return the dish to the oven for a few moments. Each grain should be separate, when the dish is prepared correctly.

Milk Toast

149 calories

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

Cream Toast

240 calories

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

Wine Panada

185 calories

[Pg 106] Sugar may be sprinkled over crackers if desired, but it is not ordinarily done.

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

Oatmeal Cookies

3333 (about) calories

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

Baked Tapioca

550 calories

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

Orange Tapioca

570 calories

[Pg 107] Mix and bake as directed in plain baked tapioca custard. Any other fruit juice may be substituted for the orange, raspberry, pineapple, or grape juice.

Apple Tapioca

475 calories

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

Brown Betty

470 calories

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

[Pg 108]

Starchy Desserts

Rice Custard

309 calories

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

Orange Rice Custard

532 calories

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

Snow-Balls

356 calories

Place in a double boiler and cook without stirring until milk is absorbed and rice is tender. Then either pack in egg cups (wet first so that rice will slip out without breaking), or take a square of cheesecloth 8 inches square, dust with flour and place about 4 tablespoons of the cooked rice [Pg 109] in center, draw the corners together and tie firmly into a ball. Set the ball in a steamer and steam 1 hour. Remove the cloth gently to prevent breaking the balls. They may be served with custard as a dessert, or as a vegetable with tomato dressing.

Tapioca Custard

503 calories

Flavor with vanilla or nutmeg, or ¼ square chocolate grated. Scald milk. Boil tapioca in hot water until transparent like jelly, using one cupful of boiling water. (If tapioca does not absorb all of the water, pour off the surplus.) Beat egg and sugar together and add with the milk to the tapioca. Pour into a double boiler, and cook until the raw egg flavor has disappeared. Flavor as desired. 43 calories extra with chocolate.

Sponge Pudding

772 calories

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

[Pg 110]

Sunshine Cake

1716 calories

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

Angel Food Cake

721.5 calories

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

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

Cereal Pudding

1470 calories

Stir cereal into scalded milk and cook until mixture thickens, remove from fire, add rest of the ingredients [Pg 111] except eggs. When mixture has cooled somewhat, add the lightly beaten eggs, turn into a buttered baking dish and steam 3 hours. This pudding may be made without steaming by cooking the cereal and milk in double boiler for 1 hour, then add rest of ingredients and bake 30 minutes.

Sauces for Puddings

Foamy Sauce

494-497 calories

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

Wine or Fruit Sauce

381-434 calories

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

Hard Sauce

231 calories

[Pg 112] Cream butter and sugar together until there are no lumps or grains in mixture. Beat the egg white stiff and fold into the sugar and butter mixture. Flavor.

Foamy Sauce

794-797 calories

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

Sauce for Puddings

758.4 calories

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

Meats

Beef, Lamb, Veal, Poultry, Fish and Shellfish

Meats.—The flesh of animals, poultry, and fish comes under the head of meat. These food materials form one of the most important sources of protein in the diet, the foodstuff being in concentrated form easily handled by the digestive apparatus and absorbed almost completely, leaving little residue in the intestinal tract. The chemical composition [Pg 113] of different meats is very much alike, as will be seen in the table, the bulk of the weight being water, while the proteins range from 18.3% (E.P.)[40] in beef to 9.9% in bacon. The fats range from 17.9% in beef to 64.8% in smoked bacon.

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

Quality of Meats.—The quality of meat depends upon several factors: age, sex, care, feeding, and the length of time it is hung. Cold storage beef is much more apt to be tender than that cut from a freshly killed animal. Animals that are not allowed to run over a large area, but are kept in a small inclosure and fed on fattening foods, produce meat of a high quality. This is because the muscular tissue has not been hardened with exercise. The worked muscle is always tougher than the quiet one. For this reason the tenderloin of beef is more tender than the flank. It is [Pg 114] situated in the part of the animal that is exercised the least. The tough parts, however, are not lacking in flavor or nourishment, but the manner in which they must be cooked to assure them of being tender deprives them of much of their original flavor. This is demonstrated in broths and soups made from the tough cuts of meat. The extractives from which meat derives its flavor and the soluble albumens are drawn out by the water, and if it is to be used as hash, croquettes, etc., needs to be seasoned, since the broth, while it has taken very little of the actual nourishment from the meat, has deprived it of practically all of its flavor. In making broth or soup, if the meat is covered with cold water instead of hot, more of the extractives will be drawn out and the broth will be more highly flavored and much more stimulating. The color, odor, and freshness of the muscular and fatty tissues of meat are all indicative of their quality. Fresh meat is firm in texture and free from offensive odor. Stale beef and that cut from an old steer exhales a pungent odor of butyric acid. The color of beef should be dark purplish when fresh cut but this changes quickly to a bright red; it should contain preservatives of no kind and must be cut from animals free from all disease. The fat should be of a yellowish white and be crumbly, and should be distributed throughout the muscular tissue and around the organs.

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

Selecting of Chicken and Turkey.—In selecting chicken for the diet of invalids, use only the young birds for broiling, those a few months older for baking and roasting, [Pg 115] and the fowls for soup and broth. To test a chicken for broiling and roasting, select one in which the cartilage at the end of the breastbone is soft and pliable; the pinions (lower part of the wings) and the feet should be soft and readily bent. The breastbone of a fowl is firmer and the wings and feet harder than those of the younger chicken. The young chicken has an abundance of pin feathers while the old fowl has not. In fact, one of the means of differentiating between the old chicken and the young, even if they are practically of the same weight, is the presence of the long hairs instead of pin feathers. The fowl selected for broth should not be very fat, as this fat will melt into the broth, causing it to be greasy and unpalatable. Turkey, even when it is young, is not quite so digestible as young chicken; the fibers are longer and the connective tissue more abundant. Goose and duck are richer in fat and not so desirable as chicken in the invalid dietary. Squab, quail, and young squirrel are all palatable and readily digested. The squirrel must, however, be young, or the flesh will be tough and more difficult of digestion.

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

Shellfish.—Of the shellfish, the oyster and the clam are exceedingly useful. The soft parts of the oyster are palatable and easily digested. They are not highly nutritious, [Pg 116] but give a nice variety to the diet. When used in broth or for the juice, clams are particularly useful. Many cases of nausea are relieved by the taking of iced or very hot clam juice when they resist other remedies. The necessity of having both oysters and clams absolutely fresh is of the greatest importance, since a type of poison results from tainted shellfish which is exceedingly dangerous.

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

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

[Pg 117]

TABLE

Cuts of Lamb and Mutton

[Pg 118]

Broths and Soups

Standard Broth
Beef, Veal, Mutton, or Chicken

1 Pint, 80 calories, with rice or barley 105 calories

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

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

[Pg 119]

Clam or Oyster Broth

11.5 calories without milk; 162.5 calories with milk

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

Clam Broth

Without milk, 55.6 calories; with milk, 113.4 calories

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

Beef Juice

One-fourth pound lean beef.

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

[Pg 120]

Chicken Jelly

308 calories
1 serving, 75.8 calories

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

Calf’s-foot Jelly

376.6 calories

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

[Pg 121]

Broiled Quail or Squab

418-543 calories

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

Quail or squab cooked inside the stove is often more palatable than that cooked on a broiler. The bird is split as for broiling, and placed in a small pan just large enough to hold it; a strip of bacon pinned about the breast; add 1 tablespoonful of butter in bits, dust the cut surface first with salt and pepper, then with flour; add ½ cup of hot water. Turn another pan over the bird (it must fit closely to keep in the steam), place inside the oven and cook about 10 minutes; turn the bird over and cook 10 minutes longer. Lift the bird from the pan and place it where it will keep hot, add a tablespoonful more water and a teaspoonful more flour to the gravy in the pan, stir briskly to remove any lumps, remove bacon and place the bird upon a slice of nicely browned toast; pour over it the gravy, garnish with a sprig of parsley, and serve at once.

Birds à la Bain-Marie

Split birds or chicken as for broiling, place one-half in a chafing dish or double boiler (bain-marie), dot the cut surface with butter, sprinkle over it the parsley, dust with pepper and salt; place the other half of the chicken or bird on top of this, add the rest of the butter, dust with salt and pepper, cover, and place the pan over the hot water [Pg 122] pan; allow to steam for about 1 hour, lift from hot water pan and place in oven or under the flames to brown lightly. Serve on buttered toast.

Chicken (one-half)

355 calories

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

Roast Chicken, Turkey or Duck

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

Make a dressing from one-third of a small loaf of bread broken into small pieces; ¼ cup chopped celery, 1 tablespoonful of chopped parsley, 1 tablespoonful of butter and one egg beaten lightly. Stuff the cavity with dressing, sew up the opening and place in dripping pan. Place pan under the flame for a few minutes to brown, unless a regular roasting pan (savory roaster) is used; allow to bake from 45 minutes to an hour and a half for chicken and duck according to the size, and from an hour and a half to three hours for turkey according to size. A cupful of boiling water may be poured into the pan in which the chicken, etc., is being roasted and flour may be sifted over the top; dust with salt and pepper. When an ordinary pan is used for baking, the fowl will require frequent basting to keep it moist and tender. Just as the baking is finished, more [Pg 123] butter, flour, and seasoning may be added, with a cup or more of boiling water to make additional gravy.

Sweetbreads

209 calories

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

Broiled Oysters

174 calories

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

Beefsteak

267 calories

3 inches long by 2 inches wide by 1½ inches thick (weighing about 3 ounces).

Wipe steak off with a wet cloth and dry before cooking. Slightly grease the broiler and place under the flame, count [Pg 124] ten as the clock ticks and turn the steak over, count ten again and again turn; continue this for about 3 minutes or until the steak is seared upon both sides, lift the broiler to a lower part of the oven and continue the cooking for 5 to 8 minutes; run a sharp-pointed knife between the meat and the bone (if the steak is a porterhouse or sirloin), and if the flesh is red, continue the cooking a minute or more. If it is pink, lift to a hot plate, place 1 teaspoonful of butter upon it, dust the surface with salt and pepper and serve hot. Pan broiling is done on the top of the stove in a flat frying pan. Wipe the pan with a clean wet cloth, place upon the stove and heat piping hot, and place the steak (without greasing the pan) upon the hot surface. Proceed as in broiling under the flame. After the first 3 minutes of cooking, place the pan on a cooler part of the stove to finish the cooking.

Lamb or Mutton Chops

2 chops, 304 calories

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

Veal Cutlets

2 cutlets, 275 (about) calories

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

Cutlets or chops may be cooked in paper bags if desired. Wrap the chop in a thin slice of bacon, grease the paper (a piece of heavy brown paper), place the chop inside and secure the ends with paper clips or pins; place in a pan and [Pg 125] cook in the oven, or under the flame. It is wise to slip the bag containing the chop inside of another bag; in this way the meat will not taste of scorched paper if the outer bag should burn.

Bacon (1 Slice)

194 calories

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

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

Fish

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

Fish Steaks, Stuffed with Oysters

3 ounces, 168.3 calories (about)
Halibut, trout, or any good baking fish, 235.8 calories (about)

Lay fish for one hour in a French dressing made from ½ cup of oil, ⅓ cup of vinegar, salt and pepper; drain and place upon slices of bacon, placed upon a fish sheet or dripping pan. Dip oysters first in melted butter, then in bread crumbs, and place upon the slice of fish, adjust second slice above, cover top with bread crumbs, dot with butter and bake 30 to 45 minutes in moderate oven. Serve with hollandaise sauce.

[Pg 126]

Lobster or Crab

1 serving lobster, 157 calories
1 serving crab, 154 calories

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

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

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

Hollandaise Sauce

178 calories; 1 tablespoonful, 22 calories

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

Vegetables and Fruits

Among the plants known as vegetables, some are seeds, some leaves, some stems or bulbs, some roots or tubers, and some are the fruit surrounding the seeds. Under the head of seeds we find peas, beans and lentils, this class of vegetables being spoken of as legumes or pulses; they are rich in [Pg 127] protein (especially when dried) and contain an appreciable amount of carbohydrates as well, some contain fat. Green, or fresh legumes are more easily digested than the dried legumes. They are important sources of iron and phosphorus and contain a certain amount of calcium; in the body they act as neutralizing agents since the base-forming elements in these plants predominate over the acid-forming elements.[42]

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

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

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

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

Fruits.—Fruits have practically the same value from a dietetic standpoint as vegetables, and the same care must be given to their selection. Some fresh fruit should be given to children every day to safeguard them against scurvy. And adults should have fresh fruit several times a week, the remainder of the time dried fruits may be used. [Pg 128] Canned fruits while good are not so valuable as fresh fruits and are more expensive than the dried fruit.

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

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

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

Peas

121 calories

[Pg 129] Add salt and peas to boiling water; allow to cook from 30 to 60 minutes, or until they are perfectly tender, drain and add butter and additional salt if necessary, or 1 tablespoonful of cream sauce. In gastro-intestinal disorders and with young children, it is best to press peas through sieve or remove the indigestible parts.

String Beans

94 calories

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

Spinach

90 calories

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

Carrots (with Cream Sauce or Butter)

82-117 calories

Carrots, about ½ cupful after they are cut in cubes, or 3½ ounces. Serve with 2 tablespoonfuls of cream sauce, or with 2 teaspoonfuls of butter and a little salt and pepper. Scrub carrots and scrape off the skins; cut into slices or [Pg 130] cubes, drop into slightly salted boiling water and cook until tender; drain and add butter or cream sauce.

Baked Potato (White)

140 calories

1 potato weighing about 3 ounces; scrub well with a brush; dry and slightly grease surface, place in moderately hot oven and bake about 45 or 50 minutes. (The potato should feel tender upon pressure.) When done, make an incision of 1 inch in the skin and gently press out the steam; cover closely with cloth and keep in a warm place until ready to serve. Put teaspoonful (about ⅙ ounce) of butter in the cut and serve very hot.

Creamed Potato

182 calories

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

Potato Stuffed with Meat

197.5 calories

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

[Pg 131]

Scalloped Potatoes

250.8 calories

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

Vegetable and Fruit Salads

Cucumber

62.5 calories

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

Tomato (No. 1)

with mayonnaise, 61 calories
with French dressing, 131 calories

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

[Pg 132]

Tomato (No. 2)

63 calories

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

Fruit Salad (No. 1)

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

Fruit Salad (No. 2)

1217 calories (about)

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

Tomato Jelly

77 calories

[Pg 133] One slice of onion may be added if there is nothing to contra-indicate it, but care must be taken in adding onion, as it is apt to disagree with many people. Boil all of the ingredients together (except the gelatin) for 20 minutes, press through a sieve, then through a cloth, return to the stove and allow to boil up; add the gelatin and boil 5 minutes; strain into wet molds.

Whole Tomato Stuffed with Rice

167 calories

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

Broiled Tomatoes

353 calories

Heat broiler or frying pan very hot, grease lightly; season crumbs with salt and pepper; dip slices of tomato in cracker crumbs, covering both sides well, and place upon the broiler; when one side is browned, turn over carefully, to prevent breaking, and allow the other side to brown. Lift the broiler to the lower half of the oven and let the [Pg 134] tomatoes cook gently for 10 minutes. Place bits of butter upon each slice, then arrange these on the buttered toast.

Stewed Tomatoes on Toast

171 calories

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

French Dressing

131 calories

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

Use as little salt as possible in nephritic conditions.

Mayonnaise Dressing

2109 calories

Method of Mixture: Mix dry ingredients with yolk of egg thoroughly; add all the acid (use Dover beater). Now add, one teaspoonful at a time, the olive oil; beat continually until the mixture thickens (after 8 teaspoons of oil have been added). Put in oil by tablespoonfuls until [Pg 135] all is incorporated. This method shortens the time of making at least one-half, and the dressing rarely curdles as it often does in the old methods.

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

Gelatin Jellies

Lemon Jelly

150 calories

Orange Jelly

280 calories

Grape Juice Jelly

315 calories

Method for Fruit Jellies.—Soak gelatin in cold water about 2 or 3 minutes, then pour over it the boiling liquid; add sugar and fruit juice; strain through cloth into wet molds. Set in cold place to stiffen; when firm, unmold. Serve with whipped cream, or pour liquid into baskets made from oranges or grapefruit hollowed out and the edges [Pg 136] scalloped, or pour into shallow pans, and cut in ½-inch blocks when firm, and serve on a bed of whipped cream.

Wine Jelly

127 calories

Method for Wine Jelly.—Put water, wine, lemon juice, peel, cinnamon, and sugar into a saucepan, allow to boil 5 minutes, pour over gelatin (which has been soaked in cold water). If jelly looks cloudy return to saucepan, and add ½ egg white beaten stiff, allow to boil 1 minute, stirring constantly, and strain into mold. Serve with whipped cream.

Water Ices

Lemon

276.5 calories

Orange

311 calories

Grape Juice

362.6 calories

[Pg 137]

Method of Mixture

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

Apricot

384 calories

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

Strawberry and Raspberry

346-393 calories

Proceed as in other ices.

Currant

526 calories

Wash currants carefully and place in a saucepan on a warm but not hot part of the stove, allow to heat gently until the currants are soft, press through a cloth, and add [Pg 138] the water and sugar; stir until dissolved (or make a sirup of the water and sugar and add the currant juice and lemon and freeze as directed in other ices). The egg white may be added if desired.

Lemon Cream, or Milk Sherbet

Mix cream, milk and ¼ cup of sugar and pour into freezer; freeze until half frozen (mushy). Add juice of 3 lemons and 1 whole lemon (peel and pulp) shaved into very thin slices sweetened with remainder of sugar (if not sufficiently sweet add more sugar and make allowances for same in fuel value). Continue the freezing until sherbet is of the right consistency.

Miscellaneous Desserts

Nut Charlotte

with wine 758 calories; without wine 745 calories
Two servings

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

Orange Charlotte

631 calories

[Pg 139] Pour jelly mixture into a bowl and surround with cracked ice; when it begins to stiffen, fold in the stiffly beaten cream.

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

Snow Pudding

428 calories for orange pudding

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

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

Prune or Prune Fig Whip

184.4 or 244.9 calories

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

[Pg 140]

CHAPTER VI

INFANT FOODS AND FORMULAS USED IN ABNORMAL CONDITIONS

Formulas Used In Feeding Infants

Whey

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

Barley Water

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

[Pg 141]

Oat Water

Mix and proceed as in making barley water.

Albumen Water with Brandy

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

Beef Juice

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

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

Malt Soup

347 calories

[Pg 142] Dissolve malt soup extract in ½ cup of hot water and measure in enough cold water to cool the mixture. With the remaining cold water mix the flour until it is free from lumps; and to the malt soup mixture, add milk. Pour all into a clean saucepan and bring slowly to the boiling point; simmer (not boil) for 20 minutes. Now increase the heat and allow the mixture to boil 5 minutes; strain and use as directed.

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

Buttermilk Mixture for Infants

544.6 calories

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

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

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

Eiweissmilch[45]
(Protein or Albumen Milk)

[Pg 143] Heat whole milk to 100° F., add essence of pepsin and stir thoroughly. Allow to stand at same temperature until the curd is formed. Pour mass into muslin bag and drip the whey from the curd. When the mass is as dry as it is possible to have it, remove it from the bag to a fine strainer. Press curd through the strainer with a wooden spoon or potato masher (the author has found that a potato ricer with a piece of copper gauze, such as is used in a chemical laboratory, inserted, facilitates the breaking up of the curd). The mass must be passed several times through the strainer in order to make the precipitate sufficiently fine to look like milk. During the process of straining, the buttermilk is added. The composition of above formula is, according to Finkelstein and Meyer, as follows:

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

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

FORMULAS USED IN DIET FOR CONSTIPATION

Prunes and Figs

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

Conserve

Boil prunes just enough to allow of the pits being removed. Cool and pass with the senna leaves, figs and raisins [Pg 144] through the food chopper. After passing through once return to chopper and pass through a second time. See that the senna leaves and fruit are thoroughly mixed and finely chopped. Place in a quart jar and give in doses of from 1 to 2 teaspoonfuls night and morning.

Bran Gems (No. 1)

560 calories

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

Bran Gems (No. 2)

832 calories

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

Bran Biscuits

706 calories

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

[Pg 145]

Bran Cookies

2187.5 calories

½ cup raisins or nuts may be added, due allowance being made for the additional fuel value.

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

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

Nutrient Enemas[46]

No. 1. Milk and Egg

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

No. 2

No. 3

[Pg 146]

No. 4. Singer’s Enema

No. 5. Boas’ Enema

No. 6

No. 7. Milk and Starch Enema—Von Leube

Malted Milk Enema

Normal Saline Solution

Formulas Used in Diabetes[47]

* Bran Agar Wafers

Makes 30 wafers.

[Pg 147] Mix agar-agar, saccharin, salt and water. Boil until dissolved. Pour over dry bran. Mix thoroughly and mold into muffin tins while hot. Bake in a slow oven about 20 minutes, or until wafer is dry and will whirl in the tin.

* Agar Jelly

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

* Spinach and Egg Salad

Add:

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

* Mayonnaise Dressing

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

The percentage composition of this dressing is

Fat—83%. Protein—0.9%

[Pg 148]

Cellu Bran Crackers

Makes 12 crackers about 4 inches by 4 inches and ⅛ inch thick (resembling Graham crackers).

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

These crackers have practically no food value.

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

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

** Olmsted Brancakes

(Recipe 41)

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

** Soya Manna Muffins

(Recipe 42)

[Pg 149] Beat eggs, add cream and then flour, beating all the time. Add water and melted butter. Mold into 12 cakes and bake. Each cake contains 6 grams protein, 6 grams fat: approximately 75 calories.

** Noodle Soup

(Recipe 43)

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

** Chicken Supreme

(Recipe 44)

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

** Salisbury Steak

(Recipe 45)

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

[Pg 150]

** Veal Bird

(Recipe 46)

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

** Salmon Molded

(Recipe 47)

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

** Cabbage Soufflé

(Recipe 48)

Chop cabbage fine, add meat, cream, beaten egg, salt and pepper. Put into mould and sprinkle grated cheese [Pg 151] over top. Bake in a moderate oven until firm and brown. Food value, 5 grams carbohydrate, 15 grams protein, 17 grams fat.

** Celery Ramekins

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

** Baked Onion

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

** Squash Pie

(Recipe 92)

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

[Pg 152]

** Spice Cookies

(Recipe 93)

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

Cream of Cauliflower

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

Tomato Bisque

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

Spinach Soup

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

[Pg 153] Other Cream Soups, except Tomato Bisque, are made by the same recipe.

Vegetables

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

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

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

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

Boiled Corned Beef With Cabbage and Other Vegetables[48]

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

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

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

[Pg 154]

Parsley Butter

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

Neufchâtel Cheese Salad

Season with salt and paprika and dress with cream dressing.

Cheese Salad

Mash cream cheese with fork; add tablespoonful chopped pecan nuts to ⅓ Neufchâtel cheese. Season with salt and pepper and dress with French dressing.

Tuna Fish Salad

Dress with French Dressing.

Egg Salad

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

Tomato Aspic

Boil all ingredients (except gelatin and celery hearts) 20 minutes. Measure. Add hot water or tomato juice to make one cup; add gelatin; allow to cool; cut celery fine, [Pg 155] place in mold; pour in the tomato aspic and allow to jelly in a cold place.

Bread Substitutes

Bran Biscuits, or Muffins

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

Diabetes Muffins[49]

(The Equivalent of an Egg)

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

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

Lister Muffins

So arranged that each muffin is equivalent to one egg:

[Pg 156] Make 17 muffins; each muffin contains 6 grams protein, 6 grams fat.

Bran Biscuits for Constipation

(By F. M. Allen)

Tie bran in cheesecloth and wash under tap until water is clear. Bring agar-agar and water (100 c.c.) to boiling point. Add washed bran and salt and agar-agar solution (hot). Mold into ten cakes; place on oiled paper and let stand ½ hour, then when firm and cool, bake in moderate oven 30 to 40 minutes. The bran muffins are more palatable if butter and eggs are added. This may be done, provided the patient allows for them in the diet.

Casoid Flour and Bran Muffins

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

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

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

Lister Flour and Bran Muffins, or Biscuits

[Pg 157] Squeeze all the water from the bran, then add flour and melted butter, salt, well-beaten egg yolk and cream. Whip egg white stiff and fold into mixture. Add baking powder and enough water to make thick batter. Use less water if biscuits instead of muffins are desired, and knead into a dough. Roll out into a sheet one-half inch thick and cut with biscuit cutter.

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

Soya Meal and Bran Muffins[50]

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

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

Almond Biscuits

Beat egg yolk until light, add cream and saccharin; stir this into almond meal. Fold in the stiffly beaten white. [Pg 158] Drop on a greased paper and bake until golden brown in a moderate oven.

Almond meal or flour is prepared as follows:

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

Cocoanut Flour

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

Cocoanut Biscuits

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

Spanish Cream

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

[Pg 159]

Lister Cream Puff

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

Custard

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

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

Snow Pudding

Make ½ cup gelatin, as directed below.

Whip in 1 egg white.

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

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

Jellies

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

Lemon

16.6 calories

[Pg 160]

Irish Moss Pudding

Carefully pick over and wash through several waters 1 tbs. Irish moss. Place in double boiler with ⅓ cup of water and 3 tbs. 40% cream and ¼ grain saccharin. Cook until mixture thickens when dropped upon a cold saucer. Pour over 1 stiffly beaten egg white; add 3-4 drops of vanilla extract. Mold and set on ice.

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

Orange

54 calories

Wine

40.8 calories

Method for Fruit Jellies

Soak gelatin in cold water about 2 or 3 minutes, then pour over it the boiling liquid; add saccharin and fruit juice, strain through cloth into wet molds. Set in cold place to stiffen; when firm, unmold. Serve with whipped cream, or pour liquid into baskets made from orange or grapefruit, hollowed out and the edges scalloped, or pour into shallow pans, and cut in ½-inch blocks when firm and serve on a bed of whipped cream.

[Pg 161]

Wine Jelly

Put water, wine, lemon juice and peel, cinnamon, and saccharin into a saucepan, allow to boil 5 minutes, pour over gelatin (which has been soaked in cold water). If the jelly looks cloudy, return to saucepan, and add ½ egg white beaten stiff; allow to boil 1 minute, stirring constantly, and strain into mold. Serve with whipped cream.

Ices

Lemon

30 calories

Orange

75.5 calories

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

Ice Cream

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

Whip cream, add saccharin and nuts. Pour into a small ¼-pound baking powder can, seal the edges of mold or can [Pg 162] with a thin strip of buttered muslin. Pack in equal parts of salt and ice for two hours.

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

Nut Charlotte

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

1 tbs. sherry wine and 1 tsp. gelatin soaked in 1 tbs. cold water and melted over hot water may be substituted for vanilla to vary the above recipe.

Orange Charlotte

Soak gelatin in cold water; dissolve over hot water, add to orange juice; add saccharin; set aside until it begins to jelly. Whip cream and add to partially jellied orange juice; fold in the stiffly beaten egg white; mold. Serve 30 grams.

[Pg 163]

SECTION III

THE HUMAN MACHINE

[Pg 165]

CHAPTER VII

THE HUMAN BODY

Chemical Composition of the Body.—It has been estimated by various writers that the human body has an approximate average chemical composition[51] of—

Dependence of the body upon Food.—The human body, like any other piece of machinery, undergoes a constant wear and tear incidental to the work it performs, but in the human machine this is not all that must be included in its upkeep. The replacing of the dead and cast out cells with new ones, the repairing of the worn cells, the furnishing of heat, not only for the running of the engine but for the maintenance of the body temperature,—all of these must be considered and cared for if life is to continue. In man-made machinery, the renewal of the worn parts, and the replacing of those no longer useful must be accomplished by an outside agency. But in the body this work is [Pg 166] performed by the organism; and the material used for the purpose, as well as that which is used to furnish the heat necessary for the internal and external activities of the body is food.

Exceptions to this Rule.—Under normal conditions the body never uses its own structure either for fuel or to replace tissue losses. In starvation the body rebuilds its important tissues, such as the nerves and glands, at the expense of the less important ones, such as the connective tissues and the skeletal muscles (Taylor).

Science has proved that for the most part the body does not use the food materials in their original form, but carries them through a series of transformations into substances more easily handled by the organism.

Roughly speaking, we may say that the body carries the foodstuffs through practically four processes on the pathway through the body, namely, digestion, absorption, metabolism, elimination.

Processes Included in Digestion.—There are several processes concerned in this transformation of the food materials. Some are purely mechanical and have to do with the movement of the food mass through the digestive tract: others are of a chemical character and bring about distinct changes in the food materials themselves. These mechanical and chemical processes with the retarding and stimulating agents that influence them are called digestion.

Absorption.—After the food materials have undergone digestion, or simplification into more available substances, these substances are absorbed, that is, they are passed through the membranes lining the walls of the intestinal tract, and thence to the blood.

Metabolism.—The utilization of the transformed food materials and their final fate in the human body is included under the term Metabolism.

[Pg 167] Elimination.—After the food materials have been utilized to the extent of the body’s ability to handle them, their waste products are cast out of the organism by way of the skin, the lungs, the intestines and the kidneys.

A brief description of these processes seems desirable here.

Digestion.—Mechanical digestion begins in the mouth, where through the action of the teeth, the tongue and the muscles of the jaw, the food material is ground up and liquefied to a certain extent and made ready for the chemical action which takes place, to a limited degree only, as a result of the salivary enzyme in the mouth. The eating of food causes a flow of saliva from the three pairs of large salivary glands, and from the numerous secretory cells situated in the membranes of the mouth. As a rule the food stays for too short a time in this organ for any appreciable amount of chemical action to take place, but the liquefaction of the food mass with the salivary juices which contain the ferment (ptyalin), prepares for its passage into the gastric organ, and allows the digestion of the starch (the only foodstuff affected by salivary digestant), to continue in that part of the stomach until its action is checked by the hydrochloric acid in the gastric juice.

Arrangement of Food in the Stomach.—To simplify the study of the gastric organs it may be well to think of the stomach as being divided into three regions, i.e., “the fundus, the middle region, and the pyloric end,”[52] each of which differs slightly from the other. After being swallowed, the food enters the region situated at the cardiac end, known as the fundus.

Motor Processes in the Stomach.—There are no peristaltic waves in the fundus of the stomach, and the movement of the food mass is accomplished through the stretching and contraction of the muscular walls of the organ [Pg 168] which tends to churn and further mix it with the salivary juices as it is gently pushed out into the middle region. In this region the peristaltic waves begin and travel toward the pylorus and increase in force as digestion progresses, ceasing only with the emptying of the organ. When the first stratum of food reaches the middle of the stomach it is caught by these oscillating peristaltic waves and forced forward through the pyloric region and against the pylorus, from whence it is returned back through rings of constriction. This forward and backward movement continues as long as there is food in the stomach, thus thoroughly mixing the mass with the gastric juice and allowing the enzymes existing in the juices to have an opportunity for action (chemical digestion).

Passage of Food from Stomach.—The material prepared in the stomach, known as chyme, is passed into the duodenum through the pylorus. The opening of this sphincter is controlled, according to Cannon, to a certain extent by the liquefication of the chyme, but more especially by the presence of free acid in the stomach side of the pyloric orifice.

Behavior of Food in the Intestines.—The food does not pass at once along the canal, but waits in the duodenum until several portions have passed through. As the food mass is made alkaline in the presence of the intestinal juices, the pyloric valve closes, opening again as the contents nearest it on the stomach side are acidified.

Intestinal Movements.—The peristaltic waves in the small intestines begin in the upper part and start a course ever downward. These waves in the intestines are two-fold in character; the quick shallow wave which forces the food string forward, breaking it up into segments, and backward joining the segments together again, and the strong deep wave which carries the entire mass forward after each segmentation. This method of movement in the small [Pg 169] intestines is the best one possible under the conditions which prevail in this region of the digestional apparatus, since it not only mixes the food material with the juices necessary for its digestion, but likewise spreads it out over a wide space, insuring a greater contact with the absorbing walls of the small intestines.

The Effect of Muscular Constrictions.—The muscular constrictions occurring in the intestines producing segmentation of the food string have, according to Sherman, the effect of “(1) further mixing of the food and digestive juices, (2) bringing the digested food into contact with the absorbing membrane, (3) emptying the venous and lymphatic radicles in the membrane, the material which they have absorbed being forced into the veins and lymph vessels by the compression of the intestinal walls.”[53]

Movements in the Large Intestine.—The movements in the large intestine or colon are much like those in other parts of the digestive tract. The small and large intestine are divided by a valve known as the ileocecal valve, and any food which passes through it cannot return, since the valve is a competent one. The cells in the walls of the larger intestine secrete fluids of a lubricating character, containing no enzymes of digestion but aiding in moving the fecal matter toward the rectum.

Distribution of Secretory Cells.—Secretory cells are distributed in each of the three regions of the stomach, but are more numerous in the middle region than at either end. The third region includes the pyloric vestibule through which all foods must pass before they can enter the small intestine, and terminates in the pylorus, the valve which shuts off the stomach from the duodenum and the rest of the intestinal canal.

Chemical Digestion.—The chemical changes in the food materials, after they are eaten, are brought about [Pg 170] through the action of certain substances known as soluble ferments or “enzymes.” These enzymes exist in every tissue of the body, and their province is first to break down the food materials themselves into simpler compounds, and then to reconstruct the simpler substances into those of a more complex character, which are more available for the various uses of the organism.

Action of the Enzymes.—As Sherman has stated, “all fermentation is brought about either directly or indirectly by the activity of animal or vegetable organisms or cells. When the organisms or cells act directly and the chemical changes occur only in their presence, the fermentation is said to be due to an organized ferment. When the action is not brought about directly by the cell itself, but by means of a substance secreted by the cell but acting apart from it, this substance is called a soluble or unorganized ferment or ‘enzyme.’” The enzymes concerned in digestion and metabolism, their source and their action, may be found in the following table:

[Pg 171]

TABLE OF ENZYMES[54]

Source and Action of Enzymes

[Pg 172] Classification of Enzymes.—Sherman classifies the enzymes of the body according to their effects:

1. The hydrolytic enzymes:

(a) Proteolytic or protein-splitting enzymes.
(b) Lipolytic or fat-splitting enzymes.
(c) Amylolytic or starch-splitting enzymes.
(d) Sugar-splitting enzymes.

2. The coagulating enzymes, such as thrombin or thrombase (the fibrin ferment) and rennin, which causes the clotting of milk.

3. The oxidizing enzymes or oxidases (which, if the oxidation be accompanied by a splitting off of amino groups, may be called “deaminizing” enzymes).

4. The reducing enzymes or “reductases.”

5. Those which produce carbon dioxide without the use of free “deamidizing” oxygen, such as zymase of yeast.

6. Enzymes causing the breaking down of a larger into a smaller molecule of the same composition, as in the production of lactic acid from glucose.

DIGESTION (CHEMICAL)

Salivary Digestion.—The table shows that enzymic action begins in the mouth. Saliva, the characteristic secretion of this region, contains the enzyme ptyalin which exerts its influence upon the starches and dextrins. The food mass remains in the mouth for so short a time, however, that a very small percentage of the starch is changed to maltose under salivary digestion. The action of ptyalin, however, continues in the fundus of the stomach until stopped by the acid in the gastric juice.

Gastric Digestion.—The conditions existing in this region of the gastric organ of digestion are particularly favorable to the continuance of salivary digestion on account of the neutral character of the juices secreted by the cells there, and because there is so little movement taking [Pg 173] place. The cells in the middle region, however, secrete a fluid rich in acid, and as the food mass is gradually pushed forward by the contraction of the stomach walls into this portion of the stomach, further conversion of starch and dextrin to maltose is checked. Gastric juice is secreted by cells situated in all parts of the stomach. The character of the secretions differs in different parts of the organ. However, that in the fundus is neutral in character or even slightly alkaline, according to Howell, while that in the middle region is highly acid. The pyloric end of the stomach exhibits strong peptonizing powers and much of the hydrolysis of protein takes place here. As the food is pushed out of the fundus it is caught by the waves of peristaltic action and swept toward the pylorus. This movement of the food mass to and from the pylorus under the influence of the muscular constriction in the stomach tends to mix it thoroughly with the juices in all parts of the stomach, and in a measure to liquefy it to the “souplike” mixture known as chyme.

Rate of Carbohydrates, Proteins, and Fats.—Carbohydrates, for example, do not require any acid for their digestion, hence all of the acid with which they come in contact can go toward acidifying them, while the proteins require hydrochloric acid before the enzymes can begin to exert their activities. Consequently they leave the stomach much more slowly than the carbohydrates. The fats leave more slowly than any of the other food combinations. If carbohydrates and proteins are taken together they leave the stomach more slowly than if the carbohydrates were fed alone, but more quickly than they would if the meal consisted of protein alone. When the meal consists of fats and proteins, the stomach is emptied more slowly than is the case when either is fed alone.

Intestinal Digestion.—Digestion proceeds in an orderly manner throughout the intestinal canal. The [Pg 174] pancreatic juice, bile, and intestinal juice are poured upon the food mass on its entrance into the duodenum. The enzymes work simultaneously. Trypsin in the pancreatic juice takes up the hydrolysis of the proteoses and peptones and those proteins which have escaped gastric digestion. The amylopsin likewise in the pancreatic secretion acts upon the starch and dextrin, changing them to maltose. The lipases split the fats to fatty acids and glycerol.

The erepsin in the intestinal juice, “succus entericus,” brings about further change in the proteins, with the production of amino acids. The bulk of the carbohydrates are converted into monosaccharids in the small intestines. The lactose, maltose, and sucrose are changed through the activity of the lactase, maltase, and invertase into glucose. Sherman states that “it is possible that the splitting of the lactose (milk sugar) may occur in the intestinal wall rather than in the food mass.”[55]

Bile.—Human bile, the secretion most actively concerned in the digestion and absorption of the fats, contains water, bile salts, bile acids, bile pigments, cholesterin, lecithin, and a peculiar protein derived from the mucous membranes of the bile ducts and gall bladder.

Stimulation of Intestinal Secretions.—The flow of the intestinal juices is stimulated by a substance or hormone known as “secretin.” This hormone is the result of the action of hydrochloric acid upon some substance in the intestinal wall. Starling claims that the formation of hormones and their circulation through the blood to the reactive tissues is sufficient to account for the activity of the pancreas; he doubts if the nervous system plays any part in the activity of that organ.

Secretion of Water in the Stomach.—The secretion of water by the cells of the stomach is such, according to [Pg 175] Taylor, as to produce chyme of quite constant consistency, the solid particles being held in suspension in the fluid medium.

Factors Influencing Gastric Digestion.—The factors influencing digestion in the stomach constitute all those mechanical, electrical, chemical, and psychical factors which stimulate or retard the action of the gastric juices. The movements in the stomach are involuntary, but their activities may be stimulated by the flow of gastric juice. Sleep retards digestion in the stomach by retarding the movements in the organ itself.

Stimuli to Gastric Flow.—The division and liquefaction of the food in the mouth hastens gastric digestion by making the food better fitted for the action of the enzymes in the gastric juice. The type as well as the character of the food acts as a stimulus to the gastric secretion.

Water is probably the best of all the agents for stimulating the secretion of gastric juice, while dextrin (toast, zwieback) and the extractives of meat likewise exert similar powers.

Retarding the Gastric Flow.—The nervous system, on the other hand, at times checks or entirely inhibits a flow of these juices. Worry, excitement, anger, fatigue, chill; each plays its part in promoting poor digestion in the gastric organ. As chemical factors, water and salts are the two necessary substances for gastric digestion, since the enzymes in the juices cannot act except in their presence.

Alkaline carbonates and fatty foods both check the flow of gastric juice, and retard digestion. The psychic factors which result in a stimulation of the secretory cells in the stomach are exerted through the sight, smell, and taste. One often hears the expression: “The food looked, smelled, or tasted so good that it made my mouth water.” This actually occurs; hence the secretion has been named appetite juice. This appetite juice acts as a direct stimulant [Pg 176] to the cells in the mucous lining of the stomach, causing a flow of gastric juice. It cannot be said to cause digestion, but it certainly institutes that process, thus starting the whole digestional procedure.

Digestion in the Larger Intestine.—Science has proved that most of the nourishing part of the food ingested is digested and absorbed before it reaches the larger intestine. The two portions of the alimentary canal known as the small and large intestine are separated by the ileocecal valve. Cannon claims “that this valve is competent, that is, under normal conditions the food mass which passes through into the colon cannot be forced back into the small intestine.” The food mass sometimes contains materials which have escaped digestion, likewise some of the active enzymes which bring about their hydrolysis, in which case a certain amount of their digestion may continue in the large intestine.

So far, investigators have found no enzymes in the fluids secreted by the cells in the walls of the large intestine, but they have found an alkaline fluid which assists in completing the digestion of the foods which has started in other parts of the intestinal tract.

Absorption.—Absorption of food occurs in all parts of the intestinal canal, but the major portion of it occurs in the small intestines, the mucous membrane lining of which seems particularly adapted for this purpose. According to Taylor there is no absorption of fats, carbohydrates, or proteins in the stomach. Other investigators believe that some of the protein is absorbed and also some glucose in concentrated solution. However, the stomach cannot be considered of great value as an absorbing organ. Physiology teaches that the absorption of the products of digestion occurs by means of the millions of small projections or villi with which the intestinal wall is lined. These villi contain numerous capillary blood vessels and spaces known as [Pg 177] lacteals. The former converge into the portal vein, the latter into the lymphatic vessels and thence into the thoracic ducts.

The Absorption of Fat.—The fats, as has been described, are split into their two constituents, fatty acid and glycerol. The former is dissolved by the bile to form soap; the latter is readily soluble in water. These constituents thus dissolved pass through the walls and recombine in the form of neutral fat droplets, probably during the passage through the walls, since they appear in this form in the cells. They pass into the thoracic duct and thence into the blood stream.

Absorption of Carbohydrates.—The carbohydrates are chiefly absorbed in the form of monosaccharids. This has been proved by introducing cane sugar or lactose into the blood vessels and getting the greater portion of it back unchanged by way of the urine. As the monosaccharids are taken up by the capillaries lining the walls of the small intestines, they are passed on to the portal vein and carried by the portal blood into the liver, where they are stored temporarily as glycogen, and given out to the blood in the form of glucose as needed. After a meal rich in carbohydrates, the portal blood will be rich in glucose, while the blood in general circulation contains about the same amount as usual, about 0.1%.

Absorption of Proteins.—The absorption of the products of protein digestion occurs through the capillary blood vessels and passes on to the portal vein. The metabolism of protein is more complex than that of any of the foodstuffs. It is probable that each living cell contains enzymes which are capable of breaking down the body proteins with the production of amino acids just as the proteins of the food are broken down by enzymes of digestion, and according to Sherman “it is not improbable that protein synthesis also may be brought about by every living cell.”

The Absorption of Water.—This does not occur in [Pg 178] the stomach, as was formerly believed, but in the small intestines.

The Absorption of the Mineral Salts.—This occurs in conjunction with the other food material. Some of the mineral salts are much more soluble than others and are more readily absorbed. The function of the mineral salts in the body has already been described, and since they form a part of every tissue and fluid in the body their absorption and fate in metabolism must be studied with that of the other chemical combinations.

ABSORPTION IN THE LARGE INTESTINES

The digestion of the food as it is passed into the last portion of the alimentary canal has been largely completed. However, that part which has escaped digestion in the small intestine is finished and absorbed here. The important peristaltic waves occurring in this region are antiperistaltic in character and have the property of churning the food thoroughly and bringing a larger portion of it in contact with the absorbing walls. The water which is left in the food mass together with the products of the digestion of the foodstuffs is absorbed in the first part of the large intestine, leaving the remainder more solid. This residue is known as feces or fecal matter.

The diagram on page 179 shows the various processes through which the foodstuffs pass after absorption.[56]

Bacterial Action in the Alimentary Canal.—The changes in the foods so far mentioned have been chiefly the result of the activity of the enzymes existing in the various digestive processes throughout the body. But there are other changes which occur in the foods during their sojourn in the digestive tract which are not accountable to enzymic [Pg 179] action, but which, in fact, modify to a certain degree the changes wrought by the enzymes. These are the result of the activity of certain specific bacteria which inhabit the entire digestive tract of the individual from a few hours after birth until death. Some of these have so adapted themselves to the existing conditions that, unless present in overwhelming numbers, they are not only harmless, but they actually assist in protecting the organism from the inroads of more harmful species. Many experiments have been made to find whether or not bacteria are essential to human nutrition, and the results of these experiments prove that they are not. However, since they are so firmly established in the body it is well to study the various types and learn as much as possible of the products of their activity and the influence which they exert in human nutrition.

Types of Bacteria.—It would be impossible and unnecessary to consider the action of all of the bacteria in the body in this text, but it is necessary to consider those which are prominent in bringing about decomposition of the foods in the digestive tract. Sherman holds that there are three main types having this property: “(1) the bacteria of fermentation, such, for example, as the lactic acid bacteria; (2) the putrefactive bacteria, such as the anaërobic B. aërogenes capsulatus; (3) bacteria of the B. coli type, showing [Pg 180] the character of both the fermentative and putrefactive organisms but tending in general to antagonize the putrefactive anaërobes.”[57]

Fermentation in the Stomach.—In the stomach, fermentation of the carbohydrates with the production of organic acids, and at times alcohol, occurs. The types of fermentation taking place in the stomach are alcoholic, lactic, butyric, acetic, formic, oxalic, and cellulose. The bacteria inhabiting the gastric organs are dependent upon air for existence, while those in the intestines are not.

Factors Influencing Excessive Fermentation.—The factors influencing excessive fermentation in the stomach are lack of “tone” and motility in the organ, insufficient amount or absence of free hydrochloric acid in the gastric secretion, dilatation of the stomach, and an excess of carbohydrate foods in the diet. Of the latter, sucrose and glucose are especially susceptible to the action of fermentative bacteria. Under normal conditions, that is, in health, the conditions prevailing in the stomach are very unfavorable to the development of bacteria of the putrefactive type, the gastric juice exhibiting decided germicidal properties. Then, too, the presence of air acts against their development. Much of the so-called gastric fermentation does not occur in the stomach but rather in the duodenum.

Bacterial Action in the Intestines.—In the lower part of the small and in the large intestines, the bacteria of the anaërobic type increase, conditions more favorable to their development existing there than farther up in the intestinal tract. However, there are a great many bacteria in the whole of the small intestine. Those producing decomposition of the unabsorbed proteins are especially prominent in the colon.

Herter[58] states that “the presence in the colon of [Pg 181] immense numbers of obligate micro-organisms of the B. coli type may be an important defense of the organism in the sense that they hinder the development of that putrefactive decomposition which, if prolonged, is so injurious to the organism as a whole. We have in this adaptation the most rational explanation of the meaning of the myriads of colon bacilli that inhabit the large intestine. This view is not inconsistent with the conception that under some conditions the colon bacilli multiply to such an extent as to prove harmful through the part they take in promoting fermentation and putrefaction.”

Effect of Bacterial Activity in the Body.—In summarizing the effects of bacterial action in the body it is found that with the exception of oxalic acid, which is exceedingly injurious, and which, according to Herter, results from the eating of large quantities of meat and sugar, the products of fermentation are simply irritating in character, while those resulting from putrefaction are distinctly toxic. Among the substances deserving mention under this head we have indol, skatol, cresol, and phenol. These substances are very soluble and upon absorption combine with the sulphuric acid formed in the body and are excreted by way of the kidneys where they appear in the urine as “conjugated sulphates,” the chief of which is indican. The amount of indican in the urine is taken as a measure of the intensity of the putrefaction taking place in the body.

Metabolism.—Under the term metabolism we understand the series of processes through the foodstuffs and carried (a) in the conservation of the tissues of the body and (b) in the maintenance of body temperature and physical work (Taylor). The processes concerned in metabolism are chiefly those of building up, “anabolism,” and breaking down, “catabolism.” In the processes of anabolism the products absorbed are built into the tissues and cells of the body. In catabolism, the worn particles from the cells, [Pg 182] and the dead cells no longer useful are broken up and thrown out of the body. According to Taylor, “side by side with these processes are the reactions of combustion, whereby the temperature necessary for the life of the cells is maintained, and the energy needed for external work furnished.”

Behavior of Carbohydrates in Metabolism.—As Sherman[59] has said: “At least two kinds of enzymes are believed to be involved in the combustion of glucose in the tissue cells, (1) cleavage enzymes, which split the molecule into fragments more easily oxidized, and (2) oxidizing enzymes or oxidases which stimulate the oxidation of the cleavage products. Both kinds of enzymes are widely distributed through the body and are believed to be normal constituents of all active cells.”

Production of Energy.—It has been proved that the energy for external and internal work is produced largely from the glucose brought by the blood and oxidized in the muscles.

When a surplus amount of carbohydrate food is eaten, over and above the immediate needs of the body for fuel, it is stored in the liver and muscles as glycogen, which can be readily reconverted into glucose. When the supply of carbohydrate food is greatly in excess of the body’s needs, that is when the liver and muscles cease to store glycogen, it is built up into adipose tissue and furnishes a readily available source of emergency fuel.

Fate of the Carbohydrates.—After their oxidation the end products of carbohydrates, that is, the substances which are no longer available for use in the body, leave it in the form of carbon dioxide and water by way of the kidneys (urine), the skin, the lungs, and the intestines.

Fate of the Fats.—The fats upon absorption are taken [Pg 183] up by the lymph vessels instead of the capillaries and enter the blood with the lymph. According to various investigators, the fat which causes the turbidity of the blood plasma at the height of absorption will, as a rule, disappear after a few hours, part of it being burned as fuel, producing energy for the internal and external work of the body, and at least a part of the fats eaten being rebuilt into body fat. The end-products of fat metabolism, like those of the carbohydrates, consist of carbon dioxide and water, and leave the body by the same excretory channels.

When the normal oxidation of the fatty acids is interfered with or is overtaxed, a different reaction from that which usually occurs may take place, and this results in an excretion of acetone in the urine (see Chapter on Diabetes).

Protein metabolism is certainly more complex than that of either of the other active organic food groups. The amino acids which are the products of protein digestion are taken up by the capillary blood vessels in the intestinal walls and are passed by them into the portal vein, soon to become available for the needs of the body.

Fate of the Proteins.—After utilization in the body, the proteins, like the other foods, leave certain waste products which indicate to a greater or lesser extent the completeness with which the organism has made use of the food materials. The end-products of protein metabolism are: urea, ammonium salts, purin bodies, and creatinin. These products leave the body chiefly in the urine. The chief end-product in man is urea. This substance represents from 82-88% of the total nitrogen excreted by the kidneys. However, the less highly oxidized products represent the incomplete products of protein metabolism and thus indicate the changes through which these products must pass before being changed into urea. If for any reason there is [Pg 184] an impairment of the liver through which they must pass and where the change into urea is accomplished, there will be a rise of ammonia and a corresponding decrease in the output of urea in the urine. Thus, ammonia is formed at the expense of the urea. This occurs in fevers, diabetes, and certain structural diseases of the liver. According to Sherman:[60] “Normally about 2 to 6% of the total nitrogen eliminated is in the form of ammonium salts, the amount depending largely upon the relation between the acid-forming and base-forming elements in the food.”

Acid-forming and Base-forming Foods.—Mendel[61] states: “There are foods which act as potential acids and others which function as bases in the organism. When burned up either in the laboratory or in the body cells, they have a preponderance of acid or base, as the case may be, in their ash.” In this respect potatoes, apples, raisins, and cantaloupes, for example, are base-forming foods which depress the output of ammonia and increase the solubility of uric acid in the urine, whereas meal, cereals, and prunes (the latter with their content of benzoic acid) furnish acids in predominance.

Purin Bases.—These compounds are formed in the body as cleavage products of nucleoproteins or taken into the body in food. The chief of these products are adenin, guanin, hypoxanthin, xanthin, and uric acid. The latter is the most highly oxidized of all the purin bases and is the form in which they are chiefly eliminated in the urine.

Formation of Uric Acid.—The formation of uric acid can in a measure be controlled by attention to the diet, eliminating those foods known to be purin-bearing. Normally from 1 to 3% of the nitrogen eliminated will be in the form of uric acid. The normal human being [Pg 185] oxidizes about half of the purins eaten and excretes about half, mainly in the form of uric acid. According to Mendel, the formation of uric acid takes place throughout the body, and its partial destruction is accomplished by the kidneys, muscles, and liver. The formation of purins in the body and their elimination in the form of uric acid is especially significant in certain pathological conditions, gout, for example, in which the body has difficulty in eliminating these compounds.

The purin bodies are both endogenous and exogenous—that is, they may be brought into the body in food as such, or they may be formed as a result of the metabolism of the body tissues. For this reason the damage wrought by these substances may to a certain extent be controlled by eliminating the purin-bearing foods from the diet. Flesh-foods are high in purins, especially the highly nucleated glandular organs, liver, thymus (sweetbreads), etc., kidney, beef, mutton, veal, pork, chicken, turkey, goose, sardines, anchovies, all kinds of fish except cod. Among the vegetable foods asparagus, beans, peas, and spinach are highest in purins. Boiling extracts much of the purins from food. Meat especially should be prepared by this method, if used in the diet of individuals suffering from gout. Eggs and milk are purin free, and may be used freely. Certain substances increase the difficulty of eliminating uric acid. Alcoholic beverages for example are especially deleterious.

Creatinin.—This end-product of protein metabolism is, like uric acid, endogenous and exogenous. It is one of the normal constituents of the urine. The quantity is fairly constant for the individual, averaging about 0.02 gram per kilogram of body weight per day.

Mineral Metabolism.—A study of the organic foodstuffs reveals the fact that many of the mineral salts concerned in nutrition enter the body in organic combination with those constituents. Certain of the mineral salts, [Pg 186] however, enter, exist in and leave the body in the same organic form in which they occur in the food materials. This is true of chlorine, which for the most part, functions in and leaves the body in the form of chlorides (chiefly sodium chloride). A small part of the chlorine is used in the production of the hydrochloric acid of the gastric juice.

Sulphur and iron, both enter the body as essential constituents of proteins, and their metabolism occurs with that of these foodstuffs; the sulphur being converted largely into sulphuric acid must be neutralized at once, and it leaves the body by way of the urine as inorganic sulphates. Part of the sulphates are excreted as ethereal (conjugated) sulphates; the amount excreted in this form depending largely upon the extent of purification in the intestinal tract.[62]

Phosphorus.—This mineral salt is found to be present as an essential constituent of certain proteins, fats and carbohydrates. It also enters the body in the form of inorganic phosphates. During the digestion and metabolism of the organic foodstuffs the phosphoric acid radical is split off and eventually nearly all of the phosphorus leaves the body in inorganic form (inorganic phosphates).

Calcium.—Being the chief constituent of the bones, large quantities of calcium salts are stored in the skeleton of the child both before and after birth. The functions of calcium have already been discussed. That part not stored, which has finished its work in the body is excreted through the intestinal wall and leaves the body by way of the feces, only a small part of the calcium concerned in metabolism being excreted in the urine.

The Process of Osmosis in the Body.—The influence exerted upon the process of osmosis in the body is one of the most important parts played by the mineral salts in [Pg 187] metabolism. The fact that these chemical substances are indispensable to the metabolic processes makes it necessary for the nurse to know where they can be found in food and how best to use them.

Metabolism of Body Tissues.—The constant breaking down and building up of the tissues of the body and the evolution of heat as a by-product of the energy expended may be summed up in the term “metabolism.” The metabolism of the body is normally supported by the food ingested. However, it is a known fact that were no food eaten the processes would continue just the same, the difference only being the use of the body structure instead of food materials. According to Sherman, the chemical changes and energy transformations are of course inseparable. It has become customary to speak of the metabolism of matter and the metabolism of energy, and to regard the extent of the metabolism of any material substance as measured by the amount of its end products eliminated, and the extent of the energy metabolism as measured by the amount of heat or of heat and external muscular work which the body gives off.

In summarizing the important factors in the utilization of food by the body several distinct points are made evident:

1. The composition of the body, and the composition of food, are practically the same.

2. Food must make good the losses resulting from metabolic processes and physical activity.

3. Utilization of food by the body necessitates:

(a) Transformation through a series of processes:
(1) Digestion.
(2) Absorption.
(3) Metabolism.
(4) Elimination.

[Pg 188] (b) Factors influencing use of food:
(1) Stimulation of secretory cells through appetite juice (stomach); hormone secretin (intestines).
(2) Factors retarding use of food:—Fear, worry, anger, nervous excitement, fatty foods and alkaline carbonates (bacterial action causing fermentation and putrefaction).

PROBLEMS

[Pg 189]

SECTION IV

DIETO-THERAPY

[Pg 191]

CHAPTER VIII

PREGNANCY AND LACTATION

There are many traditions in regard to the food requirements of the prospective mother. Many of these have been proved fallacies. As a matter of fact it is the woman more than the developing child who is likely to suffer if the diet is insufficient or badly balanced.

Factors Affecting Diet during Pregnancy.—In formulating a dietary for the pregnant woman, then, not only must the needs of the child be considered but those of the mother also, since the developing embryo draws from the body of the woman materials necessary for its growth, and if these needs are not covered by an increase in the diet, her body and that of the child also will show evidences of lack of nourishment.

Phosphorus and Calcium Requirements.—If, for example, the mother’s diet is lacking in those materials which produce growth, or is deficient in those mineral salts, such as those of phosphorus and calcium, which are requisite and necessary for the growth of bones in the infant, the mother’s bones and teeth will show this loss and in all probability the baby will sooner or later also show a like deficiency. However, it must be remembered that the pregnant woman is under a strain, both physical and mental. She must not be encouraged to eat beyond her needs or the digestion will be disturbed.

Nutritional Disturbances in Early Months.—The nutritional disturbance manifested by nausea and vomiting in the morning is due, not to the stomach or any disturbance therein, but to the fact that a mild form of poisoning [Pg 192] occurs, resulting from the substances produced through the formation of the placenta reaching the general circulation on account of the incomplete establishment of the connection between the embryo and the mother. As soon as this connection is complete and fetal circulation is established this “morning sickness” disappears.

Food Requirements of Prospective Mother.—The food requirements of the prospective mother are not materially affected during the first four months of gestation, and even after this, when the infant is developing rapidly, and up to the date of its birth, the mother’s requirements are only increased about 20%. The amount of food necessary to cover the body needs, for maintenance and energy of a woman living a sedentary or moderately active life, plus 20% for building materials for the growing child, will be adequate for the pregnant woman. Thus, if her needs are ordinarily from 2,000 to 2,400 calories per day, after the fourth month they will probably be increased to 2,400 or 2,800 calories a day and will rarely ever be more than 3,000 calories a day.

Dietetic Treatment of Normal Pregnancy.—The peculiar conditions surrounding the woman at this particular time must be taken into consideration in arranging her diet. The building foods which are necessary for the developing child must be given in the simplest form, milk and eggs being used liberally and meat sparingly to obviate any unnecessary tax being placed upon the kidneys. The use of fruit and green vegetables to supplement the milk and eggs is urged. It has been found advisable at such times to give small meals frequently rather than the regular meal three times a day. The feeling of “fullness” which often occurs during the last two or three months of gestation makes it more comfortable for the pregnant woman to eat less at a time and oftener. If, for example, she be given a glass of rich milk or a nutrient beverage, either of [Pg 193] enforced malted milk, albumenized orange juice, buttermilk, zoolak, or koumiss, at about eleven o’clock in the morning and again about four o’clock in the afternoon, she will have taken sufficient nourishment to meet the new requirements without taxing her digestion or imposing extra work upon the kidneys.

Abnormal Symptoms.—The chief point to keep in mind is any abnormal symptom which may develop. The chief of these is albumen in the urine. The urine must be examined frequently and measures taken immediately to overcome albuminuria should it occur. It is wise, as has already been stated, to restrict the meat in the diet, and in cases where albumen is found in the urine even when the meats are restricted, it may be necessary to place the patient upon a milk diet for a time until the urine clears up.

Supplementary Feeding.—Cereals, especially the whole cereals, must be used liberally. Gruels made with milk are often found valuable additions to the dietary. The prospective mother must be urged to take a regular amount of gentle exercise, not to become over-tired, or excited, to eat sparingly at night, and to drink plenty of water. She must avoid becoming constipated by eating plenty of green vegetables and fruit.

Sample Diet Sheets.—The following dietary is suggested: Breakfast should consist of thoroughly cooked cereals, wheatena, cream of wheat, malt breakfast food, cracked wheat, rolled or cracked oats, served with cream or sugar or both, whole wheat bread, muffins, or biscuits, with butter, raw or stewed fruit, coffee, tea or cocoa with milk. Luncheon may consist of milk or vegetable soups, eggs in any form, boiled potatoes, sweet potatoes, string beans, greens, or any green vegetables, simple desserts such as custards, rice or tapioca puddings, bread pudding, etc., milk, tea, cocoa, buttermilk, zoolak or koumiss as beverages. For dinner, if albuminuria is not present, a small piece of [Pg 194] meat may be taken, together with green vegetables, rice, potatoes, simple salads, and a simple dessert, milk or coffee with milk as a beverage.

Selection of Food.—The following foods may be used to formulate the diet sheet: Wheat, oat, or corn cereals, rice, tapioca, made into simple puddings or served as breakfast foods; fruits, oranges, prunes, apples, raisins, dates, figs, or grapefruit, stewed or raw. The fruit juices may be used instead of the whole fruit if the latter disagrees. Vegetables: peas (green or dried), beans (string beans or dried beans), spinach, greens (turnip, mustard, or beet), cabbage, onions, celery, lettuce, served as vegetables or in soups, potatoes. Meat: lightly broiled beefsteak or stewed or boiled meat or chicken served not more than once a day or three times a week. Eggs, prepared in different ways. Cheese dishes. Breakfast bacon or ham in moderate quantities, butter, olive oil (or other salad oils) in moderation, whole wheat, graham or bran bread, Boston brown bread and crackers, milk, cocoa, chocolate, buttermilk, malted milk, koumiss, or zoolak; coffee and tea in moderation.

The diet, as has already been stated, may be supplemented by nutrient beverages or milk gruels.

DIET IN LACTATION

The diet of the nursing mother, as has been explained in a previous chapter, must not only cover her own requirements but must likewise be adequate to furnish the extra requirements imposed by the nursing infant.

Food Requirements of Nursing Infant.—When the baby is a month old he should be growing rapidly, and his food requirements at this period and until he is about three months old will be approximately fifty calories per pound of body weight in the twenty-four hours. As he grows older his requirements grow gradually less in proportion to his weight. This is because the rate of growth is less, so that [Pg 195] for the next three months the requirements are from 43 to 40 calories per pound of body weight per day, and 35 calories per pound during the last three months, or by the end of the first year of life.

It has been estimated, as before stated, that the average infant will take 2⅓ to 2½ ounces of mother’s milk per day[63] to each pound of body weight and that every ounce of mother’s milk will yield on an average 20 calories. Hence a month-old baby weighing ten pounds will be taking about 23 ounces a day, yielding 460 calories. Scientists have estimated that for every calorie produced by the milk two extra calories must be provided by food, so that for the baby requiring 460 calories per day, to cover his requirements the mother will be obliged to consume extra food to yield 920 calories, or the regular amount to meet her normal requirements plus the extra food to make sufficient food for the baby.

Diet of Nursing Mother.—The diet of the nursing mother need not be different from that to which she is accustomed. She should be warned against overwork or over-fatigue, nervous excitement and worry, since these factors affect the digestion of the nursing baby. She must be careful not to eat indigestible foods or foods which disagree with her, as such things will undoubtedly affect the digestion of the infant. When an article of food does cause digestional disturbances in the baby, it should be carefully omitted from the mother’s diet.

Factors Retarding and Stimulating Milk Secretion.—Constipation in the mother reacts quickly and unfavorably upon the secretion of milk. The same has proved to be the case when she becomes excited, nervous, worried, or over-tired.

The average diet for the normal woman is safe for the nursing mother. If her supply of milk is deficient, it may [Pg 196] be at times increased or stimulated by the drinking of a glass of milk between meals or by taking a cup of hot cereal milk gruel. It was formerly believed that beer, ale, or stout acted directly upon the mammary glands, stimulating the secretion of milk, but there is little proof of this and the drinking of alcoholic beverages need not be encouraged on this account, since often more nourishing beverages fulfill the purpose more efficiently and without bad results.

SUMMARY

Gastric Disturbances.—The nausea and vomiting so often a part of early pregnancy is not believed to be the result of a disordered stomach but primarily a mild form of poisoning resulting from the incomplete establishment of the fetal circulation.

Adjusting the Diet.—The adjustment of the diet to cover the needs of the prospective mother and those of the developing child is essential. The amount of food taken by the mother is not materially changed during the first three months of gestation. An average normal diet is all that is necessary. After this time a twenty per cent. increase in the woman’s diet will furnish adequate means both for her maintenance and for the growth and development of the child.

Type of Food.—The kind of food which is necessary for the pregnant woman to take during this period is very similar to that taken ordinarily. It is necessary to furnish food materials rich in calcium and phosphorus, with an adequate supply of proteins in their simplest form in order to meet the requirement of the growing organism. Milk and eggs furnish the most efficient foods in this respect and the prospective mother should see that they form the chief items of her daily dietary. Milk furnishes calcium in its most available form for the developing skeleton of the growing infant, hence it is necessary to provide the mother with [Pg 197] food to replace the mineral which is withdrawn from her body.

Meat in the Diet.—Meat should be eaten sparingly by the prospective mother, as it imposes needless work upon the already taxed kidneys and, if eaten in excess, will give rise to dangerous complications. Milk and eggs will provide ample protein for all purposes.

Albumen in the Urine.—Albuminuria is one of the most frequent complications in pregnant women. It should be combated and controlled as soon as possible. The allowance of meat should be cut down or entirely eliminated from the diet until the urine clears up. When albuminuria is persistent in spite of efforts to overcome it, the patient must be placed upon a strict milk diet as used in acute nephritis, to prevent dangerous complications arising.

LACTATION

Diet of Mother.—Her dietary need not differ materially from that to which she is accustomed. She must avoid indigestible foods or any article which has been proved to disagree with either the infant or herself.

Factors Regarding Secretion of Milk.—Constipation, worry, nervous excitement, and over-fatigue all have an unfavorable effect upon the secretion of milk and must therefore be avoided by the nursing mother.

The Bowels.—Constipation of the mother reacts quickly and unfavorably upon the health and comfort of the baby, hence it should be avoided by eating coarse breads, green vegetables, and fruits, when they do not disagree with the baby, by drinking plenty of water and taking a certain amount of outdoor exercise to keep her own health in good condition.

Stimulating the Milk Production.—When the milk supply is deficient it will be advisable for the mother to drink a glass of milk or a bowl of cereal milk gruel between [Pg 198] meals. Alcoholic beverages are not necessary to insure an adequate secretion of milk. The milk or milk gruels answer the purpose more efficiently and without bad results.

Energy Requirements of Infant.—The average baby requires fifty calories per day per pound of body weight to cover his energy growth and development needs for the first three months of life, after which the rate of growth is less and his requirements decrease from forty-three to forty, then to thirty-five calories per day per pound by the end of his first year.

Amount of Milk Needed for Infant.—Approximately two and one-third ounces to each pound of body weight per day covers the needs of the average baby.

Fuel Value of Mother’s Milk.—Each ounce of milk yields twenty calories.

The Making of Milk.—It has been estimated that for every calorie yielded by milk, two extra calories must be provided by food.

PROBLEMS

[Pg 199]

CHAPTER IX

INFANT FEEDING

In taking up this part of our study on nutrition, there are several points to be kept in mind by the nurse: (1) that it will be difficult, if not impossible, to understand the metabolic changes taking place in abnormal conditions unless those occurring in the normal human body are understood; (2) that certain diseases are due directly to errors in diet; (3) that in other diseases, diet plays the chief part both in the bringing about and in the relieving of the conditions; (4) whereas there are certain other diseases not affected by diet, save in so far as well or poorly selected and prepared food always affects the individual, whether normal or abnormal, and that in the latter conditions the organism is more susceptible to bad influences.

This being the case it behooves the nurse to examine herself to find whether or not she understands the fundamental principles underlying the nutrition of the human body, that she may efficiently deal with the changes which occur more or less when the body is attacked by disease.

We include normal infant feeding in this section, because in no other age is it quite so necessary for care to be observed in formulating and carrying out a diet. Errors during this period may only appear to exert a local influence, causing disturbance which may readily be relieved, but the danger is in laying too little stress upon these disturbances, forgetting that the delicate organism of a child may be permanently injured by a constant disregard of nature’s mandates. In the words of the old adage, the pitcher may go once too often to the well, and an injured digestive apparatus is even more difficult to mend than the proverbial pitcher.

[Pg 200] In this section, then, the metabolic changes due to pathological conditions and the dietetic treatment thereof will be discussed.

Age and Weight.—As has already been stated, there are certain points to be kept in mind in attempting to provide an adequate diet for the human machine; First, the age and weight. The gain during infancy should be steady—an allowance of 40 calories per pound of body weight to cover the energy requirements and 4 protein calories per pound to cover the nitrogen needs. During the second and third years the energy requirements will be covered by 30 to 40 calories per pound and the nitrogen needs by 3 to 4 protein calories per pound. From the fifth to the eighth year the nitrogen needs continue to be covered by 3 to 4 protein calories per pound and the energy requirements by 35 to 37 calories per pound during the fifth year; 32 to 34 calories per pound during the seventh year. After the body has reached its full development its requirements will be met if sufficient protein is provided to cover its maintenance needs and if the energy calories are regulated according to the amount of exercise taken, keeping in mind that the energy requirements of a man at rest (sitting) will be about 2,000 calories per day and that exercise, especially that taken in the open air, raises the energy needs of the body.

Daily Gain.—In estimating the relative daily gain in body weight of children of different ages, Mendel[64] gives the following table:

TABLE

[Pg 201] Retention of Nitrogen in Infancy.—When the baby is gaining in weight and strength there is a retention of both nitrogen and salts, and when the baby is not gaining there may be a loss of both of these bodies; when one is retained in the body the other is apt to be retained.[65]

NORMAL INFANT FEEDING

Much has been written in the past few years on the care and feeding of infants and children. This is well, since statistics show an alarming increase in the rate of infant mortality during the early years of life, and anything which can be done to check this lamentable and often avoidable waste of valuable life should be resorted to with care and attention.

Food for Infants.—The natural food of all young mammals is the milk of their own mother. The rate of growth and development differs in every species; the calf, for example, doubles birth weight much more quickly than does the baby of the same age. However, the milk of the cow, which meets the needs of the calf perfectly, falls short of meeting the requirements of the infant, whose rate of growth is not nearly so rapid. For this reason if for no other, it would be advisable to give the baby its natural food rather than to attempt a substitute which is, at best, a poor one.

Weight.—The average infant weighs from six to seven pounds at birth. This weight should be doubled in the first five or six months of life and tripled by the end of the first year. The most important business, then, in the life of the child during the early years is growth and development. To achieve this properly the baby’s habits must be adjusted to his needs.

Regularity in Feeding.—He must have the proper food and enough of it, and have it given at regular intervals, [Pg 202] “by the clock,” for guesswork is fatal in infant feeding. He must be given water between meals. Babies often cry from thirst when they are thought to be doing so from hunger or temper, or both. The healthy baby sleeps about twenty-two hours out of twenty-four during the early months, and even during the latter six months of the first year more time is spent in sleeping than in waking.

The Bowels.—The bowels should move several times a day, the stools being smooth and of a yellowish color, of the consistency of pea soup. After the first month, twice a day is about the normal number of stools for the healthy baby. The infant should be placed upon a vessel held in the lap of the nurse at regular times, preferably right before the morning bath, and in the evening. In this way regularity in evacuating the bowels is obtained, and a habit formed which will prove valuable through life.

The Bath.—The daily bath is likewise necessary for the health and comfort of all babies; so, too, are fresh air and sunshine.

As has already been stated, breast milk is much better for babies than cow’s milk or any artificial food. There is something in the mother’s milk which gives strength and resistance to the baby which is absolutely lacking in any other food no matter how carefully it is selected and prepared, and for this reason young mothers must be prevailed upon to nurse their babies whenever it is possible for them to do so. When circumstances, such as having to be away all day at work, make it impossible for a mother to nurse her baby at regular intervals, she can be taught how necessary are two or three breast feedings a day to the future welfare of her child. When social reasons or lack of desire on the part of the mother make her unwilling to nurse her baby, it is the part of the nurse to lay the case before her and let her judge whether or not she is willing to accept the responsibility of bringing into the world a [Pg 203] life for which she is unwilling to provide weapons with which to fight the good fight.

Habits of Mother.—The mother must be taught how to efficiently nurse her baby; she must keep in mind that upon her good health and temperate habits depend the health and comfort of her baby. It devolves upon her to provide food efficient in quality and quantity. To do this, her own diet must be simple and wholesome. The nursing mother must remember that she has to provide, not only for her own maintenance and energy requirements, but also for the infant whose fuel requirements are ever demanding more food to provide for its rapid growth.

Food and Its Relation to Milk.—It is believed that two calories of food extra are necessary to produce one calorie of milk, and since a month-old baby requires 2⅓ ounces of mother’s milk to every pound of his body weight, and one ounce of mother’s milk will yield 20 calories, it is clearly seen that the mother will have to increase her diet to cover the requirements of the baby. For example, if the baby weighed 12 pounds, he would require 28 ounces of milk in 24 hours, or 560 calories. Thus if it requires two calories of extra food to make one calorie of milk, the mother’s diet would have to provide 1,120 calories extra, or about as much food as would fulfill the needs of a laboring man, 3,000 to 3,500 calories, even if she were doing practically no actual work; while if she were actively employed and doing a certain amount of physical labor, her rations would have to approximate those of a man doing heavy muscular work (about 3,500 to 4,000 calories per day).[66]

Breast Milk versus Cow’s Milk.—Consensus of opinion shows that breast-fed infants require less energy than the ones who must be nourished artificially. This is probably due largely to the fact that the constituents of human milk are in a more available form than those in cow’s milk, the [Pg 204] former requiring a lesser expenditure of energy on the part of the organism to become available than the latter. Very active babies, ones who kick and throw themselves about or cry violently, have a greater energy requirement than the more placid baby who sleeps more and is more quiet in movement and who cries less when awake. Breast-fed babies are generally more quiet than their less fortunate artificially fed brothers. It has been demonstrated that the artificially fed baby has a much harder fight for existence than the baby who receives his natural food; hence the necessity of using every available means to make the food digestible, and to lessen the danger arising from the additional work put upon the entire apparatus. Cow’s milk contains practically the same chemical elements as are found in human milk, but these elements are combined in a slightly different manner, and are not so easily handled by the immature organs. The proteins of milk consist of casein, which is insoluble, and albumen, which is soluble. According to Van Slyke the proportion of insoluble to soluble protein in cow’s milk is 3.6:1, while in human milk the proportion is only 1:1. The ash constituents in cow’s milk are in excess of the needs of the infant organism, but since a great part of these salts is in an inorganic form they are not retained to the same extent as those contained in human milk, which are in an organic form.

Rules and Regulations.—It is not possible to lay down hard and fast laws to cover the subject of infant feeding. The food must be adapted to the individual needs of the baby in question. The nurse must see that the milk is obtained from a responsible dealer, certified milk being of course the safest. The bottles of milk should be wiped off carefully and placed directly on the ice as soon as they are received. The milk generally used in infant feeding has a fat content of 4%. That having a higher percentage of fat is technically cream. The following table showing the [Pg 205] fat, sugar, and protein composition of whole milk, cream, skimmed milk, and whey was arranged by Morse and Talbot:[67]

TABLE

Seven per cent. (7%) cream is obtained from the upper 16 ounces of a quart bottle of milk which has been allowed to stand undisturbed for six hours. The upper third of the bottle contains 10% fat, while the whole fat layer from the quart bottle, regardless of the number of ounces, contains about 16% of fat.

Methods of Artificial Feeding.—The use of whole milk, top milk, or skimmed milk, diluted with water, and either milk sugar, malt sugar, or sucrose (cane sugar) added, is the method of feeding most commonly used, and upon it are based the formulas universally advised by infant specialists. There are cases in which simple dilution is not advisable. In premature or very young infants, for example, the whey mixtures have been found to give the best results. In toxic diarrheas, where the putrefactive bacteria make the use of all but the minimum amount of protein inadvisable, the above method is contraindicated, as it is likewise in cases where vomiting of casein curd is a prominent feature.[68]

The Use of Alkalies.—There are many cases in which [Pg 206] the physician deems it advisable to add an alkali to the milk mixture. The one generally selected is limewater. However, sodium citrate and sodium bicarbonate are also used. The reasons for adding alkalies to the milk mixtures are: (1) to check the coagulation of the casein, (2) to hasten the emptying of the stomach, or (3) to chemically change the formation of the curd. In certain cases it is only necessary to delay the coagulation of the casein in the stomach, in which case a certain amount of limewater is used. Its action is to swell the protein of the milk and in this way effect the precipitation of the casein. In other cases it is found advisable to prevent the formation of curd and hasten its departure from the stomach. Cannon[69] claims that milk before it coagulates leaves the stomach quickly like water in gushes. Hence, if an alkali like limewater, bicarbonate or citrate of soda is added to the milk this coagulation will be checked and the digestion be facilitated.

Amount and Type of Alkali Used.—The amount of alkali[70] necessary to bring about any change in the general effect of the formula must be determined by the amount of milk and cream in the mixture, since these constituents alone determine the acid content. However, it is impossible to judge exactly the amount of alkali to add, but an approximate estimate is made from the work done by the various investigators. It has been estimated that from 25 to 50% of limewater must be added to milk to change it to any marked degree. In using bicarbonate of soda, a much less quantity brings about the desired result, 1½ grains of bicarbonate of soda being equal to one ounce of limewater. The action of these two alkalies is different. The soda acting upon the milk causes the curds to be more porous, and therefore more easily acted upon in digestion.

[Pg 207] Sodium citrate likewise tends to prevent the formation of tough curds. It is added in amounts of 1 to 2 grains to each ounce of milk or cream in the mixture whenever it is found necessary to use it at all.

The addition of any alkali to the formula is resorted to if the symptoms indicate the need for it, but the type and quantity is entirely within the province of the physician, not the nurse.

The Addition of Sugar.—Lactose is the form in which the carbohydrates are found in milk, and it has been a general rule to employ this sugar in making up the sugar content of a formula, using from 6 to 7% of the mixture in this form to cover the necessary energy requirements of the infant. Other sugars are used, however; and of late years malt sugar has been widely employed for this purpose. The form now generally accepted is known as dextri-maltose, which is a combination of dextrin and maltose, both of which are readily acted upon by the sugar-splitting enzymes of the digestive juices. In digestion, lactose or milk sugar is split to dextrose and galactose and utilized in the body, both as a source of energy and as a food for the lactic acid bacteria which are active in the small intestine.

Malted Foods.—The addition of malted foods or malt sugar to the food of infants tends to bring about a more rapid gain, both in energy and in body weight, than is generally the case where other sugars are used. This sugar is used as a substitute for milk sugar in many formulas, especially in those cases in which the casein of cow’s milk needs to be made more digestible in form. Malt sugar is indicated in the following conditions:[71] (1) in severe atrophies, (2) in cases of fat indigestion before the atrophic stage is reached, (3) in cases where there is slight curd indigestion, indicated [Pg 208] by some vomiting and slow gain in weight, (4) in cases where excessive intestinal fermentation is manifested by gas and colic.

Malt sugar (dextri-maltose) is contraindicated to a slight degree in cases “of simple acute diarrhea where lactose, by supplying fermentative media, more easily restores the normal bacterial balance.”

Diluents.—Barley and oatmeal water are used as diluents to the amount of one-fourth or more of the mixture. Oatmeal water or jelly is used more during the winter months than in the hot summer months. As the fat content of the oatmeal gives it a more laxative effect, it is undesirable to use it at the season in which the summer diarrheas are prevalent. Barley water has something of a colloidal action upon the casein, causing the curds to be finer and less tough in character. Both barley and oatmeal water are used in place of plain water for babies when this colloidal effect upon the curd of the milk is desired, also where the weight of the infant shows a disposition to remain stationary, especially where there are no other symptoms to account for the lack of gain.

Whey is used with babies who cannot digest the insoluble protein of cow’s milk. This is often the case in premature babies and is manifested by a persistent vomiting of curd. The energy requirements are obtained by the addition of cream and lactose to the whey.

Buttermilk Mixtures and “Eiweissmilch.”—It is often found desirable to use some other form of milk than whole, top, or even skimmed milk, and for this purpose lactic acid, milk and the albumen or “Eiweissmilch” are substituted. In the buttermilk mixtures the precipitation of the casein is brought about by lactic acid bacilli (Bulgarian culture). This prevents the coagulation of the casein into tough curds. Lactose buttermilk or lactic acid milk is used in the feeding of infants who have persistent green stools, and in cases of [Pg 209] acute toxic diarrhea brought about through the action of gas bacillus.

Buttermilk is more difficult to administer to babies than formulas made from plain milk by reason of its flavor. However, the results are remarkable in the above-mentioned conditions.

“Eiweissmilch” is used in atrophic cases where there are bad green stools.

“Homogenized Milk.”—Dr. Ladd of the Children’s Hospital in Boston has presented many cases of infants who showed an intolerance for butter fat. These cases he has treated with formulas containing foreign fat, usually olive oil. This milk is subjected to a treatment which brings about a more complete emulsification of the fat than is possible in cow’s milk, causing it to resemble in character the quality of the mother’s milk. Homogenized milk has been used with success in cases where it was impossible to supply the infant with breast milk.

The process is accomplished by the use of an apparatus known as an “homogenizer”[72]; in this machine the fat globule is crushed and so finely divided as to prevent its re-formation. The greatest drawback to the use of this process lies in the scarcity of available machines. Cod liver oil is now used in many cases where the infant shows a failure to gain or is in possible danger of developing rickets, with the homogenizer it is possible to add the oil to the formula, thus facilitating its use.

Technique of Milk Modification.—The absolute necessity for cleanliness has already been dwelt upon in respect to milk, and in infant feeding the vigilance which must be observed in the preparation of the food cannot be too strongly emphasized. The milk itself must be of known purity. Where there is any uncertainty about its source, it [Pg 210] must be sterilized or pasteurized according to the doctor’s orders. The bottles and nipples should be washed as soon as they are used, first with plain water to remove the milk, then with soapsuds and a bottle brush. The bottles should then be filled with boric acid or bicarbonate of soda solution until needed, when they should be emptied and placed in a deep pan filled with cold water and allowed to boil for a few minutes. They should not be taken from the water until they are to be filled with the milk mixture. The nipples are washed thoroughly and boiled once a day and dropped into a solution of boric acid or bicarbonate of soda when not in use. The plain black rubber nipples are best as they can easily be turned inside out and cleaned. If the milk drops too slowly from the bottle, the nipple may be pierced in one or two places with a darning needle.

The morning is the best time in which to prepare the baby’s food; the milk has not stood too long and it is easier to regulate the feedings if a fresh start is made each morning. Let the bottles and the rubber corks with which they must be stopped be boiled and cooled while the milk mixture is being prepared.

Preparation of Diluents.—If barley or oatmeal water is to be used as a diluent, let that be prepared first, that it may be cool before adding it to the milk. Cover the table with a clean cloth or oilcloth, upon this place the pitcher in which the milk is to be modified, have the funnel, milk dipper, and spoon which are to be used boiled with the bottles, cover the mouth of the pitcher with a clean square of gauze or cheesecloth, read the formula carefully and measure the sugar, dextri-maltose, lactose, Mellin’s Food, or cane sugar as directed and place it in a clean glass; now measure the diluent, water, oatmeal water, barley water, or whey; use part of this diluent to dissolve the sugar.

Measuring Milk according to Percentage of Fat.—Now dip off the required layer of top milk, that is, the layer [Pg 211] containing the desired percentage of fat and protein. Mix this thoroughly and dip out the requisite number of ounces into the pitcher. If there is not sufficient cream in one quart bottle to fill the formula, the cream must be dipped from a second bottle and mixed with that of the first before it is measured into the pitcher. The dissolved sugar and rest of the diluent, together with the correct amount of limewater, are strained into the pitcher, mixed thoroughly, and strained through the absorbent cotton lining the funnel into the bottles, allowing the correct number of ounces for each feeding in every bottle.

Pasteurizing the Milk.—The corks are then adjusted, the bottles placed in the pasteurizer[73] and pasteurized for the desired number of minutes. The water in the pasteurizer must be cold in the beginning and the rise of temperature recorded on the thermometer, which is adjusted at a convenient place in the pasteurizer where the scale can be read easily. If the temperature of the water is too high, add cold water and lower the flame beneath the pasteurizer. When the desired number of minutes has elapsed, lift the bottle rack above the water for a few minutes and allow a stream of cold water to flow into the pasteurizer, taking care not to chill the bottles too suddenly or they will crack. Cool the bottles as quickly as possible and place on ice until needed, warming the bottle of milk as needed in warm water.

Amount Given at Each Feeding.—At birth a baby will usually take from one half to one ounce at each feeding, this amount is increased at the rate of a quarter of an ounce each week until the baby is receiving eight ounces at each feeding. Or the food is measured to allow of from one ounce to an ounce and a half more than the child’s age in months. For example a baby six months old would receive from [Pg 212] seven to seven and a half ounces at each feeding. Some babies are bigger and stronger than others and require the maximum amount, while others are less vigorous and the amount of food which they can handle at a feeding may fall slightly short of the above amounts, but the quantities indicated above will serve as a guide in measuring the formula.

Method of Calculation of Formula.—The calculation of a formula consists in determining the amount (in grams or ounces), of the various constituents contained in the formula when the percentage of each is known. Or, in determining its percentage composition when the amount of fat, protein, carbohydrate and diluent is given. There are certain inaccuracies in all simple methods of calculation and the use of the Babcock tester to determine the fat content in the milk to be used, is advised in all milk or formula rooms. The following method of calculation has been found satisfactory, and the nurse must master it in order to intelligently carry out the directions of the pediatrist.

Determining the Composition of Formula.[74]—Gravity cream and skimmed milk are used in this method, the cream is estimated as containing 16% fat, and consists of the entire cream layer from a quart bottle of milk which has been allowed to stand without being disturbed for six hours or longer. The cream must be dipped off with a cream dipper, or poured off. If there is not a sufficient number of ounces in one bottle of milk, a second must be used, the entire cream layer taken, then mixed with that obtained from first bottle, before the required number of ounces are measured off. Skimmed milk is estimated as being fat-free (although this is not entirely accurate). Both gravity cream and skimmed milk are estimated as containing 3.2% protein, and 4.5% sugar. In this method, [Pg 213] one rounded tablespoonful of milk sugar is estimated as weighing one half ounce (dextri-maltose may be estimated in the same way). With this brief explanation of the terms used we will proceed with the method itself.

It is always essential before beginning the calculation of the formula, to know what percentages of fat, sugar, and protein it is to contain, and the amount to be given in twenty-four hours; it is also necessary to know how much lime water is to be added if this substance is to form a part of the formula.

Suppose a thirty-two-ounce mixture is to be made containing 3% of fat, 6% of sugar, 2% of protein, and lime water sufficient to equal 25% of the cream and skimmed milk in the mixture. The fat in the food must be derived from cream, since it is the only substance containing fat to be used in the formula. If the food was composed entirely of gravity cream it would contain 16% of fat. Since it is to contain but 3% of fat it is evident that only 3/16 of the mixture must be gravity cream, 3/16 of thirty-two ounces is six ounces. Six ounces of gravity cream will, therefore, provide the 3% of fat desired in the mixture. The gravity cream contains protein as well as fat. There are six ounces of gravity cream in the thirty-two-ounce mixture. The protein content of gravity cream is 3.2%. The protein content of a thirty-two-ounce mixture containing six ounces of gravity cream is evidently 6/32 of 3.2% or 0.60%. Two per cent protein is, however, desired in the mixture. The gravity cream has provided only 0.60%. One and forty hundredths per cent of protein, the difference between the percentage of protein desired and that furnished by the gravity cream, must be obtained in some other way. It must be obtained, moreover, from some substance which does not contain fat. Skimmed milk is such a substance. Skimmed milk contains 3.2% protein. In order to get 1.40 per cent in the mixture by the [Pg 214] use of skimmed milk, it is evident that 140/320 of the mixture must be skimmed milk. 140/320 of thirty-two ounces is fourteen ounces. Fourteen ounces of skimmed milk will, therefore, provide the additional 1.40% of protein desired.

Both gravity cream and skimmed milk contain 4.50% milk sugar. Twenty ounces of gravity and skimmed milk are required to furnish the desired percentages of fat and protein. These twenty ounces in a thirty-two-ounce mixture must add 20/32 or 4.50% of sugar to the mixture. Twenty thirty-seconds of 4½ or 20/32 of 9/2 = 180/64, or practically 3% of milk sugar. It is, however, desired to have 6% of milk sugar in the mixture. That is, 3% more of milk sugar is required. This additional sugar must be added in the form of dry milk sugar. Three per cent of thirty-two ounces is 3/100 of thirty-two. This will give the amount of sugar desired in ounces. The sugar is to be measured in rounded tablespoonfuls, or half ounces. If the figures given above are multiplied by two, the result will be the number of rounded tablespoonfuls needed. That is, 3/100 of 32 × 2 = 192/100 rounded tablespoonfuls, or for all practical purposes, two rounded tablespoonfuls.

It is also desired to have the amount of lime water in the mixture equal to 25% of the cream and milk in the mixture. There are twenty ounces of cream and milk in the mixture. Twenty-five per cent of twenty ounces is five ounces. Five ounces of lime water must therefore be added. The total quantity of the mixture is to be thirty-two ounces. The milk sugar goes into solution and, therefore, does not add to this quantity. The difference between thirty-two and twenty-five ounces is seven ounces. Seven ounces of water must, therefore, be added to make up the quantity desired.

Changing the Formula.—It is often found necessary to change the formula when using artificial feeding for [Pg 215] infants, and under these circumstances it is necessary to know the percentages of the food constituents contained in the formula already in use. For this purpose the following method, quoted from “Diseases of Nutrition and Infant Feeding,”[75] is included:

Morse and Talbot’s Method.—Suppose that a baby is taking a food made up of—

“The barley water is made with two teaspoonfuls of barley flour in a pint of water. The total quantity of the mixture is 48 ounces. Gravity cream contains 16% fat. Twelve ounces of gravity cream in a 48-ounce mixture will give, therefore, 12/48 of 16% of fat, or 4% fat. Both gravity cream and skimmed milk contain 3.20% protein. There are 30 ounces of gravity cream and skimmed milk in the mixture; 30 ounces in a 48-ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of protein. Both gravity cream and skimmed milk also contain 4.50% of sugar. Thirty ounces of gravity cream and skimmed milk in a 48-ounce mixture will therefore furnish 30/48 of 4½ which is the same as 30/48 of 9/2 or almost 3.00% of milk sugar. Four rounded tablespoonfuls of milk sugar are equal to two ounces. Two ounces of sugar in a 48-ounce mixture is equal to 2/48 of 100% or 4%. The total percentage of sugar is, therefore, 7%. Two teaspoonfuls of barley flour in a pint of water makes a 1.50% decoction of starch. Twelve ounces of barley water of this strength in a 48-ounce mixture will give 12/48 of 1.50% or about 0.35% starch. There are six ounces of limewater in the mixture and 30 ounces of gravity cream and skimmed milk. 6/30 of 100% is 20%. The [Pg 216] limewater is, therefore, 20% of the milk and cream. The mixture thus contains 4% fat, 7% sugar, 2% protein, and 0.35% starch, while the limewater is in the proportion of 20% of the cream and milk.”

If, therefore, the nurse will follow out the plan suggested by Drs. Morse and Talbot, it should be a simple matter to change the percentage of any of the food constituents in any formula.

The following schemes for feeding well babies are included to facilitate the work in the home. A nurse may teach the mother the manner in which these schemes are used, keeping in mind that there can be no iron clad rule for feeding all babies. No nurse should recommend a formula without directions from a physician. And no formula should be changed without his permission.

The following milk formulas are used in the Nathan Straus Pasteurized Milk Laboratories of New York:

Formula No. 1.—Infants from 1st to 4th week, by A. R. Green.

24 ounces of mixture divided into 8 feedings of three ounces each, fed at intervals of 2½ hours:

¾ oz. 16% cream
3 oz. full milk
19 oz. water
1¼ oz. limewater
1½ oz. milk sugar

Formula No. 2.—Infants 1st to 3d month, by Dr. R. G. Freeman.

1½ oz. 16% cream
3 oz. full milk
13 oz. water
½ oz. limewater
1 oz. milk sugar

Divided into 6 feedings of 3 oz. each, fed 3 hours apart.

[Pg 217] Formula No. 3.—Infants 2d to 6th month, by Dr. R. G. Freeman.

18 oz. full milk
16½ oz. water
1½ oz. limewater
1½ oz. milk sugar

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

Formula No. 4.—Infants 3d to 7th month, by Dr. A. Jacobi.

18 oz. full milk
18 oz. barley water
1 oz. cane sugar
20 grains salt (less than ¼ tsp.)

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

Formula No. 5.—Infants 7th to 9th month, by Dr. A. Jacobi.

2½ oz. full milk
7½ oz. oat or barley water
1½ oz. cane sugar
30 grains (about ¼ tsp.) table salt

Divided into 5 feedings of 6 ounces each, fed at intervals of 3½ hours.

SCHEME FOR FEEDING NORMAL INFANTS

(First Year)

Scheme based on Holt and Shaw’s “Save the Babies.” Pub. by Am. Med. Ass’n.

Whole Milk Method

At the beginning of 7th or 8th month, or earlier if necessary, it is advisable to add orange juice, giving from 1-2 tablespoonfuls between the two morning feedings.[77]

After the 4th month it is well to eliminate the night feeding between 10 P.M. and 6 A.M.

At end of 11th month add 1-2 pieces of stale bread, toast or zwieback. Part of soft-cooked egg may be given every other day at noon meal by end of 11th month. The orange juice may be increased to 3 tbs. if bowels are not loose.

The strained cereal should be given twice daily by the end of the first year, and the milk should be undiluted at this time unless the digestion of the infant forbids.

Cooled boiled water should be given several times each day between feedings. Babies cry from thirst as well as from hunger.

SCHEME 2

For Feeding Well Babies

Scheme based on Dr. Richard M. Smith’s “The Baby’s First Two Years.”

A full-term baby will usually take a formula made as follows:

After 3d day increase cream and milk at the rate of 1 ounce each week, and sugar 1 tsp. every other day until at one month the baby will be receiving a formula such as—

[Pg 220] At two months—

From this point the formula may be increased by adding 2 ounces of skimmed milk each month until the baby is eight months old. For each ounce of milk added, an equal amount of water should be omitted. The sugar in the formula should be reduced one half tbs. every three months.

At six months the baby would be taking—

At eight months—

This amount will not be found sufficient in quantity for a twenty-four-hour mixture for children of this age. Increasing the amount of the last formula in the same proportion, it will be—

At this age the formula usually may be changed so as to be made from whole milk instead of cream and skimmed milk. The formula may be made as follows:

From this point on the formula may be increased by replacing the boiled water with whole milk, two ounces each month up to thirteen months. At this age the boiled water may be omitted from the formula one ounce each week. Beginning at the age of eight months the sugar may be eliminated from the formula, one tablespoonful each month.

Barley Water.—At the age of five months, or at any time thereafter, barley water may be substituted for boiled water in the formula. [Pg 221] This should be substituted when the baby is not gaining in weight. It may be substituted in many instances when the movements are not well digested.

Lime Water.—It is frequently found to be advisable to add lime water. It is not necessary in every instance, but should be given if the baby is inclined to spit up, or in cases where the stools are too frequent in number and are slightly green in color.

Determining the Fuel Value of a Formula.—The computation of the fuel value of a formula is very essential since the growth and development of the infant depends largely upon whether or not its energy expenditures are well covered. The method is simple, requiring the same methods used in the computing of other dietaries. Take the formula just calculated, its fuel value would be estimated as follows: Thirty-two ounces are equal to 960 grams. In each 100 grams there would be 3 grams of fat, 2 grams of protein and 6 grains of sugar. Hence in 9.6 one-hundred-calorie portions there would be 9.6 × 3—28.8 grams of fat, 9.6 × 2—19.2 grams of protein, and 9.6 × 6—57.6 grams of sugar, in a thirty-two-ounce mixture.

To determine the fuel value of the formula, these results must be multiplied by their physiological fuel factors, 9 and 4 and 4 respectively. Thus:

Scheme for Adding Solids to Infants’ Diet.—

From 9th to 15th month:

From 15 months to 2½ years:

From 3 to 6 years:

[Pg 223]

Vegetable Soup

Finely divide the vegetables. Add the vegetables, barley and rice to 2 qts. of water. Boil down to 1 qt., cooking 3 hours. Add pinch of salt. Pass through fine sieve.

Morse and Talbot advise baked potato, plain boiled macaroni, rice and wheat germ, bread and butter, baked custard, plain blanc-mange, and plain boiled tapioca to be given when the child is 1½ years old. When the child is nearly two years old they add meat in the most digestible forms, such as the white meat of chicken, lamb or mutton chops, and scraped beef.

The following dietary is suggested for a child two years old:[78]

“Whole milk, butter, mutton broth, chicken broth, beef juice, soft-cooked eggs, dropped eggs, white meat of chicken, lamb or mutton chops, scraped beef, French bread, stale bread, toasted bread, whole wheat bread, milk toast, zwieback, plain white crackers, plain Educator crackers, barley, jelly, oatmeal, cream of wheat, wheat germ, Ralston’s Farina, rice, baked potato, plain boiled macaroni, orange juice, baked apples, stewed prune pulp and juice, junket, baked custard, cornstarch pudding, plain blanc-mange, plain tapioca. It is not advisable, as a rule, to begin green vegetables until the baby is 2½ years old.”

It will be seen in the foregoing dietaries how authorities differ in their beliefs as to the requirements of the child. The dietaries included in this text are selected from those used in different parts of the country by physicians who [Pg 224] have successfully cared for the infants and children under their charge.

THE FEEDING OF PREMATURE INFANTS

The digestion of premature infants is naturally not as strong as that of infants born at term. Very little is positively known, but the consensus of opinion goes to show that in the majority of cases the tolerance for sugar is greater than that of either the proteins or fats. The loss of heat is relatively greater in proportion to its surface area in small than in large bodies. This is a well-known fact, hence the premature baby must require more food in proportion to its weight than the baby who is born at the normal time. Then, too, as the premature infant is thinner he does not keep warm like the older infant, and this must be taken into consideration in feeding him. Breast milk is of course by far the best food for such babies, not only because its constituents are in a more available form for the feeble digestive organs, but because the mother’s milk furnishes a resistance which is lacking in even the most carefully modified of milk formulas.

Energy Requirements of Premature Infants.—Experiments made upon premature infants have proved that the caloric needs of these babies are greater than in the case of full-time babies; that is, they require more per kilogram of body weight. According to Morse,[79] “most premature babies need 120 calories per kilogram of body weight. But there are many exceptions, some thriving on as little as 70 calories per kilogram. No attempt should be made to reach 120 calories per kilogram during the first few days. Thirty calories per kilogram is as much as is wise to give in the first 24 hours of feeding. This amount should be gradually increased each day, watching carefully for symptoms of [Pg 225] indigestion and diminishing it if these appear. One hundred and twenty calories per kilogram can be given in about 10 days.”[80]

Necessary Dilution.—Even breast milk must be diluted with an equal amount of water or a 3% sugar solution. The amount of milk should be increased and the amount of dilution decreased until the undiluted breast milk is given in four or five days. Like older babies, the next best food for premature babies is the properly modified cow’s milk, but the utmost care will have to be observed, as these babies are more easily upset than older and stronger ones.

Premature Infant Feeding.—The following method of feeding may be suggested, keeping in mind that it is an easy matter to increase the strength of a mixture if the baby shows the need of such an increase. The premature baby is rarely strong enough to take the breast.

Method of Administering Milk.—The most satisfactory method of administering the food in such cases is by means of the Brick feeder, which consists of a graduated glass tube, open at either end. On the small end is placed a small nipple like those seen on medicine droppers; this one is perforated and goes into the mouth of the baby. A large rubber finger cot is attached to the other end of the tube. The milk is forced into the mouth by pressing the finger cot. In case the infant is too feeble even for this method of feeding, the desired amount is dropped into the mouth from a medicine dropper; 5 c.c. (about 1 dram or 1 teaspoonful) of diluted milk being given at each feeding. This amount is increased gradually from day to day.

Whey Mixtures.—Whey mixtures have been found to meet the needs of premature infants more efficiently than ordinary mixtures. As the proteins in whey are in a more digestible form, they throw less work on the immature [Pg 226] digestive apparatus. As a rule the casein and whey are in proportion of 1:1.

The following formulas[81] show the amounts in which the food constituents are combined and are suitable for premature babies:

or

PROPRIETARY FOODS

A word as to the use of Proprietary Infant Foods: These prepared foods may be classified under four heads, as follows: (1) condensed milks; (2) malted foods, those consisting chiefly of carbohydrates in the form of maltose and dextrins; (3) those consisting almost entirely of starch, and (4) those composed partly of soluble and partly of insoluble carbohydrates.

(1) Condensed milk may be sweetened or unsweetened. These milks are never given undiluted, the directions calling for one part condensed milk to nine parts water, which gives a mixture containing 0.90% fat, 5.49% sugar, and 0.80% protein if “Eagle Brand” Condensed Milk is used.[82]

(2) Malted Foods: Mellin’s Food and malted milk are examples of this group. These foods contain the carbohydrates in soluble form and when added to milk make an acceptable addition, as they furnish the carbohydrates in the most digestible form. When fed alone, diluted only [Pg 227] with water, they result in a mixture deficient in both fat and protein.

(3) Imperial Granum is an example of this group, and there are several others with similar compositions. These foods are very much like wheat flour which has been subjected to heat, changing to a small extent the starch to dextrose and dextrin.

(4) Nestlé’s Food, Eskay’s Albumenized Food, and Allenbury’s Food are examples of this group, each containing sugar and a percentage of starch. Upon dilution with water, the amount of fat in the mixture is just a trace.

Incomplete Foods as a Source of Danger.—The ease with which the majority of these foods are prepared and the way in which they agree with the baby constitute the chief danger of their use. If they are added to milk, with the exception of the condensed milk, they result in a modified milk containing the carbohydrates in a more or less digested form. But they are expensive, and give no better result as a rule than a carefully modified milk containing a cereal gruel.

The giving of foods like malted milk alone is dangerous because they are deficient in some of the most necessary constituents, and babies fed in this way, while growing fat, are apt to have soft or brittle bones and muscular tissue higher in fat and water than in protein, so that they do not grow and develop in a normal way, and when they are attacked by the diseases so prevalent in the early years of life, they succumb rapidly, because the resistance given by a properly modified food is lacking.

Condensed milks act in a like manner. That is, in the sweetened milks the carbohydrate content is far in excess of the needs, and the proteins and fats are deficient, so that while the baby fattens he does not receive the building foods commensurate with his body requirements.[83]

[Pg 228] Many mothers adopt the use of these foods because they mean less work than in modifying the milk properly, but the nurse should point out the facts just mentioned, explaining that while these proprietary infant foods are undoubtedly valuable at times to fill a place when the milk formula has not proved satisfactory, the use of these foods as a regular custom is expensive, not only from a financial standpoint but from a standpoint of health, since their disadvantages far outweigh their advantages in the long run.

SUMMARY

Breast Milk as a Food.—The superiority of breast milk over any other known food cannot be too strongly emphasized.

Regularity in Feeding.—The absolute need for regularity in feeding—“feeding by the clock” and not by guess or when the baby cries.

Indications of Health.—The normal growth and development to be used as guides as to the physical well-being of the infant; also as an indication of the use of the proper modification of milk for the individual needs of the child.

Dilution.—The amount of dilution necessary—cereal waters, whey, etc.—to increase the digestibility and nutrient values of the formula.

The Addition of Alkali.—The addition of alkalies to milk formulas to accomplish a like purpose.

Milk Sugar, Malt Sugar, Cane Sugar.—The use of the different sugars, namely, dextri-maltose, lactose, or cane sugar under various circumstances as the condition of the infant demands.

Substitutes for Whole Milk.—The substitution of different milk, such as lactic acid milk, Bulgarian culture buttermilk, Eiweissmilch, cream and whey mixtures, as the individual needs of the infant demand.

Technique of Milk Modifications.—The absolute need [Pg 229] for the nurse to understand the technique of milk modification before attempting the care of an artificially fed infant.

Percentage Computation.—A knowledge of percentage, that an accurate computation of a formula may be accomplished.

Preparation of Food.—A sufficient knowledge of food preparation to enable the nurse to prepare any food which may be deemed necessary by the physician for the welfare of the child.

Water.—The importance of giving the baby water aside from that used in modifying the milk. Many babies cry from thirst when they are believed to be crying from hunger or temper.

Increasing the Diet.—The necessity for increasing the amount and strength of the formula with the age, growth, and development of the child by the addition of solid food as soon as the physician deems it advisable.

Feeding Premature Infants.—The method of feeding a premature infant differs from that employed in feeding an infant born at term: (a) because its development has not progressed so far; (b) because its digestive apparatus being more or less immature, food handled with ease by an older baby will be totally unfit for the premature one, both as to quality and quantity.

Wet Nurse.—The advisability of procuring a wet nurse when the mother is unable to nurse the infant, (a) on account of the more digestible character of the food constituents, especially the proteins, in mother’s milk over those of cow’s milk; (b) on account of the resistance furnished by the natural food which has been proved to be very much greater than that furnished by any other food, no matter how carefully the modification of the milk is made.

Premature Infants.—Their caloric needs are greater than in full-term babies, hence their food must be adjusted to meet these needs.

[Pg 230] In fact the nurse must have an understanding of the behavior of foods in the metabolism of infancy and the laws which govern their use in the organism of the child.

PROBLEMS

[Pg 231]

CHAPTER X

CARE AND FEEDING OF INFANTS AND CHILDREN IN ABNORMAL CONDITIONS AND IN INFECTIOUS DISEASES

Digestive Disturbances.—It is a well-established fact that artificially fed infants are more subject to disturbances due to diet than breast-fed infants, the digestional disturbances of the latter yielding more readily to treatment. As a rule, with the breast-fed baby it is largely a question of adjusting the diet of the mother, of increasing the fluid in her diet, of seeing that she takes the requisite amount of exercise in the open air, and of lengthening the intervals between feedings or of giving the baby water just before putting him to the breast. With the artificially fed infant it is an entirely different proposition.

Causes in Artificially Fed Infants.—The digestive disturbances may arise from any one of half a dozen or more causes. The constituents in the milk may be in the wrong proportion. The amount given at a feeding may be too great or too little. The dilution may be too great or too small to meet the needs of the infant. Or the milk may contain the microörganisms which bring about fermentation or putrefaction. Any or all of these causes may assail the artificially fed baby. Consequently, all the care that can be exercised must be resorted to in the feeding of these babies, not only after digestional disturbances arise, but as a means of their prevention. In the preceding chapter the methods generally used in the feeding of normal infants were discussed. We now proceed to the feeding under abnormal or pathological conditions.

[Pg 232] Errors in Diet.—The majority of the ills from which the baby suffers can be traced primarily to errors in diet and in most of these cases the treatment consists chiefly in adjusting the formula to suit the condition. As a rule, these errors may be placed under two heads: those that are brought on by under-feeding and those induced by over-feeding. The pathological conditions arising from under-feeding are due not only to a lack of food, but chiefly to the improper balancing of the different food constituents in the formula. As has already been stated, so much food is required to cover the energy expenditures, so much for maintenance, and so much for storage for the growth and development necessary during the entire period from birth to maturity. These constituents must be regulated to the individual needs of the infant.

Over- and Under-dilution.—If the dilution is too great, the infant, while receiving the correct amount of the mixture, may have the necessary food constituents so reduced as to have them fail completely to do their appointed work in the body. Or if the amount of diluent is too small the baby may be receiving too strong a mixture, and develop nutritional disturbances therefrom. Under the first head the child suffers from under-feeding; the appetite is satisfied before enough of the actual food is ingested to meet his various needs. However, it is probable that the artificially fed infant suffers from the results of over-, rather than of under-feeding.

DISEASES DUE TO ERRORS IN DIET

Gastro-intestinal disturbances, colic, enterocolitis, colitis, etc., rickets, scurvy, nephritis, and diabetes are among the diseases most apt to develop from injudicious feeding, and in these cases the dietetic treatment plays the most important part in combating the condition. The disturbances caused by food are recognized by the general symptoms: [Pg 233] vomiting, rise of temperature, subnormal temperature, and the stools, the latter being the chief point of observation.

Fats as Cause.—When the fats are causing the disturbance, the rise of temperature is apt to be high, but not of long duration. The baby vomits frequently, the vomitus being acid in reaction and odor, the latter due to the presence of fatty acids, butyric acid, etc. Diarrhea often develops in a more or less acute form. In these cases there is a loss of sodium and other alkaline salts in the feces, and a consequent excess of ammonia in the urine, resulting in acidosis. Acid intoxication has been known to develop as a result of this loss of alkaline salts. The chief symptoms of this condition are rapid and deep respiration, stupor or restlessness, and cherry-red lips.[84]

Symptoms of Excess Fat in Diets.—The general symptoms in infants receiving an excess of fat in their food take the form of loss of appetite, with more or less loss of weight, or failure to gain. When the cases are not chronic, soft curds may often be seen, which are at times mistaken for casein curds, but may be distinguished from them by their translucent appearance and their solubility in ether. The color of the stools due to the excess of fat under the above-mentioned conditions is shiny and gray. In the majority of cases, especially of a more chronic character, the stools are apt to be large and dry, at times hard and crumbly. The fat in such stools is combined with magnesium and calcium salts, forming the characteristic “soap stools.”[85] The combined loss of these salts in the feces has a definite effect on the general metabolism and nutrition, giving rise to rickets.

Regulating the Fat.—The treatment consists chiefly of regulating the amount of fat in the formula, and of cutting it out altogether in the beginning when the symptoms [Pg 234] show acute acid conditions. In many cases, if the baby is given breast milk, the trouble disappears. At other times it is necessary to substitute a foreign fat such as olive oil for the butter fat. Dr. Ladd in the Children’s Hospital in Boston treated many babies who manifested an intolerance for butter fat with “Homogenized Milk,” which consisted of skimmed or separated milk and a certain percentage of olive oil, placed in an apparatus which brought about a more complete division of the fat, causing it to mix with the milk as an emulsion closely resembling human milk.

Fat intolerance is most difficult to overcome, the baby being apt to relapse into the acute stage unless the utmost caution is observed in adding the fats to the formula. It is not safe, however, to feed the baby upon a fat-free milk for any great length of time.

Excess Protein in Food.—The digestional disturbances arising from too much protein in the food are as a rule readily overcome in breast-fed infants. When it is due to nervousness or worry in the mother, it disappears as soon as the mother ceases to worry or does something to remove the cause of the nervous condition. When the breast milk is high in protein, more exercise in the open air at times adjusts the percentage of protein, provided the mother does not become over-tired, in which case the percentage of protein in breast milk increases.

Evidences of Excess Protein.—The symptoms of excess protein in the diet of the breast-fed baby are colic and flatulence, which are often persistent and difficult to overcome. Vomiting is not so common in these babies as in those who are artificially fed. The stools are increased in number, are either brown or green, and generally loose and watery. In artificially fed infants the symptoms are much the same, except that the vomitus often contains large curds which are tough and leathery. The baby suffers from gas formation and colic. The stools are at times normal, except [Pg 235] for the presence of large, hard curds; at other times they are increased in number, and are of a watery consistency and alkaline in reaction.

Regulating the Protein in Formula.—When the stools are watery and brown and musty in odor as the result of disturbed protein digestion, the treatment consists of taking out the proteins from the formula and of substituting cereal water, to which dextri-maltose or milk sugar is added, the milk being added as soon as possible to prevent too great a loss of body protein. As a rule the whey proteins do not cause the disturbances so often as the casein proteins; and at times it is possible to use whey mixtures with babies who cannot tolerate the casein at all.

Buttermilk also is used in cases of protein indigestion, as is Eiweissmilch and peptonized milk.

Regulating the Carbohydrates.—When the disturbances are due to the carbohydrates in the formula, they may be digestional or nutritional. In this form the milk sugar is more apt to be the cause of the trouble than the dextri-maltose preparations which are at times used. In the latter, when the disturbance becomes nutritional, the cause of the trouble can usually be traced to an excess of starch. When the percentage of milk sugar is greater than can be handled by the digestive apparatus of the baby, it is manifested by frequent attacks of colic, with the passage of watery green stools, highly irritating, in character on account of their acidity. In acute cases the loss of weight is often marked, and symptoms of intoxication may develop. The outlook is grave in the very severe cases, but if the baby can survive forty-eight hours after the acute symptoms develop, he is apt to pull through the attack.

Adjusting the Sugars.—The treatment in these conditions consists of eliminating the milk sugar from the formula; in less severe cases dextri-maltose may be substituted. As a rule, coincident with indigestion caused by [Pg 236] sugar there will be found to be an intolerance for much fat, so that this must be adjusted as well as the milk sugar. Skimmed milk mixtures, containing a certain amount of barley or oatmeal water, are generally found to be suitable in these cases. Dextri-maltose may be added after a few days in order to maintain the fuel needs of the body. Eiweissmilch is at times used, but whey mixtures are contraindicated on account of their high sugar content.

Dextri-maltose also disagrees at times. The baby has colic and flatulence, the stools are usually loose or watery and dark brown in color. The dietetic treatment consists of an immediate withdrawal of the dextri-maltose preparation and a substitution of milk sugar after a few days.

Evidences of Excess Starch in Formula.—The disturbances arising from an excess of starch in the diet are, as has already been stated, more apt to be of a chronic than an acute character. Vomiting is not a common symptom under these conditions, although colic is frequent. The stools are at times loose and brown, at other times dry and small. The baby at times suffers from diarrhea and at others from constipation. When the disturbance is acute the starch must be entirely eliminated from the formula. If proprietary foods are being used containing starch, whether it is dextrinized or unchanged, they must be at once abandoned, and a formula made up of protein with sugar and fat.

Modified Milk Formulas Suggested by Morse and Talbot for These Conditions

They likewise advise whey and whey mixtures under these circumstances.

Fermentation.—Fermentation is often the cause of infantile indigestion. At times it is acute and may cause a decided elevation of temperature owing to the absorption [Pg 237] of the toxic substances formed as a result of the bacterial action. In almost every case of indigestion brought on by fermentation there will be an accompanying diarrhea. As a rule the carbohydrates are more liable to the attacks of bacteria in the stomach than the other food constituents.

Treatment.—The treatment consists first of starvation, no food being given for at least twenty-four hours. Then water or weak tea, sweetened with saccharin, may be given, but nothing else. The medical treatment must be left to the discretion of the physician. When the condition warrants a return to food the formula must be made weaker than that which has caused the disturbance. Malt soup mixtures, buttermilk mixtures, whey and albumen water may be added as the condition of the baby improves. In older children the period of starvation may have to exceed that of infants, but a gradual return to normal diet is made. Weak tea and toast may be given after the first twenty-four hours and well skimmed meat broths, soft-cooked eggs, liquid peptonoids, and malted milk added to the diet as the condition of the child improves.

ENTEROCOLITIS

The dietetic treatment for enterocolitis must be adjusted according to the principal symptom. In some of these cases diarrhea is most prominent, while in others constipation is the most marked symptom. Hence the diet must be such as not only to do no harm to the child, but one that will aid in his ultimate recovery.

DIARRHEA

The treatment for diarrhea, whether it is from fermentation or putrefaction of food, has already been explained. The grave danger in the putrefactive diarrhea is the absorption of the toxic substances which result from bacterial action upon the unabsorbed food material in the small and [Pg 238] large intestine. In these cases auto-intoxication may develop and the baby may die before the condition yields to treatment. The entire intestine must be cleansed as a rule. The stomach of the baby may be reached with little trouble by using a small rubber catheter attached to a glass funnel and a solution of bicarbonate of soda. The bowels may be emptied by means of a soapsuds enema. Older children may be given oil, but this of course comes under the jurisdiction of the physician.

CONSTIPATION

Constipation is one of the most frequent troubles visited upon people of all ages. “It is not a disease, it is a condition in which the number of stools is less or the consistency of the stools is greater than is normal for the individual at the given time.”[86] It may be caused by neglect of the bowels, which should be evacuated once or twice every day during infancy and once a day after that period. If the habit of emptying the bowels every day is established in infancy it adds much to the health and comfort of the individual during the entire remainder of life. Babies are sometimes constipated as the result of the opium administered in soothing sirups. Others inherit constipation, while still others are constipated by the taking of the wrong kind of food or too little food. In any case it is decidedly bad to resort to drugs, since the habit of taking cathartics is so easily acquired and so difficult to overcome.

Factors Inducing Constipation.—With artificially fed babies a formula which contains too high a percentage of diluent and too low a percentage of solids will cause constipation, chiefly because the solids are so completely absorbed that they have no residue to form feces. A formula with too low a fat content in proportion to its protein and [Pg 239] carbohydrates may cause constipation because the latter two constituents are almost entirely absorbed, and the feces, which is largely made up of the fat, is correspondingly small. Excess of fat, however, has been proved to be one of the chief causes of constipation in infants, as has also been the case with excess starch. Boiling the milk for the baby at times results in constipation. Hence sterilization is more frequently to blame for the condition than the pasteurization of milk.

Constipation during Second Year.—During the second year, if the child is given too much milk and too little solid food, constipation is very apt to be the result. A maximum quantity of from thirty-two to forty ounces may be given. In many diseases brought on by malnutrition, constipation is an obstinate condition to be overcome. This is especially the case in rickets and anemia.

Use of Laxative Foods.—After the baby is a few months old, orange juice is given between the morning feedings. Malted foods likewise exert a laxative effect. The higher the percentage of maltose, the more laxative the food. The nurse must keep this point in mind in feeding babies. With older children and adults, the question of diet for constipation is quite as important as it is for infants. Prunes or figs cooked with senna leaves and thoroughly strained furnish an excellent adjunct to the diet under such conditions. The coarse breads such as bran and Graham or wholewheat bread should be used instead of white flour breads. Care should be taken in advising a cereal diet for children, since cereals, with the exception of oats, are apt to be constipating. Fresh fruits, stewed fruits, and fresh vegetables are all good under the above-mentioned conditions. Young children require the vegetables strained or cut fine. Adults should include one coarse vegetable a day in their dietary to obviate the development of constipation. Children should be taught to drink plenty of water, and [Pg 240] babies should not be neglected in this respect. As a rule very few adults drink as much water as is necessary for the general welfare of their bodies.

SCURVY

There is probably no disease of infancy which has come in for more study in the past few years than scurvy.

Cause.—The disease is believed to be directly due to a deficiency in the diet of the antiscorbutic vitamine, known as “Water soluble C.”

Treatment.—For many years it was known that lime juice exerted a curative effect upon scurvy. But recently the efficiency of this fruit juice has proved to fall far short of that effected by either orange, or tomato juice.

Feeding experiments have proved that animals, fed upon rations consisting of dry food without the addition of green, will develop scurvy. And that the milk of such animals will show a deficiency in the “C” vitamine which will lead to a development of the disease in infants fed upon such milk.

Milk is, in fact, by no means a perfect food, so far as its vitamine content is concerned. First, because the presence of the vitamine in milk is so dependent upon the diet of the mother or the animal, second, because the pasteurization temperatures used to insure cow’s milk of purity from a bacterial standpoint, destroys in it the greater part of its antiscorbutic power. Either of which makes it necessary to supplement the formula of the artificially fed infant, and, in case of the former, the mother’s milk of the breast-fed baby, with orange, or canned tomato juice.

The amount of either of the fruit juices which is necessary to insure the child of a freedom from scurvy, is small, ranging from one-half to one ounce of strained juice daily, this amount is increased gradually until the child is taking from one and one-half to two ounces each day. It has been [Pg 241] found advisable to administer the fruit juice between the two morning feedings. As a rule, the fruit juices are given at the beginning of the seventh month, but they may be given at a much earlier date, the time being adjusted by the physician.

RICKETS

Rickets, like scurvy, is being discussed by scientists both in America and abroad. The disease is widespread, particularly in its subacute form, and its effect upon the health of the child is so serious that no amount of effort to prevent its development should be considered too great.

Calcium Retention in Rickets.—The disease is characterized by a failure of the bones to lay down lime salts, this failure causes a softness and flexibility in the structure of the bones which permits them to bend into deformities. Then, too, it is a well established fact that any interference with the calcium metabolism in the body, will inevitably bring about disaster. (See Mineral Metabolism, page 185.)

Factors Inducing Rickets.—According to Dr. Eddy, “It is impossible at present to determine whether rickets is a true avitaminose or a consequence of deficiency in a series of factors.”

Treatment.—For breast-fed babies it is necessary to adjust the diet of the mother to include more of the vitamine bearing foods, since milk contains vitamines only in proportion to the amount eaten in food. For artificially fed children, the giving of cod liver oil has recently been adopted as the surest and safest method of curing and preventing the development of the disease. Like treatment is used with breast-fed infants if the need arises.

The value of cod liver oil in this respect has only been recently recognized. Mellanby of England claims that the oil owes its curative and preventive properties to the presence of the “A” vitamine. But scientists in this country [Pg 242] have not fully accepted this view. Eddy states, “It may be that the power of the oil is due to its ‘A’ vitamine content, in which it is known to be rich, or it may be due to a new vitamine, but the fact that the oil is a preventive in this respect gives the pediatrist another agent to insure normal growth.”

Sunshine as a Factor.—It has been found that the disease rickets is more prevalent in winter than in summer; this is believed to be due to the fact that sunshine during the summer months exerts a distinctly beneficial influence over the disease. Dr. Hess’s report of the good results which he has found to be derived from the use of the ultra violet rays as a substitute for sunshine in winter, would seem to confirm this view.

MALNUTRITION

Malnutrition is not confined to the children of the poor, though it is more common with infants of parents who have not the means to secure the best milk and give them the benefit of wholesome surroundings and plenty of sunshine. But babies of people in moderate circumstances, and even of wealthy parentage, are at times badly nourished, and require the same exacting care, the same attention to the food, the fresh air, and the sunshine that the poorer babies need in order to survive. Malnutrition may be the result of insufficient food, and it may also be due to the lack of one definite food element. Again, it may be brought on by some deformity of the mouth or stomach, which make it impossible for the baby to get all the food which he requires for his maintenance and growth. He may be born prematurely and his digestive apparatus not be sufficiently developed to care for the amount or type of food necessary for his needs, or he may have some congenital weakness which interferes with the absorption and assimilation of his food. All of these points must be considered.

[Pg 243] Evidences of Correct Feeding.—If the baby shows a steady gain, both in weight and growth of stature, without digestional disturbances, the food given him is probably correct, but it must be kept in mind that nutritional disturbances, such as rickets and scurvy, are slow in developing, and do not manifest themselves with anything like the rapidity of digestional disturbances. Hence the nurse must take care as far as she is able, not only to prevent the food from causing indigestion, but also to see that it is not given in such a form as to induce those graver and more lasting nutritional disturbances which affect the entire system from infancy throughout the life of the individual.

SUMMARY

Breast Feeding versus Artificial Feeding.—There is no doubt about the fact that the breast-fed baby suffers less from digestional disturbances and has more resistance to disease than the baby fed even upon a perfectly prepared artificial food. The majority of diseases manifested by artificially fed infants have their origin in the following errors in diet.

Over-Feeding.—Resulting in acute gastro-intestinal disturbances (colic, enterocolitis, colitis, constipation).

Under-Feeding.—Resulting in chronic, and acute deficiency diseases (scurvy, rickets, malnutrition).

Evidences of Dietetic Errors.—The stools, showing characteristic evidences of excessive quantities of, protein, fat, or carbohydrates in the formula. Loss of weight or failure to gain. The development of deficiency diseases (scurvy, rickets, xerophthalmia, rickets and malnutrition).

Evidences of Correctness in Feeding.—Normal gain, freedom from gastro-intestinal disturbances, and deficiency diseases. Rosy cheeks, bright eyes, and a vigorous body.

Treatment in Abnormal Conditions.—The treatment [Pg 244] consists in adjusting the diet to meet the needs of the particular disturbance manifested. Plenty of fresh air, sunshine and sleep.

Relapse.—One danger which the nurse must always be on the lookout for is the relapse into the acute stage. The diet is the chief treatment. In acute gastro-intestinal disturbances rest from food is essential for at least twenty-four hours. Some infants can easily endure starvation for this short period. However, when malnutrition has already been established, it is not wise to carry out the starvation treatment over-long. A cautious return to a normal diet may be made as soon as acute symptoms disappear.

Fevers in General.—It requires very little deviation from the normal to raise the temperature of a child. A slight attack of indigestion, a slight soreness of the throat, will bring up the temperature of some children out of all proportion to the seriousness of the disorder.

Diet in Fevers of Short Duration.—As a rule, in the fevers of short duration, such as intermittent fever, malarial fever, etc., the diet is a simple matter. Milk is given when it agrees, with buttermilk, koumiss, broths, and albuminized beverages to vary the diet.

Diet in Infectious Diseases.—When, however, the fever is induced by specific bacteria, such as in the case of typhoid and scarlet fever, the diet is a different matter altogether. The disease may be one in which the diet is the chief item of importance; such is the case with typhoid and scarlet fever, with the former because of its long duration, the increased rate of metabolism due to both the fever and the action of the bacteria making it necessary to increase the normal amount of food to meet the new requirements of the body; and with the latter on account of the kidney complications which must be guarded against, and which can only be handled by regulating the diet.

Infant Feeding.—The feeding of infants under febrile conditions resolves itself into an adjustment of the milk [Pg 244a] formula to meet the existing state of affairs. The digestion is always more or less disturbed by fever, especially during the early stages.

Restricting the Food.—It is not always possible to diagnose the disease immediately, so that the safe thing to do is to lengthen the intervals between the feedings for the breast-fed baby and to stop food entirely for twelve to twenty-four hours for those who are artificially fed, when there is any doubt as to the cause of the rise of temperature. Some mothers find it difficult, if not impossible, to institute this period of starvation. In these cases barley water or albumen water may be given at stated intervals. Many physicians give very weak tea, slightly sweetened, under the above conditions; it does no harm to the baby and relieves the mother from the belief that her child is being starved to death. In twenty-four hours, if the fever arises from disturbed digestion, some manifestation of the condition will be observed.

Bacterial Activity.—In cases of intestinal putrefaction the fever is apt to rise at an alarming rate and is controlled only by removing the cause. The proteins which have escaped digestion and absorption in the intestines furnish the best medium for the growth of putrefactive bacteria. Hence this food constituent must be given in its most digestible form.

Dietetic Treatment.—Milk in most instances is the best form in which to give protein food, especially to young children and babies. At times, however, it will be found that milk disagrees; it must be peptonized, or one of the fermented milks, such as buttermilk (Bulgarian culture), Eiweissmilch, or koumiss must be substituted. In cases where the putrefactive bacteria make it unwise to use milk at all, for a time the proteins should be furnished in the form of cereal gruels, and the juice of an orange strained and diluted given once or twice a day between the morning and evening feedings.

[Pg 244b] Whey is contraindicated in cases where the fever is brought on by putrefaction in the intestine, chiefly because it furnishes one of the best mediums known for the growth of the offending bacteria.

Patience is required in handling the diet for fevers in infancy. As has already been stated, it requires a very slight cause to raise the temperature of a child, but for this very reason especial care must be observed that no enlightening symptom escapes the notice of the nurse.

Complications.—Tuberculosis or scurvy may be in an incipient stage, and may be overcome if recognized in time. The nurse has a better opportunity for observing changes in an infant or child under her care than the physician who comes once a day or less. The nurse should make note of these changes, that the physician may have a chance to regulate the diet accordingly.

Fluid Diet.—With children, as with adults, the energy output in fever is greater than in health, hence the need for plenty of fluids to help eliminate the waste products due to the increased metabolism. These fluids may consist of water, fruit beverages, cereal water, whey, and broth. It is well for the nurse to remember that when the child is confined to bed, he will not need so much food as he would if he were up and about, but that if the fever is of long duration, as in typhoid, the increased rate of metabolism must be met by an increased amount of food, as the ordinary requirement standards for a child in health cannot be applied to the diet of a child under these conditions.

SCARLET FEVER

Scarlet fever is an acute infectious disease, characterized by high fever, sore throat, a red rash, and a tendency to nephritis. The disease usually begins suddenly with an attack of vomiting; the temperature rises to 104° or 105° and on the first or second day a rash appears, first on the chest and neck, and spreads over the entire body. This lasts [Pg 244c] from three to seven days, desquamation begins soon after the rash disappears and lasts from two weeks to six, the palms of the hands and soles of the feet peeling last. The appearance of the tongue is very characteristic, being coated, and through this coating are seen a few bright red points, producing the well-known strawberry tongue. After a few days the coating disappears, leaving the tongue bright red. In mild cases the tonsils are enlarged and the throat very red. In severe cases there may be difficulty in distinguishing the disease from diphtheria without a culture being taken. The tendency of the child to develop nephritis during the second or third week makes the treatment largely dietetic in character.

Dietetic Treatment.—Milk is the chief diet for the first three weeks. If it disagrees, it should be modified or peptonized to suit the condition. Koumiss and buttermilk may be substituted when it is impossible to prepare the milk so that it will not cause digestional disturbances. This, however, is seldom found to be the case during infancy. Malted milk and even condensed milk, or some of the dextrinized and malted foods at times prove valuable when whole milk disagrees. But the nurse must remember that a baby runs a risk of developing nutritional diseases of a grave character if fresh milk is eliminated from the diet for any great length of time.

Older children may have plain vanilla ice cream and plain junket, oyster or clam broth made with milk, the oysters and clams carefully strained out. Lemonade and orange juice may be given, but no meat broths or albumenized beverages or egg dishes can be admitted to the dietary.

Development of Nephritis.—Nephritis must be guarded against. The skin, being covered with a rash, is put out of commission as an excretory organ; in consequence all of the work of this description is placed upon the kidneys. In the first part of this text the work of the kidneys was defined; [Pg 244d] it was found that they were the chief organs for the excretion of the end-products of protein metabolism. It can be readily understood that when these organs are given not only their own work but that of the other organs to perform, unless the food requiring the greatest amount of effort on the part of the kidneys is confined to those types which can be most easily taken care of, such as milk, the kidneys stand a great chance of becoming impaired. Such is the case in nephritis.

Convalescent Treatment.—The return to normal diet must be made with the greatest caution. Specimens of urine must be taken often, for in this way alone can the development of nephritis be reckoned with.[87] Should nephritis develop in spite of efforts to prevent it, a farinaceous diet[88] such as is given in these conditions must be resorted to.

After three weeks, if the patient shows no disposition toward nephritis, and if convalescence is progressing satisfactorily, the diet may be increased day by day, adding milk toast, cereals, cream soups, rice, baked potato, then custards and soft eggs, the soft part of oysters, broiled or baked fish, broiled breast of chicken, and, still later, rare beef and lamb chops. Meat, however, must not be given until all danger from nephritis has passed.

DIPHTHERIA

Diphtheria.—The feeding in diphtheria follows the régime given in acute fevers. The body must be kept in good condition. At the same time it is necessary to understand the complications which make the dietetic treatment of this disease assume a place of importance.

Complications.—It may be complicated by broncho-pneumonia, albuminuria, carditis, endocarditis, and dilatation of the heart. Anemia must be combated, but care should [Pg 244e] be used not to push the diet to such an extent as to impose too great a tax upon the already weakened heart.

Dietetic Treatment.—While the fever lasts the diet must be fluid, milk, buttermilk, malted milk, and some of the proprietary infant foods such as Mellin’s Food, Eskay’s Food, and like preparations. Milk gruels, made with milk and some cereal such as farina, barley flour, fine cornmeal, arrowroot, strained oatmeal, etc., are at times more easily swallowed than the unthickened liquids. Liquid beef peptonoids, panopeptone, and like predigested beef preparations prove valuable in many cases.

Convalescent Diet.—As convalescence progresses, or in cases where the patient finds it easier to swallow a semi-solid than a liquid, soft custards, gelatin, well-cooked cereals, and ice cream may be given. Eggnog and milk punch are at times given, but only upon the advice of the physician in charge.

Rectal Feeding.—When the condition of the patient makes it necessary to nourish in other ways than by mouth, nutrient enemas[89] may be given. In certain cases of diphtheria, young infants can be fed more successfully through a tube inserted by way of the nose into the stomach than by feeding in the ordinary way. The formula is prepared in the same way as for bottle feeding, and is poured into a glass funnel and through the soft rubber catheter into the stomach. Care must be observed to prevent the patient struggling on account of the heart weakness which invariably complicates this disease.

WHOOPING COUGH

In the early months of life it is probable that whooping cough is one of, if not the most fatal of the diseases to which the infant is subjected. The period of incubation of this disease is from one to two weeks, the cough at first not appearing different from those accompanying colds of all [Pg 244f] sorts. However, in from ten days to two weeks the characteristic whoop occurs, differentiating this disease from all others. The symptoms aside from the whoop are the difficulty of taking breath and the great prostration after the paroxysm and the frequent vomiting of the food, brought on by the violent coughing.

In very young infants the whoop does not always occur. But the child coughs and holds its breath until it is blue in the face. At times young babies may have convulsions. The so-called spasmodic stage, during which the child may have from a few to a great number of paroxysms of coughing a day, lasts from a month to six weeks, and in some cases even longer. As the disease declines the cough gradually disappears and the child appears to be suffering with ordinary bronchitis. The characteristic whoop may return at any time during the ensuing six months or year if the child has an attack of bronchitis and is inclined to cough.

Complications and After-effects.—The complications and after-effects of whooping cough give it a serious character. Hemorrhage may occur from the nose. According to Ruhräh: “Paralysis may follow from meningeal hemorrhage, broncho-pneumonia, acute emphysema, and collapse of the lung may occur. Diarrhea, convulsions, and albuminuria are also met with. Tuberculosis and chronic bronchitis may follow.”[90]

Dietetic Treatment.—The diet plays an important part in whooping cough. The serious complications and after-effects of this disease upon children necessitate a rigid observance of dietary laws. With infants it is always best, when it is possible, to give breast milk. As this is the natural food it requires less effort on the part of the digestive apparatus to become available. It has been proved that even during the time when the baby is nursing the milk is projected in spurts into the duodenum without waiting to be attacked by digestive enzymes in the stomach, and [Pg 244g] for this reason the breast-fed infant is more apt to be efficiently nourished than the artificially fed baby, who loses his dinner by vomiting before absorption has had a chance to occur.

Diet under Ten Years of Age.—For children under ten years, a fluid diet is necessary, at least in the beginning of the disease while there is a fever, and later, if the vomiting is persistent. Milk, buttermilk, koumiss, broths, albuminized beverages, and cereal gruels such as barley and oatmeal gruel and arrowroot gruel can be given. Later, if the fluids are retained, cream of wheat, farina, junket, soft custards, and soft-cooked eggs may be added. Care must be taken in giving toast, unless it is softened with milk or broth, for the crumbs may bring on a paroxysm of coughing and vomiting. The best results in feeding with whooping cough are obtained by giving the food in small quantities and oftener. A few ounces given every two hours are less apt to be vomited than a larger quantity. It is also easier for the child to take the small amount after an attack of coughing and vomiting than it would be for him to attempt a larger meal.

Use of Stimulants.—In many cases where weakness is great, it has been found advisable to add some stimulant to the diet. With infants this is best given in albumen water, a small amount of good brandy acting better than other stimulants. With young children some of the predigested liquid beef preparations, such as liquid peptonoids, are found valuable. These foods are given alternately with the other fluid foods.

Hygiene and Sanitation.—Infants and children suffering with whooping cough require plenty of fresh air and sunshine. They must be kept out of doors as much as possible and sleep in well-ventilated rooms or sleeping porches. They must be protected from drafts and excitement, and never allowed to become over-tired. In this way the anemia which so often results from prolonged attacks of whooping cough is in a measure held in check. At times it is found [Pg 244h] necessary to give some kind of an iron tonic, but this comes under the jurisdiction of the physician instead of the nurse. When bad effects do occur in spite of all the care exercised during the attack of whooping cough, they must be accorded the treatment especially devised to meet the situation.

MEASLES

This is an acute, infectious disease characterized by a red eruption which appears on the fourth day. Measles is one of the most contagious of all the diseases of childhood. It may be acquired by direct contact with another case or by being in the room with a case. The infection may also be carried through the air and occasionally by a third person. Measles is more prevalent in the winter than in summer. In cities it often occurs in epidemics. The period of incubation is from ten days to three weeks, occurring generally at about two weeks after exposure.

The attack may begin with the child showing a languid attitude, complaining of headache. Then a cough develops, with nausea and fever at times. The fever is often high, reaching 104° F. on the second day. As a rule the fever gradually falls after the second day and becomes normal in almost a week. However, the temperature varies in different cases.

Complications.—Measles is not considered dangerous in itself, but the after-effects sometimes prove fatal. This is especially the case in broncho-pneumonia, which frequently develops during or after the attack.

The gastro-intestinal, as well as the respiratory, tract is attacked in measles, diarrhea being especially common. Very weak children have been known to develop gangrenous stomatitis; paralysis and tuberculosis[91] likewise develop in some cases as the direct result of measles.

Thus it is demonstrated that measles is not to be lightly treated. Even if it is not in itself fatal, the results of the [Pg 244i] disease are so dangerous that the care of the nurse is especially necessary. The great trouble is that so often a nurse is not in attendance and the child suffers through ignorance of the mother.

Dietetic Treatment.—The dietetic treatment of measles is important. For infants milk is the exclusive diet, the formula for bottle-fed babies having to be weakened on account of the catarrhal condition of the gastro-intestinal tract. For older children it is necessary to confine the diet to fluids as long as the fever lasts, and at times longer if the stomach gives evidence of digestional disturbances. Milk is the chief food, with milk soups, buttermilk, and koumiss used to vary the diet. Orangeade and lemonade may be given to allay thirst. A return to normal diet must be made gradually, giving cereal gruels, milk toast, and broth before the more solid articles of diet suitable to the age of the child. When there are complications they must be treated, as in whooping cough, according to their symptoms.

SUMMARY

Gastro-intestinal Disturbances are responsible for much of the fever manifested during infancy and childhood.

Infectious Diseases are all more or less accompanied by an elevation of temperature.

Incipient Diseases, especially tuberculosis and scurvy, may likewise cause a rise of temperature. The relief of either disease or the fever depends largely upon how quickly the conditions are discovered and the means instituted to overcome them.

Metabolism in Febrile Conditions of children, as well as of adults, is rapidly increased, hence the energy output is greater, and for this reason the fluid intake must be augmented in order to eliminate the toxic substances produced as a result of the rapid breaking down of the body tissues.

The Kidneys are more or less strained to eliminate the products of the increased metabolism and for this reason it [Pg 244j] is especially necessary to adjust the diet in order to limit, as far as possible, the foods which add to the burden already imposed upon the organs of excretion.

The Skin is an organ of excretion which, under normal conditions, shares the work of the kidneys. In infectious conditions, accompanied by eruptions which more or less cover the entire surface of the body, this organ is temporarily out of commission, hence its work, as well as their own, must be accomplished by the kidneys.

Dietetic Treatment in the majority of infectious diseases may be divided into three periods: Starvation, Fluid Diet, and Convalescent Diet.

Starvation, during which time no food is given for twenty-four hours or longer, in order to allow the digestive apparatus to rest and to give time for any substance which may be causing the elevation of the temperature to pass from the body. This treatment is also wise because it furnishes an opportunity for the symptoms of the disease to manifest themselves; Fluid Diet, given when acute symptoms subside, and Convalescent Diet when danger from relapse is over.

Scarlet Fever is treated with two main ideas in view—preventing the development of nephritis and relieving the condition should it develop.

Dietetic Treatment is logically the only means of treating or relieving nephritis. For the first three weeks, during which time this complication is apt to develop, a milk diet is necessary. This may be in the form of whole milk, milk soups, malted milk, etc. At the end of this time, if there are still no symptoms of nephritis, a convalescent diet, beginning with cereals and soft toast and progressing through the simple digestible foods such as rice, baked potatoes, soft eggs, etc., may be given. This is continued until the patient is well on the road to recovery. Meat should not be added until practically all danger of nephritis is passed.

Nephritis.—If, during the course of the disease this [Pg 244k] complication, should develop, the treatment described for acute nephritis on page 336 should be immediately instituted.

Diphtheria.—Dangerous complications at times develop as a result of diphtheria, making the treatment of this disease of the utmost importance. Heart symptoms, pneumonia, albuminuria, and anemia are among the complications to be dreaded and combated.

Dietetic Treatment in diphtheria is most important. It consists of a fluid diet made up of milk, malted milk, or buttermilk. At times the condition of the throat makes a slightly thickened mixture more easily swallowed than one which is distinctly fluid in character, and for this purpose farina, arrowroot, or barley flour may be used.

Increasing the Diet.—As convalescence advances the semi-solids, soft toast, soft custards, gelatin, and cereals may be given. Should the heart show symptoms of being affected, the intake of fluid must be restricted.

Gavage and Rectal Feeding are at times necessary. Infants may be successfully fed by passing a small rubber tube through the nose into the stomach and administering the milk formula to which they are accustomed. Rectal feeding is likewise valuable in cases of extreme anemia accompanying diphtheria.

Care must be observed by the nurse in giving gavage to babies, since any struggling on the part of the child may result in death from heart disease.

Whooping Cough.—On account of the character of the disease and the proneness of the stomach to eject the food during paroxysms of coughing, dietary measures are more or less necessary in order to enable the child to receive sufficient food to cover his daily needs.

Complications.—Hemorrhage, pneumonia, albuminuria, diarrhea, and convulsions may occur during the disease, while tuberculosis and chronic bronchitis may follow as after-effects.

Dietetic Treatment.—Breast milk is by far the best food [Pg 244l] for the baby, in this as in all conditions. In whooping cough the fact that this fluid leaves the stomach almost as soon as it enters lessens the chances of the baby losing its meal by vomiting it.

Older children do well with frequent small meals, since they are not so apt to give rise to pressure which brings on the paroxysms of coughing and vomiting. When the meal is vomited, a second should be given in order to keep the child from suffering from malnutrition.

Stimulation is found to be necessary in certain cases. Albumen water containing a spoonful of brandy or some of the prepared beef preparations, such as liquid peptonoids, may prove valuable under the circumstances.

Measles.—Complications and after-effects developing as a result of measles make the dietetic treatment of this disease important. Gastro-intestinal disturbances, especially diarrhea, are apt to occur, and tuberculosis has been known to develop as a result of measles.

Dietetic Treatment.—The fluid diet as used in any acute febrile condition is used as long as the temperature is elevated. Milk, buttermilk, malted milk, and milk soups constitute the chief items in the diet. Orangeade and lemonade are found valuable in relieving the thirst.

PROBLEMS

[Pg 245]

CHAPTER XI

THE FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL TRACT

ACUTE AND CHRONIC GASTRITIS

Predisposing Factors.—The majority of diseases affecting the stomach have as their predisposing factors, and owe their development to, one or all of the following conditions: (1) errors in diet; (2) disturbed secretory processes; (3) disturbed motility and tone.

It is probable that in the beginning the first factor was the chief offender in the case, bringing about the development of one or both of the other conditions. The other factors to be considered in this respect are heredity, occupation, poverty, and diseases which involve to a greater or lesser degree the digestion of the stomach and intestines. A child may inherit a weakened organism through excesses or disease on the part of the parent. If this weakness is not overcome while the child is growing, the probabilities are that the digestion steadily declines until in adult life it becomes a pathological condition. Lack of fresh air, poor and dirty food, unwholesome surroundings, crowded and badly ventilated sleeping rooms, insufficient water, and overwork, all act in making the digestion bad. These must be overcome if permanent good is to result.

Errors in Diet.—Errors in diet arise more often through ignorance than from any other cause. A child may be allowed to eat any and all kinds of unwholesome and unsuitable food. When the stomach rebels, showing the serious danger signals of nature, medicines are given but the diet is unheeded, until the time comes when even the medicines [Pg 246] fail to give temporary relief, and the organs of digestion are in some instances permanently impaired.

Disturbed Secretory Processes.—Consensus of opinion goes to show that the majority of cases of acute and chronic gastritis (catarrhal) and gastric ulceration are due primarily to a disturbance of the secretory processes, while the impaired motility and lack of tone in the stomach probably influence their development and aggravate the disease already present.

Composition of Gastric Juice.—In a former chapter the processes of gastric digestion were explained. The gastric juice, composed of from 0.2 to 0.3% free hydrochloric acid and several important enzymes and lipases, which act upon the proteins and emulsified fats, must be sufficient in quantity to assure good digestion, and when anything arises to interfere with the secretion of this fluid a deviation from the normal is bound to occur.

Disturbed Motility and Tone.—Again, it has been proved that good gastric digestion, like good intestinal digestion, depends more or less upon the way in which the food mass is mixed with the digestive juices and moved along the alimentary canal. Anything which interferes with the secretion of the juices or delays the food over its normal length of time in the stomach surely exerts unfavorable influences on the general metabolism of the food, for while, as we have already found, gastric digestion is not essential to the final utilization of the food in health, in disease it undoubtedly exerts a marked influence upon the general nutrition of the individual.

HYPOCHLORHYDRIA

The lack of hydrochloric acid in the gastric juice lowers the resistance to bacterial action, for this constituent exerts a decided germicidal influence in gastric digestion, preventing fermentation with the production of organic acids and [Pg 247] probably alcohol. In conditions due to hypochlorhydria (lack of hydrochloric acid) foods which leave the stomach quickly must be given with enough of the other necessary constituents in their simplest and most easily digested form to balance the diet and prevent the occurrence of the other disorders as troublesome as the original disorder.

Dietetic Treatment.—The following points must be kept in mind in formulating a dietary for patients suffering from a deficiency of hydrochloric acid: (1) boil the drinking water to destroy any bacteria which may be present; (2) use carbohydrates in the form of starch rather than sugar, since starch is less liable to fermentation from bacteria than sugar; (3) limit the foods which delay the passage of the food mass from the stomach; fats pass into the duodenum more slowly than other foods and when fed with other foods delay their passage materially; (4) avoid the use of soda bicarbonate, as it tends to reduce the normal acid content of the stomach, thus preventing its germicidal action upon the fermentative bacilli; alkaline carbonates likewise inhibit the flow of gastric juices; (5) give especial attention to the attractiveness of the food served; let it be appetizing and savory, for by such means is the appetite juice and incidentally an increased flow of the gastric juices stimulated; (6) condiments and spices, meat broths high in extractives, and salt foods such as caviar and endives may be given at the discretion of the physician; it is seldom advisable to give the foods which are indigestible, even when they act as stimulants to the secretory cells of the stomach.

HYPERCHLORHYDRIA

(Excess secretion of acid in the stomach)

The Effect of Excess Acid.—An excessive flow of hydrochloric acid has been found to be the cause of much of the acute and chronic gastritis, in fact more of the cases are traceable to an excess than to a lack of hydrochloric [Pg 248] acid. This acid is more or less irritating in character, and the tender mucous membranes lining the gastric organ being constantly bathed in a secretion composed chiefly of acid must necessarily in time suffer a certain amount of irritation and inflammation, causing the development of a pathological condition which may be temporary or permanent, that is, it may result in acute or chronic gastritis, according to the amount of acid secreted and the length of time the hypersecretion is allowed to continue.

Determining the Acid Content of Stomach.—The difference between the cases brought about by an excess flow of hydrochloric acid are more or less difficult to distinguish from those caused by a lack of this constituent in the gastric juice, chiefly because in the latter case the organic acids formed as the result of bacterial action upon the food exert an equally irritating effect upon the membranes of the stomach, and the only sure method of determining the cause of the disturbance is by an analysis of the stomach contents, by which means the percentage of hydrochloric acid is determined.

Lavage.—It has been found advisable, in some cases of acute gastritis which do not yield readily to rest and liquid diet, to wash the stomach and allow a certain period of rest before giving any food; in this way the organ is rid of all of the offending material and thus has a better chance of a quick recovery.

ACUTE GASTRITIS

Dietetic Treatment.—The following dietetic treatment for acute gastritis is advised: As the stomach is the chief seat of disturbance, all unnecessary work must be taken from this region for a certain period:

(1) That any obscure cause may manifest itself and the diagnosis may be rendered more accurately and more quickly.

[Pg 249] (2) That by resting the organ the offending materials may pass out of the body and thus prevent further trouble.

Starvation Period.—Twenty-four hours of total abstinence from food may seem extreme, but as a rule in acute cases of gastritis it is the only sane and safe method of instituting a diet and thus beginning to overcome the cause of the disturbance. After the period of starvation the diet is begun with caution.

Fluid Diet.—Fluids should be given first in the form of well-skimmed broths, which may be reënforced with egg or cereal flours when the patient is very thin or anemic. Buttermilk, made with the Bulgarian cultures, koumiss and other fermented milk foods, liquid beef preparations such as peptonoids or panopepton, albumenized orange juice, cereal gruels treated with Taka diastase when it is found necessary, and peptonized milk. These may be given in from four to six ounces at a time, every two hours on the second day.

Increasing the Diet.—On the third day if the attack is slight the diet may be increased by adding toast, softened with peptonized milk, an ordinary serving (3 ounces) of farina, cream of wheat or rice, reënforced meat broth with two crackers, a cup of tea and a slice of toast, and one or two soft-cooked eggs. If the acute symptoms are still present on the third day, the diet advised for the second day must be continued until they disappear.

Convalescent Diet.—On the fifth day, if progress is satisfactory, lightly broiled chicken or a small piece of rare broiled beefsteak may be added to the diet and the meals reduced in number from six to four.

Relapse.—The patient must be warned against overeating or eating any of the articles which are known to cause an acute attack in his individual case, since one attack predisposes to another, and chronic gastritis may develop as the result of the continual gastric disturbance.

[Pg 250]

CHRONIC GASTRITIS

The treatment in chronic gastritis is very like that in the more acute form; that is, it must be combated by removing the cause. Lack of fresh air and exercise have much to do with the development of chronic gastritis, but even they combined with a judicious amount of rest would be wasted without a proper adjustment of the diet to cover the main points of the disturbance. As has already been mentioned, the cause may be a lack of gastric juice or it may be an excess of it; it may be intensified by an atonic condition of the organ or from the food passing too quickly into the duodenum.

Test Meals.—As a rule it is not safe to make a snap diagnosis as to the cause of this disorder. Since in many instances the more serious disorders may be traced to a disregard for nature’s danger signals, the physician as a rule advises a test meal, this meal consisting of a glass and a half of water or a cup or two of tea without cream or sugar and from one to two slices of toast or water rolls. In from three-fourths to one hour or longer this is removed from the stomach by means of a stomach pump and analyzed, the result of the chemical and bacterial analyses forming the basis for diagnosis. This meal is generally given in the morning before any other food has been eaten.[92]

Dietetic Treatment.—The foods constituting the diet in chronic gastritis must be of the simplest character and prepared in the simplest manner. No fried foods are permissible. Pastries, griddle cakes, rich puddings and sauces, candies, and alcoholic beverages must be omitted from the diet as well as the following articles of food: pork, veal, shellfish except oysters, sardines, canned meats and canned fish, highly seasoned and spiced dishes, twice-cooked meats, vinegar, [Pg 251] pickles, olives, cold slaw, pickled beets, catsup, mustard, coarse fibered vegetables such as cabbage, old onions, old turnips, and cucumbers, strong tea, coffee, or chocolate, rich cream or dishes made entirely of cream. In cases of excessive acidity due to a hypersecretion of HCl the extractives of meat are contraindicated, hence all gravies and outside parts of roasted meat must be omitted or limited in the diet.

GASTRIC ULCERATION

Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. However, the character of this pain may be different, beginning soon after eating and radiating toward the back. This point may be affected by position. As a rule there is a tenderness over the seat of the ulcer. This is detected by palpation. Vomiting is one of the most general symptoms in gastric ulceration. This may begin from one to two hours after eating when the pain is at its height, or it may start as soon as food enters the stomach. As a rule the latter condition is found more often in very nervous women whose mental attitude affects the stomach to such an extent as to make it difficult to give them sufficient food to nourish them.

Hemorrhage.—Hemorrhage occurs in about half of the cases. The bleeding may be profuse and the blood bright red, or it may be less severe and the color of the blood changed by contact with the gastric juices to a dark brown like coffee grounds.

Excess Acid.—Hyperacidity is present in the majority of the cases, the percentage of HCl rising at times fifty per [Pg 252] cent. or more. Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening; and the constant development of cicatricial tissue brings about an obstruction of the pylorus, which if not relieved would allow the patient to starve.

Diet Treatment.—There are a number of treatments used in overcoming this condition. After the test meal and the diagnosis, the patient is placed upon a diet directed to overcome the chief symptom; for example, if the ulcer developed as a result of hyperacidity, the diet would be directed toward the relieving of that symptom. Boas[93] divides the treatment into three stages: (1) hemorrhage; (2) the intermediate stage; (3) the convalescent stage.

Starvation Treatment.—The majority of physicians institute a total abstinence period for the first stage, allowing no food or water to be taken by mouth. If the patient is very weak and anemic from the extended course of the disease, nutrient enemas are given from four to six times a day, alternating with saline enemas. This total abstinence continues from three to six days. Some cases have been known to be fed in this way for a month or six weeks with obvious success. However, this is not the rule but the exception. The diet must be adjusted to the needs of each individual, but a few general rules may be found helpful.

Dietetic Treatment.—Milk is the food generally utilized in the beginning. This may require peptonizing to [Pg 253] be digested, or it may have to be modified with limewater. Protein foods require HCl for their digestion. If these foods are fed they will absorb some of the excess acid, and in this way save the already irritated wall of the organ from additional irritation. When protein foods are given they must be in the form of soft-cooked eggs, scraped raw beef or beef juice, milk soups, and like protein foods.