THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES STATE t UNIVERSITY of CALIFORNIA AT LOS ANGELES LIBRARY FOOD IN HEALTH AND DISEASE BY I. BUKNEY YEO, M.D., F.E.C.P. EXAMINER IN MEDICINE AT THE ROYAL COLLEGE OF PHYSICIANS; PROFESSOR OF CLINICAL THERAPEUTICS IN KING'S COLLEGF-, LONDON, AND PHYSICIAN TO KING'S COLLEGE HOSPITAL AUTHOR OF "A MANUAL OF MEDICAL TREATMENT," ETC. WTTH ILLUSTRATIONS NEW AND REVISED EDITION LEA PHILADELPHIA BROTHERS & CO. SIR WILLIAM EGBERTS, M.D., F.R.S. IN ADMIKATION OP HIS MASTERLY KESEAUCHES IN PRACTICAL DIETETICS, THIS HUMULK CONTRIBUTION TO THE STUDY OF THAT SUBJECT IS DEDICATED. PEEFACE TO THE EEVISED EDITION. THE first edition of this work appeared in 1889. Since then several reprints have been called 01-, in which no noteworthy changes have been made. It has, however, seemed advisable, in preparing the present edition, to make certain changes and addi- tions. In the first Part a few unimportant details have been omitted with the view especially of gaining space to deal more fully with the practical subjects of the second Part. In that Part of the book gome im- portant additions have been made, and two entirely new chapters introduced, and the subject of the sterilisation of milk has been dealt with in an ad- ditional appendix. The author trusts that the work may thus be rendered more useful and more worthy of the favour with which it has been received. 44, Hertford Street, Mayfair. June, 1896. PKEFACE TO THE FIEST EDITION. IN writing this work on Food, the object I have especially aimed at has been to make it one of prac- tical utility, and to render it, as far as possible, repre- sentative of the modern aspects of the subject it treats of. In a hand-book like this, which has necessarily to be kept within strictly allotted limits, compression in certain points has been essential in order to obtain space to give adequate development to the more generally interesting details of practical dietetics. I have thought it 'desirable, in the first part of the book, to enter fully and in detail into the important subjects of Army and Prison Dietaries, School Dietaries, and Feeding during the critical period of Infancy and Childhood. The second part of the book is, to some extent, founded on a short course of lectures on " The Therapeutics of Food," which it was my duty to give in King's College Hospital as Professor of Clinical Therapeutics. In preparing this Manual I have been under great obligations to many contemporary writers on Dietetics. To the writings, amongst others, of Bauer, Konig, Landois, Oertel, Dujardin-Beaumetz, Germain See, Weir Mitchell, Parkes, Pavy, Sir Henry Thompson, and Sir William Roberts, I am deeply indebted. The subject matter of this work does not lend itself well to orderly classification. Few previous writers on Dietetics have attempted any. I have, however, thought it would be practically convenient to arrange the subjects dealt with under two main divisions Food in Health, and Food in Disease. I can only hope this book will be found to be what I have endeavoured to make it a practically useful guide to the study of the important subject of Dietetics. CONTENTS. PART I. FOOD IN HEALTH. CHAPTER PAGE I. THE NATURE, ORIGIN, AND PURPOSE OP FOOD CLASSIFICATION OP FOOD METABOLISM . . 1 II. THE NUTRITIVE VALUE AND USES OF THE DIFFERENT CLASSES OF FOOD 12 ORDINARY ARTICLES OF FOOD AND DRINK. III. ANIMAL FOODS 32 IV. VEGETABLE FOODS ..,.., .66 V. BEVERAGES. 96 CONDIMENTS 130 VI. THE ANNEXATION OF FOOD : ITS DIGESTION, ASSIMI- LATION, AND UTILISATION 132 VII. THE COOKING, PREPARATION, AND PRESERVATION OF FOOD . . . . . ' . . .155 VIII. THE SCIENTIFIC BASIS OP DIETARIES AND RATIONS 185 IX. CERTAIN DIETARIES : PRISON DIETARIES SOLDIERS' DIETARIES SEAMAN'S DIETARIES X. THE ORDER AND FREQUENCY OF TAKING FOOD XI. FOOD IN RELATION TO AGE AND CONDITION FOOD IN INFANCY AND CHILDHOOD FOOD AT SCHOOL FOOD IN ADULT LIFE FOOD IN ADVANCED AGE 240 XII. THE RELATIVE ADVANTAGES OF ANIMAL AND VEGE- TABLE FOODS VEGETARIANISM .... 289 viii FOOD IN HEALTH AND DISEASE. PART II. FOOD IN DISEASE. CHAPTER PAGE INTRODUCTORY REMARKS 300 I. FEEDING IN ACUTE DISEASE AND CONVALESCENCE . 302 II. THE DIETETIC TREATMENT OF DISEASES OF THE DIGESTIVE ORGANS ACUTE AND CHRONIC GASTRIC CATARRH GASTRIC ULCER CANCER OF STOMACH DILATATION OF THE STOMACH DYS- PEPSIA CONSTIPATION DIAIUUKEA . . . 326 III. FOOD IN DIABETES 3G3 DIABETIC DIETARIES 396 IV. DIET IN ALBUMINURIA 405 V. DIET IN GOUT AND CALCULOUS DISORDERS . . 421 VI. THE DIETETIC TREATMENT OF OBESITY . . .439 VII. DIET IN ANAEMIA, CHLOROSIS, NEURASTHENIA, AND ALLIED DISTURBANCES OF NUTRITION . . 459 VIII. FOOD IN RICKETS, SCURVY, SCROFULA, CONSUMPTION, AND CHRONIC FEBRILE CONDITIONS FORCED FEEDING (SURALIMENTATION) .... 474 IX. DIET IN AFFECTIONS OF THE CIRCULATORY AND RESPIRATORY ORGANS 494 X. FOOD IN ACUTE AND -CHRONIC RHEUMATISM AND IN RHEUMATOID ARTHRITIS IN SKIN DISEASES IN INSANITY AND CERTAIN OTHER AFFECTIONS OF THE NERVOUS SYSTEM BENEKE'S DIET FOR CANCER 508 XI. CERTAIN SPECIAL DIETETIC CURES : THE " DRY " CURE MILK AND WHEY CURES THE KOUMISS CURE THE GRAPE CURE . . " ^ . .523 XII. ON ARTIFICIAL DIGESTIVE AGENTS AND ON ARTI- FICIAL ALIMENTATION 535 APPENDIX I. HOSPITAL DIETARIES 549 ,, II. THE STERILISATION AND PASTEURISATION OF MILK 557 III. INVALID'S DIETARY SELECT RECIPES . . 564 INDEX . . . .577 FOOD IN HEALTH AND DISEASE. POOD IN HEALTH. CHAPTER I. THE NATURE, ORIGIN, AND PURPOSE OF FOOD CLASSI- FICATION OF FOOD METABOLISM. ALL living things undergo change. Change is a necessary condition of growth and development, of decay and of repaii'. Change, change of substance, is, then, a necessary and constant condition of life and activity. In the living and normally active body there are, therefore, always changes taking place, losses pro- ceeding from within, and gains accruing from with- out to compensate for those losses ; otherwise it would cease to be active, it would cease to live. These gains from without are derived from what we call Food, and the purpose of food is to supply the living organism, however complex or however simple it may be, with the substances or elements necessary for its growth and repair, and for the production and execution of those forms or modes of energy which we speak of as its functions. A perfect and complete food for any living thing must necessarily comprise all the elements of which its tissues and all the solids and fluids of its body are composed. 2 FOOD IN HEALTH [Paul. When its composition is simple, its food may be simple. The simplest vegetable organisms require for their food nothing beyond water and the gases of the atmosphere. The carbon and nitrogen which enter into the composition of their simple structures are derived from the carbonic acid and the minute quantity of ammonia always found in the atmo- sphere, and in solution in rain-water. But when we come to consider the food of so complex an organism as that of man, with which we are now mainly concerned, we shall find his fool requirements to be correspondingly complex. The simplest organisms also appropriate their food in a very simple manner; and in, the whole of the vegetable kingdom there is nothing to be found comparable to the function of digestion in the higher animals ; but in these latter, most elaborate processes, mechanical and chemical, are called into operation in the appropriation of the complex substances they take as food. These processes are comprised in what are known as the functions of digestion and assimilation. So, then, we may define food to be any substance which, when introduced into the living organism, can minister to the maintenance of its structure and its activities ; and a perfect and complete food for any living body will be one which comprises all the ele- ments which enter into the composition of the tissues, juices, and secretions of the body, as well as those which are needed for the maintenance of the chemical changes connected with its functional activity. In the young and growing animal a considerable amount of food is needed for the growth and develop- ment of its organs. When these are complete, and growth is at an end, food is needed to maintain the integrity of the body structures, and to repair such waste as is involved in the exercise of their functions ; while alike in the growing and in the mature body, food is needed to supply the elements necessary for the maintenance of those chemical changes which are essential to the development of animal activities, such Ch.np. i.] NATURE AND PURPOSE OF FOOD. 3 as muscular and nervous action, heat formation, nutri- tion, secretion, assimilation, and reproduction. But a substance in order to be suitable for food must not merely possess the elements indicated, it must also contain them in a mode or combination which enables them to be appropriated, i.e. to be digested and assimilated, by the organs of the body it is to feed. The plant the grass-plant, for example is enabled to appropriate, and therefore ro use as food, the soluble mineral matters of the soil in which it grows, dissolved in the rain-water which falls upon it, together with what it absorbs from the gases of the air. It is a characteristic of the members of the vegetable kingdom that they are able to feed on inor- ganic substances. Animal organisms are unable to do so ; they are dependent on vegetable organisms to provide them with food that they can appropriate. The ox is enabled to appropriate, and use as food, the grass that is itself fed on inorganic substances, upon which the ox cannot feed ; and from this grass it is enabled to build up structures, and to perform functions of the same kind as those possessed by man himself. Yet grass, such as the ox feeds on, is not a suitable food for man, because its component elements are not so arranged as to enable his organs to digest and assimilate them ; but, on the other hand, the same elements having undergone some further elabora- tion, as in the ripe seed of certain species of grass, when fitly prepared, form one of the most useful foods that man can obtain, as the meal of wheat, barley, oats, etc. Tims, in considering the origin of food, we learn how the simplest vegetable forms grow and feed on the constituents of the atmosphere alone, the carbon and nitrogen of their tissues being derived from the carbonic acid and ammonia always present in small quantity, together with aqueous vapour, in the air. The larger vegetable forms feed also, to some ex- tent, on the gases of the air, but they also feed largely on the organic and inorganic constituents of the soil B 2 4 FOOD IN HEALTH. [Parti. in which they are planted. The organic substances in the soil consist chiefly of decomposing vegetable matter, and these must be resolved by decomposition into carbonic acid and ammonia before they can be absorbed by plants. The animal, unable to construct organic substances from inorganic matters, is depen- dent on the vegetable kingdom for his food. If we examine the chemical composition of those organic compounds prepared by the vegetable world, and which serve as food for animals, we find they consist chiefly of the following elements : carbon, hydrogen, oxygen, nitrogen, sulphur, and phosphorus. Of these elements nitrogen is the most important, as it is the essential element of all living things ; vital phenomena, the activity and change characteristic of all living things, are only found where this element is present. This has been well expressed by Parkes. " Every structure in the body," he says, " in which any form of energy is manifested (heat, mechanical motion, chemical or electrical action, etc.) is nitrogenous. The nerves, the muscles, the gland-cells, the floating cells in the various liquids, the semen, and the ovarian cells, are all nitrogenous. Even the non-cellular liquids passing out into the alimentary canal at various points, which have so great an action in preparing the food in different ways, are not only nitrogenous, but the constancy of this implies the necessity of the nitrogen in order that these actions shall be performed ; and the same constancy of the presence of nitrogen, when function is performed, is apparently traceable through the whole world. Surely such constancy proves necessity." We see, then, that the simplest forms of vegetable life derive their food from the atmosphere in which they live and grow, the elements of the carbonic acid, and the ammonia, and the water always present therein, sufficing for their nutrition and growth. The higher vegetable forms, in addition to the elements they derive from the constituents of the atmosphere, Chap, i.] ALIMENTARY PRINCIPLES. 5 are able by their roots to absorb and use as food the inorganic salts of the soil. In this way, under the influence of the solar rays, vegetable organisms pre- pare and store up organic compounds suitable for the food of animals. Animals, in the processes of nutrition, and in the development of their various forms of energy, feed upon, that is to say appropriate, these products of vegetable life ; convert them into other organic com- pounds, or decompose them in the process of nutrition, with the aid of the cxygen absorbed from the air, into simpler substances, which are in course of time re- stored to the atmosphere and to the soil, and resolved finally into the simple elements from which they originally proceeded. It is not necessary, for our present purpose, that we should pursue the subject of the origin and nature of food, in its general sense, further than this. The subject of dietetics is a practical one, and it is with the question of food in relation to the various practical wants of the human body, in health and in disease, that we are now concerned. The various organic and inorganic compounds which enter into the composition of the human body may all be resolved into the following thirteen ele- ments : carbon, hydrogen, oxygen, nitrogen (these four in far greater proportion than the others), sul- phur, phosphorus, chlorine, iodine, potassium, sodium, calcium, magnesium, and iron. A few other elements (such as fluorine, silicon, manganese, etc.) have been discovered in the human body, but it is doubtful if they are invariably or necessarily present. All these thirteen elements must be represented in the food of man, and they must be, for the most part, combined in the form of organic products capable of being appropriated by his digestive organs. Classification of food: alimentary prin- ciples. In attempting a general classification of foods, it is convenient and usual to examine, in the first place, the various definite compounds which can 6 FOOD IN HEALTH, [Parti. bo derived by chemical analysis from the different substances commonly used as food, and these are termed alimentary principles. The classification generally adopted was originally founded on the analysis of that perfect and complete food upon which the young of all mammalian animals for a time are fed, and which is therefore pioved to contain all that is necessary for supporting and main- taining the growth, development, and activities of the animal body in its highest form. That perfect and complete food is milk. On analysing this fluid we find : 1st. That it contains a large quantity of a prin- ciple rich in nitrogen, termed casein, as well as some other nitrogenous or albuminous substances in small quantity. 2nd. It contains a considerable quantity of oil or fat (cream or butter). 3rd. It contains a form of sugar, namely, lactose or lac/ine (milk sugar). 4th. It contains water holding in solution various mineral constituents or salts (chiefly chlorides, phos- phates, and sulphates of magnesium, calcium, potas- sium, sodium, arid iron). Adopting this convenient basis of classification, we are enabled to establish four great divisions of alimentary principles, the members of each group possessing a remarkable similarity of composition, and differing widely both in physical and chemical characters from the members of fcbe other groups. These different groups also appear to serve, more or less, different purposes in nutrition, although to some extent the members of one group may replace those of another; and a combination of all four classes appears to be necessary for the maintenance of the body in perfect health. 1. The first class, comprising the chief nitrogenous alimentary principles, may be conveniently termed afbuminates (albumen being taken as the typical member of the group). These used at one time to chap, i.] ALIMENTARY PRINCIPLES. 7 be named proteids (a term still employed by many authors), from the circumstance that they could all be made to yield the substance protein, which is now, however, simply regarded as a product of chemical manipulation. The chief of these nitrogenous alimentary prin- ciples are : JHoocl fibrin. Syntonm\ or muscle fibrin. Mynsin, from muscle. Albumen in its various forms. Vegetable fibrin, or Gluten. Cumin, animal and vegetable, the latter sometimes termed Leyiunin. Globulin, occurring in the contents of the blood cor- puscles. The members of this class present a remarkable uniformity of chemical composition, and can replace one another in nutrition. They contain from 15-9 to IG'Sper cent, of nitrogen ; their other elements being carbon, hydrogen, oxygen, and sulphur, or phosphorus. The following is a close approximation to their percentage com position : Nitrogen ........ 15'5 Carbon 5S - o Hvdrogcn , . 7'0 Oxygen 22-4 Sulphur 1-6* It is usual to consider as nearly related to the members of this class the substances gelatin and chondrin, which approach the albu minutes in chemical * Chemical composition of the allntminatcs. -The following has been sugge-ted as a hypothetical general formula for the albu- minates. It represents an albuminoid as a compound of cellulose plus ammonia minus water : - C 3 -H'''N'O< = 2((J fi H"'O 5 ) + 3NH 3 - GH-O Allni'iiiiiuiil Cellulose Ammonia Water Mulder's view that all these bodies had a special principle, which he termed protein, as a base, is no longer accepted ; and A. Gautier has advanced the view (by no means generally held) that they are built up on the cydnojcn compounds as a sort of chemical frame- work, and that in the body these toxic compounds are eliminated, as useless or dangerous, in the. form of Icucomaiiicy. I'iJc Du- jardin-Heauiiitti!, *' I/Hygiene Alimcntaire," p. 17- 8 FOUD IN HEALTH. [Parti. composition and in their richness in nitrogen ; but they have not the same nutritive value, nor can they be made to yield protein. Gelatin is derived from bone and fibrous tissues ; and chondrin from cartilage. They contain a larger proportion of nitrogen than the albununates. 2. The second group, the fats, or hydrocarbons, comprise the various animal and vegetable fats, oils, wax, etc. These resemble one another in chemical composition, and are especially rich in carbon, their percentage composition being represented by the following figures : Carbon ........ 79 Hydrogen 11 Oxygen 10 They differ somewhat in their physical state, some being solid and hard, like wax; others softer, like butter ; others quite fluid, as certain oils. They vary also in their digestibility, and therefore in their value as foods. 3. The third class comprises all the starchy and saccharine substances used as food, and these are termed carbohydrates, from their chemical composi- tion, in which hydrogen and oxygen exist in the proportions to form water. The composition of starch, which may be taken as a type of this group, is C 6 H 10 5 . The chief members of this class are : The various vegetable Starches. Cane, Grape, and Milk Sugar (Sucrose, Glucose, and Lactose). Gum : Dextrin. Cellulose : together with a few other substances closely related to them in chemical composition. Pectin, or vegetable jelly, is sometimes referred to this class, although it does not contain hydrogen and oxygen in the propor- tions to form water. 4. The fourth class includes water and the various mineril substances which occur in the animal body. Chap. I.] CLASSIFICATION OF FOODS. These four groups of alimentary principles corn prise all that is necessary for the growth, maintenance, and activities of the animal body. In addition, however, to these four groups may be mentioned the various substances termed food acces- sories, comprising the several condiments which give flavour to food, or stimulate the digestive secretions, and the well-known " stimulants," tea, coffee, cocoa, alcohol, etc. Foods have also been classified into organic, those derived from the animal and vegetable kingdoms, and inorganic, namely, mineral substances or salts ; also into nitrogenous, those containing the element nitrogen, and non-nitrogenous, those containing no nitrogen. Arranged in tabular form, these various classifica- tions may be thus represented : '1. Albuminates Nitrogenous substances, having the' same or nearly the same chemical composition as Albumen. Examples. Albumen, Fibrin, Synto- nin, Myosin, Globulin, Casein, from the Animal; Gluten and Legumin, from the Vegetable King- dom. (a) Subordinate nitrogenous substances icferrcd to this class, and known as Gelatisrenous substances 2. Fats or Hydrocarbons, containing Carbon, Hydro- gen and Oxygen the proportion of oxygen being insufficient to convert all the hydrogen into water. Examples. Olein, Stearin, Mar- garin (Butter is a familiar one). Carbo-Hydrates, containing Carbon, Hydrogen and Oxygen, the two latter elements in the propor- tions to form water. Examples. Starch, Dex- trin, Cane Sugar, Grape Sugar, Lactose or Milk Sugar. (a) The Vegetable Acids, Oxalic, Tartaric, Citric, Malic, Acetic and Lactic, are by some authors referred to this class. j | 4. Mineral. 2 / Water. M Salts. Sodium and Potassium Chlorides, Calcium jg I Magnesium Phosphates, Iron, etc. io FOOD IN HEALTH. [Paul. Metabolism. The word "metabolism" is often used in connection with the utilisation of the food rttceived into the body. It refers in the first place to those phenomena manifested by all living organisms in the exercise of their power of appropriating the substances taken in as food and incorporating them into the tissues of their bodies ; the process, in short, of assimilation. It also refers to that power which the animal organism possesses of accumulating from its food supplies a store of potential energy, which it is able to transform into kinetic energy, and which manifests itself com- monly in the form of muscular work and the produc- tion of heat. It further includes the formation of those excretory products which result from the changes which occur in the constituents of the tissues as the necessary accompaniment of such transformations of energy. Normal, healthy metabolism, therefore, requires a due supply of suitable food, suitable in quality and quantity ; it also involves the storing up of a portion of this food within the body; audit demands a regular ch/miical transformation of the tissues, and the forma- tion of the effete excretory products resulting from these changes, which have to be eliminated through the organs provided for that purpose. The term equilibrium of the, metabolism is used to signify that the bodily income and expenditure are balanced ; that while the normal physiological condi- tions are maintained, there is exactly the same amount of new material absorbed and assimilated as there is of effete matter, the products of the retrogressive tissue-changes, removed by the organs of excretion ; the destruction of tissue is exactly compensated for by the formation of new tissue. Of course, while the body is growing rapidly there is greatly increased formation in the parts participating in the rapid growth, and the metabolism in these parts is corre- spondingly increased ; on the other hand, during senile decay the expenditure is in excess, and the body in consequence wastes. Chap, i.] METABOLISM, 1 1 The physiological equilibrium is practically deter- mined by physicians by simply weighing their patients, and observing that the body remains of the normal weight with a given diet. When the body is in this state of physiological equilibrium, about 90 per cent, of all the carbon taken in t! e food is excreted, in the form of carbonic acid, by the lungs and skin, and about 10 per cent, in the urinary excreta and fteces. Almost all the nitrogen of the food is excreted in the form of urea within twenty-four hours. The hydrogen is eliminated chiefly in the form of water ; the oxygen chiefly in the form of carbonic acid and water. Owing to the oxidation of hydrogen, more water is eliminated than is taken in. The soluble salts are mostly discharged in the urine ; the insoluble and less soluble ones (especially those of potash) in the faeces ; some pass off in the perspiration. The sulphur which is contained in albumen is, in part, excreted in the form of urinary sulphates, and in part in the fa?ces (Taurin), and a small proportion by the skin (epidermal scales). CHAPTER IL TBR NUTRITIVE VALUE AND USES OP THE DIFFERENT CLASSES OF FOOD. WE now pass on to the consideration of the purposes or uses, in the nutrition and maintenance of the structure and functions of the body, of the several groups of alimentary substances set forth in the last chapter. As the human body is chiefly composed of albu- minous or nitrogenous substances, and as the various functions of the body are mainly concerned with the physical and chemical changes these undergo, we shall be pre .pared to find that the class of albuminates, or the nitrogen-containing group of foods, plays a very important part in its nutrition, and in the develop- ment and maintenance of its energies. " The presence of nitrogen in an organised struc- ture, and its _ participation in the actions going on there, is a necessary condition for the manifestation of any energy, or any chemical change. . . If the nitrogen be cut off from the body, the various func- tions languish. This does not occur at once, for every body contains a store of nitrogen, but it is at length inevitable. . If it is wished to increase the manifestations of the energies of the various organs, more nitrogen must be supplied ; . . . without the participation of the nitrogenous bodies, no oxidation or manifestation of energy is possible." * Liebig's theory, which taught that the functional activity of the nitrogenous tissues involved a pro- portionate waste of the structural elements of those tissues, and necessitated a corresponding consumption * Parkes's "Hygiene," chap, viii., on Food, 8th edition. By Professor Nottcr. Chap, no FUNCTIONS OF THE ALBUMINATES. 13 of nitrogenous material to replace that loss, has been found inconsistent with later researches, and his con- clusion that the class of albuminates or nitrogenous foods was solely applied to the repair of the waste or destruction of the nitrogenous tissues, involved in their functional activity, is no longer accepted, nor his definition of this class as exclusively the " plastic " or " tissue-forming " foods, in contradistinction to the carbohydrates and the fats, which he termed " respira- tory " or " heat-forming " fooJs. The functions of the class of albuminates are no doubt threefold 1st, They contribute to the formation and repair of the tissues and fluids of the body, and in an especial manner of the nitrogenous tissues. 2nd, They regulate the absorption and utilisation of oxygen, and so play a very important part in the chemistry of nutrition. 3rd, Under special conditions they may also con- tribute to the formation of fat, and to the develop- ment of muscular and nervous energy, and to the production of heat. We have already pointed out how large a part of the whole body the nitrogenous tissues, form, and that it is entirely through their agency that all bodily energy is developed ; the active principles in the various secretions of the body are also nitrogenous ; the development and maintenance of these tissues and secretions are, therefore, the primary functions of the class of albuminates. It has, however, been proved that the elimination of urea in the urine is closely proportioned to the amount of the nitrogenous ingesta, and it is therefore certain that the nitrogenous alimentary principles must undergo such chemical changes in the system as result finally in the production of urea. They must therefore play an important part in the " absorption and utilisation " of oxygen in the system. It has, in the third place, been experimentally established that fat may be formed at the expense of 14 FOOD IN HEALTH, [Parti. albuminates; "so that the nitrogenous substance plays two parts : 1st, that of the organic framework, i.e. of the regulator of oxidation and of transformation of energy; and 2nd, it may form a non-nitrogenous substance which is oxidised and transformed."* Voithas pointed out that the albumen in the body exists in two conditions : 1st, that which is organised, and which forms part of the tissues, and which may, therefore, be termed " organic albumen ; " and 2nd, that which exists in the fluids, permeating all the tissues, and which may be called " circulating albu- men." The former is relatively stable, but the latter undergoes rapid changes in the processes of functional activity : whereas, according to Voit, 70 per cent, of the latter is used up in twenty-four hours, only 1 per cent, of the former is consumed. It is now generally admitted that, in ordinary conditions, only a small amount of the " organic albu- men. " undergoes decomposition, and that metabolism of the nitrogenous tissues is but slightly influenced by the activity of the organism. On the other hand, tlie " circulating albumen " under the influence of the cellular elements of the tissues undergoes transforma- tion to a considerable extent, such transformation probably taking the form of a splitting-tip of its con- stituent elements into nitrogenous waste substances such as creatin, uric acid, and especially urea, which are rapidly eliminated, and non-nitrogenous sub- stances, some of which may be deposited in the tissue? in the form of fat, and some may be consumed and oxidised in the production of heat and functional energy. It is quite true, however, that in certain patho- logical conditions, and especially in febrile maladies, the " organic albumen " becomes less stable, and may then undergo rapid changes, attended by notable waste of tissue and emaciation. It is certain that the functional activity of the organism is greatly dependent on the presence of * Parkes's 'Hygiene,'' chap, viii., on FooJ. Chap. IT.] FUNCTIONS OF THE ALBUMIN ATES. 15 alburninates in the food ; and no other class of ali- mentary substances can adequately replace albumen in sustaining the vital processes. Albumen exerts the greatest influence on the energy of the metabolic O ~/ processes, since it easily undergoes a splitting-up in the nutrient fluids, and at the same time enables the living colls to break up other matters in larger quantities. Albumen (together with water and salts) is able alone to support the vital processes, and it is the only alimentary substance that can do so. If can, there- fore, replace in nutrition the fats and carbohydrates, but, when taken exclusively, it is very unsuitable diet, as the amount thus required to maintain the constitu- tion of the body is disproportionate and wasteful. As has already been said, it is now general!}' admitted that fat can be formed from albuminates. Pettenkofer and Voit concluded from their experi- ments that albumen is split up in the body into a nitrogenous and a non-nitrogenous part, the latter having nearly the same composition as fat ; this may be either stored up in the organism or further trans- formed into carbonic acid and water ; ami Henneberg states that 100 grammes of albumen split up into 33 - 5 grammes of urea (which carries off all the nitro- gen) and 60 5 grammes of non-nitrogenous matter, which combine with 12-3 grammes of water, and after the elimination of 27 - 4 grammes of carbonic acid, yield 51-39 grammes of fat.* Lawes' and Gilbert's experiments on the fattening of pigs appeared to show that two-thirds of the total fat stored up must have originated in other sources than the fat taken in the food. It would seem, also, that even glycogen and sugar can be formed from albu- minous substances, for glycogen has been found in the liver of animals fed exclusively on albumen and fibrin, t and in certain forms of diabetes the sugar must be * Bauer, "Dietary of the Sick," p. 27. Von Ziemssen : s "Handbook of General Therapeutics." t G. See, "Du Ke"gime Alimeiitairc, 71 p. 13. 16 FOOD IN HEALTH. [Parti. derived " either from proteids or fat, most probably the former." * In the pathological condition known as fatty de- generation, the fat deposited in the tissues appears to be formed at the expense, and by the splitting up, of the " organic albumen." The functions of the class of albuminates may now be thus briefly recapitulated : (1) They are the essen- tial agents by which the nitrogenous organised tissues are developed and repaired, as well as all the other nitrogenous substances in the fluids and secretions of the body ; (2) They stimulate functional activity. and promote oxidation and metabolism in the body ; (3) They are capable of splitting-up in the organism into a nitrogenous and a non-nitrogenous part, and from the latter fat may be formed and deposited in the tissues or consumed in the production of force. Before passing on to the consideration of the food- value of the other classes of alimentary substances, it will be well to state what has been determined as to the utility in nutrition of the gelatigenous substances, as these are also nitrogenous, and are even richer in nitrogen than the albuminates. It has been long known that gelatin cannot replace the albuminates in the repair and maintenance of the tissues, as it undergoes rapid and complete metabolism within the body, being eliminated chiefly in the form of urea. It is, therefore, of no direct value as a " plastic " food. It must not, however, be hastily concluded, as was at one time done, that gelatin is on that account worthless, and that it answers no nutri- tive purpose. The very rapidity and ease with which gelatin undergoes decomposition within the body give it a value as a substitute, in a certain sense, for albu- minates, the metabolism of which it diminishes. It is, therefore, an albumen-sparing food, and, except for the purposes of building-up and repairing the tissues, can suitably, and to a certain limited extent, take the place of albuminates in nutrition. " By the * Parkes's " Hygiene," 8th edition, p. 244. Chap, ii.] FUNCTIONS -OF THE HYDROCARBON.'}. 17 administration of gelatin very large quantities of albumen can be spared in the body, or devoted to increase of bulk." (Bauer.) Gelatin has been observed to induce a slight dimi- nution also in the metabolism of the non-nitrogenous substances in the body. Owing to the larger propor- tion of nitrogen that enters into its comjxxsition, gelatin, when introduced into the body, leads to a greater elimination of urea than albumen, and this excessive excretion of urea induces increased diuresis and consequent thirst and demand for fluid, if large quantities are consumed. Schift' has stated that gelatigenous substances promote the secretion of the gastric juice, and there- fore belong to the group of peptogenic foods. It may be accepted as a practical conclusion that gelatin is useful as an " albumen-sparing " food, and that alimentary substances containing it tend to pre- vent the destruction of albuminates and fats. It is especially appropriate to those febrile states in which the stability of the "organic albumen" is threatened, and at the same time the capacity of assimilating albuminous food is greatly diminished. In the next place we must consider the purposes served by the class oifats or hydrocarbons in nutri- tion. Liebig's views with regard to this subject also have been shown to be erroneous. He considered the function of fats to be entirely respiratory, and that by combining with oxygen, admitted into the system in respiration, they were consumed in the production of heat, and that the completeness of this combustion depended on the amount of inspired oxygen. But it has been observed that when an exclusive diet of fat has been taken, there has been less fat metabolised and less oxygen absorbed than in fasting, and also that, in certain circumstances, the whole of the albu- men in the food is metabolised in the body, and the fat is appropriated to increase the body- weight ; an inver- sion of the formerly assumed roles of hydrocarbons i8 FOOD IN HEALTH. and albumiriates. From which it would appear that, under certain conditions, fat is split up into simpler bodies with greater difficulty than albumen, and must not, therefore, be regarded as the same easily combustible substance in the organism that it is outside. It is not, then, through the direct action of oxygen that the non-nitrogenous foods any more than the nitrogenous ones are split up into simpler products, but by the agency of the cellular tissues, and the oxygen enters into these products " little by little." Indeed, under the influence of fat tissue- waste is lessened, and, therefore, less oxygen is taken into the system ; less oxygen being abstracted from the blood by the products of metabolism. We thus see that one of the great purposes served by fat in the food is to diminish albuminous metabo- lism, and it is, therefore, regarded as an " albumen- sparing" food. "If flesh alone be given, large quan- tities are required in order that nutrition and waste may balance one another, but if fat be added the demand for flesh is less." (Bauer.} But the fats have also an important relation in the body to the production of force and heat, to body-work and body-temperature. While, unlike the albuminates, the metabolism of hydrocarbons is independent of the amount taken in as food, it is notably affected by bodily exercise, which produces little effect on nitro- genous metabolism. The fats, therefore, undoubtedly minister to force-production, and undergo destruction and oxidation in the process ; so that the amount of carbonic acid given off during exercise is much greater than during rest. External temperature also influences the meta- bolism of the hydrocarbons, and therefore the amount of carbonic acid excreted ; the lower the temperature, so long as that of the body itself is maintained, the greater the metabolism of non-nitrogenous foods, and the greater the amount of carbonic acid discharged from the body. This is one of the chief means of chap, ii.] FUNCTIONS OF THE HYDROCARBONS. 19 regulating the temperature of the body, and keeping it constant. When, however, the temperature of the body itself is distui'bed, as in fever, then the higher the tempera- ture the greater the waste of the non-nitrogenous, as well as of the nitrogenous, constituents of the body, and the greater the excretion of carbonic acid, as well as of urea. Tt is probably through the nervous system that the external temperature influences the metabolic processes in the body, and especially through the peripheral sensory nerves. It would appear that albuminates and fats are, to a certain extent, opposed to one another in their action on the organism, as the former increase waste and promote oxidation, while the latter have the effect of diminishing them, and this they do pro- bably by affecting the metabolic activity of the cells of the tissues themselves. It is a matter of common observation that fat animals bear privation of food better than thin ones ; in the latter, their small store of fat is quickly consumed, and then the albumen is rapidly decomposed. It is for the same reason that corpulent pei'sons, even on a very moderate amount of food, are apt to become still more corpulent. The influence of fat in the storage of albumen is exemplified by the fact that if 1,500 grammes of lean meat be given alone, it will be wholly decomposed ; l>ut if 100 to 150 grammes of fat be added, then it will yield only 1,422 grammes of waste. It has also been shown that the balance of income and expendi- ture of albuminates, although the amount taken in the food may be very small, is readily established as soon as one adds a certain quantity of fat. A dog who took daily 1,200 grammes of lean meat was observed to be still losing some of the albuminous constituents of the body ; whereas, with only 500 grammes of flesh and 200 grammes of fat, the nutritive balance was rapidly re-established. The same has been observed in man. Rubner found that an individual taking C 2 20 FOOD IN HEALTH. [Parti. daily 1,435 grammes of meat, containing 48'8 grammes of nitrogen, lost by the kidneys 50 - 8 grammes of nitrogen ; whereas another taking meat and bread containing 23 '5 grammes of nitrogen, to which were added 191 grammes of fat, only eliminated 19 grammes of nitrogen on the second day of the diet ; * so that a small quantity of albumen, when combined with fat, is sufficient to maintain the albuminous structures of the body. As a practical conclusion from these considerations, we should note, that if we wish to increase the weight of the body and add to its con- stituents, we must not rely on an excess of albu- ininates, as these given alone only lead to increased waste ; but if we combine fats with albuminates in proper proportions, an appreciable increase of both the nitrogenous and non-nitrogenous constituents of the body can be maintained for a considerable time. We see, then, how a proper use of fat economises the albuminous elements of food and checks the waste of the albuminous tissues. Fat enters into all the tissues. By its decomposition and oxidation it yields muscular force and heat, and it is therefore largely consumed in muscular exercise. By its capacity of being stored up in the body as adipose tissue, it provides a reserve store of force-producing and heat- generating material which can be utilised as required. The supporting influence of fat under great muscular fatigue is strongly maintained by Ebstein : and it is stated that the German Emperor, in the war of 1870, recognised this fact by requiring that each soldier should have served out to him daily 250 grammes of fat bacon ! As glycerin is derived from fats, it was thought it might possess the same albumen-sparing functions, but experiment has shown that this is not the case ; on the contrary, it raises the amount of albuminous waste, and increases the flow of urine, in which it is eliminated in large proportion. * Germain See, "Du Regime Alimentairc." chap, ii.] FUNCTIONS OF THE CARBOHYDRATES. 21 The class of carbohydrates have much in common with the fats. They serve the same purpose of checking albuminous waste ; like them, they are re- solved by combustion within the body, ultimately, into carbonic acid and water, and so, like the fats, are capable of yielding heat and mechanical work. Unlike the fats and the albuminates, however, they do not appear to enter into the structure of the tissues, although they are found in some of the fluids and organs of the body. All the carbohydrates are converted into glucose, or grape sugar (or maltose), before they are absorbed, and in this form they are much more readily meta- bolised than the fats or albuminates. It is believed by many, and the weight of evidence, as will be seen, is in favour of the conclusion, that carbohydrates can be converted into fat within the organism. Bauer,* however, is indisposed to accept this view. Basing his opinions on the experiments of Pettenkofer and Voit, who showed that carbo- hydrates, even when admin istered in great excess, are almost completely destroyed within the body, he maintains that although the carbohydrates, when given together with albumen and fat, favour an in- crease of the constituents of the body, and especially of fat, yet it is not because they are themselves converted into fat, but because, owing to the facility with which they are metabolised, they protect the other food-stuffs from destruction. " When fat and carbohydrates co-exist in the food, the latter ai-e always the first to be consumed ; and when they are present in sufficient amount, the consumption of fat in the body may be completely suspended." And he explains in a similar manner the fact that a deposit of fat may be observed to take place when the diet consists of albuminates and carbohydrates alone, without any fat; for in that case, he says, the fat, which " originates as a product of the splitting-up of albumen, is withdrawn * "Dietary of the Sick : Value of Food Stuffs," p. 32. 22 FOOD IN HEALTH. [Pani. from further metabolism in favour of the carbo- hydrates, and contributes to the gain." He also rejects the view that the ready decomposition of the carbohydrates in the body depends on their great affinity for oxygen ; he considers it lies rather in the properties of the animal tissues, and he points out that the assumed equivalents of starch and fat, as 240 of the former to 100 of the latter, calculated on the quantity of oxygen required for their combustion, are incorrect; and that in the living organisms "175 parts of starch are in the material actions approxi- mately equivalent to 100 of fat." Germain Se"e begins by supporting the view taken by Bauer, and asserts that tlie principal function of the carbohydrates is the immediate development of heat and mechanical work ; that they are not an- nexed in any way directly or indirectly to the organ- isms ; and that the fat that is de-posited in consequence of their use is derived from the splitting-up of albu- minates. He urges the experiments of Boussingault, who found that when he fed ducks on a pure carbo- hydrate like rice, they grew thin ; but on adding a small quantity of butter, they grew fat. The same experimenter also asserted that milch-cows only gave out the quantity of fat in their milk that was con- tained in their food.* See also points out that the particular kinds of grain selected for fattening animals are always such as contain, like maize, a considerable quantity of fat. But, notwithstanding all this, he appears in the end to yield to the weight of evidence that fat may be, under certain circumstances, formed from carbohydrates. Dujardin-Beaumetzf believes in the possibility of the transformation of glucose, the product of the digestion of carbo-hydrates, into fat. He sees a great analogy between the formula for glucose, C 6 H 12 O 6 , and that of glycerine, C.^HgO,,, and thinks that the latter * The accuracy of BoussingauL's conclusions was called in question by l.ieb'g. f '' L'Uygiene Alimenlahc." Chap, ii.] FUNCTIONS OF THE CARBOHYDRATES. 23 may result from the splitting up of the former with the addition of hydrogen. He also shares, to a certain extent, Pavy's views, and considers that a portion of the glucose derived from the digestion of carbo- hydrates is deposited as " hepatic glycogen " in the liver, and thus furnishes the glucose necessaiy to the organism when the food does not contain any carbo- hydrates. Pavy maintains, as is well known, that saccharine matter, when absorbed, " on reaching the liver is transformed by that organ into amyloid sub- stance [glycogen], which is stored up in its cells for subsequent further change preliminary to being ap- propriated to the purposes of life." The occurrence of this " amyloid substance " in the liver, even when a purely animal diet has been taken, he accounts for by the supposition that the liver is the organ in which the splitting-up of the albuminates into urea and a non-nitrogenous substance occurs, and that the latter is metamorphosed by the liver into " glycogen." Pavy believes that carbohydrates are first converted into this " amyloid substance," and that this is afterwards converted into fat. But he points out what is doubt- less a most important condition in the conversion of carbohydrates into fat, namely, " the co-operation of nitrogenous in conjunction with saline matter," for it is probably by the changes occurring during the meta- bolism of the albuminates that this transformation is excited. The presence of a small amount of fat with the carbohydrates would seem also to favour this conversion, for the rapid deposition of fat which some- times occurs when animals are fed on such a mixture appears to be more than can be accounted for by the small quantities of fat ingested. Pavy does not admit that any of the carbohydrates undergo direct oxida- tion in the system, or contribute directly to force production. In connection with this interesting and important discussion, the following observations by Tscherwinsky are referred to in Lanclois' "Text-book of Human Physiology." He " fed two similar pigs from the 24 FOOD IN HEALTH. [.Parti. same litter. No. 1 weighed 7,300 grammes ; No. 2 7,290 grammes. No. 1 was killed, and its fat and proteids estimated. No. 2 was fed for four months on grain, and then killed. The grain and excreta and the undigested fat and proteids were analysed, so that the amount of fat and proteids absorbed in four months was estimated. The pig then weighed 24 kilos. ; it was killed, and its fat and proteids were estimated : No. II. contained 2-50 kilos, of albumen and 9'25 kilos, of fat No. I. 0-94 0-69 Assimilated 1'oG 8'oG Taken in in Food 7'49 0'66 Difference 5'93 +7'90 There were therefore 7*90 kilos, of fat in the body which could not be accounted for in the fat of the food. The 5*93 kilos, of albumen of the food which were not assimilated as albumen could yield only a small part of the 7*90 kilos, of fat, so that at least 5 kilos, of fat must have been formed from carbo- hydrates. Lawes and Qilfeert calculated that 40 per- cent, of the fat in- 'pigs was derived from carbo- hydrates. How the carbohydrates are changed into fat in the body is entirely unknown." As has already been stated, the weight of evidence appears to be distinctly in favour of the conclusion that, in some way or other, the carbohydrates are capable of being converted into fat in the system ; but, in any case, the same result occurs, and they promote, either directly or indirectly, the deposition of fat within the body. The probability that lactic and other acids of the same class are formed in the body, chiefly or solely from carbohydrates, is drawn attention to by Parkes.* "The formation of these acids is certainly most impor- tant in nutrition, for the various reactions of the fluids, which offer so striking a contrast (the alkalinity of the blood, the acidity of most mucous secretions, of the * "Hygiene,'' 8th edition, p. 244. Chap, n.j FUNCTIONS OP MINERAL SUBSTANCES. 25 sweat, urine, etc.), must be chiefly owing to the aciion of lactic acid on the phosphates or the chlorides, and to the ease with which it is oxidised and removed." We may conclude, then, that the carbohydrates by their capacity for rapid metabolism contribute largely to the production of heat and mechanical work, and also that their use greatly favours an in- crease in the constituents of the body, and especially of the albumen and fat. If we desire to increase the albumen without adding greatly to the store of fat, we should (according to Bauer) give a liberal allowance of albuminates with relatively small quantities of carbohydrates. But if we desire a substantial addi- tion to the fat, the food should contain less albumen and more carbohydrates, with a fair proportion of fats. Our fourth class of foods comprised mineral sub- stances and water. These are of great importance, and are as essential to nutrition as the albuminates. There is no tissue that does not contain lime, chiefly in the form of phosphate, and it would seem that cell growth cannot go on without it ; indeed, calcium phosphate is the most abundant salt in the body, forming more than one-half our bones. Calcium carbonate occurs associated with this phosphate, but in relatively much smaller quantity. Sodium chloride is also a very important salt, and occurs in all the tissues and fluids of the body. It plays a very important role in promoting the diffusion of fluids through membranes, and its presence is necessary for maintaining the globulins in solution. It is absolutely necessary to existence, and its entire withdrawal from food would be speedily fatal.* Rather more than 200 grains are excreted daily, chiefly in the urine. It is a matter of common experience in the feeding of cattle that the addition of common salt to their food greatly improves their * "Deprival of common salt causes albuminuria." Landois' "Physiology." 26 FOOD IN HEALTH, [Parti. condition. The phosphates of sodium and potassium are also important salts. The alkaline reaction of the blood-plasma and some of the other fluids is due partly to these alkaline phosphates. The acid sodium phosphate is the chief cause of the acid reaction of the urine. Sodium carbonate* and bicarbonate are also found in the blood-plasma ; they are ingested in small quantities in the food, and they are partly formed in the body from the decomposition of the salts of the vegetable acids. They play an important part in the blood in carrying the carbonic acid from the tissues to the lungs. Sodium and potassium sul- phates occur only in small quantity in the body, and are partly derived from the oxidation of organic substances containing sulphur. Potassium chloride is widely distributed, and is found especially in the coloured blood corpuscles and in muscular tissue. Magnesium phosphate occurs together with calcium phosphate, but in much smaller amount ; it is probably essential to the growth of some tissues. Iron is an essential constituent of haemoglobin, and therefore of the red blood corpuscles ; it is found, also, in striped muscle and in other tissues in ntinute quantity. The two alkalies, potash and soda, have a different distribution in the body, and cannot replace one another. The potassium salts exist especially in the formed tissues, as the blood corpuscles and muscular fibre ; and the sodium salts are found more abundantly in the interstitial fluids ; so in the blood, sodium .and the chlorides are found especially in the plasma, and potassium and phosphates in the corpuscles. The chlorine of the chlorides would appear to be easily set free in the body, so that it can combine with hydrogen and form a powerful acid, having a special solvent action on albuminates. The sulphur and phosphorus of the tissues appear to be introduced, as such, in the albuminates. * " The alkaline salts serve to neutralise the sulphuric acid formed by the oxidation of the sulphur of the proteids. Landoia' "Physiology." Chap, ii.] FUNCTIONS of MINERAL SUBSTANCES. 27 All these mineral substances are introduced into the body as constituent parts of the various ordinary articles of human food, animal and vegetable, with the exception of sodium chloride, which is usually added to various articles of food, in greater or less amount, in addition to what they may themselves contain. Certain salts, such as the lactates, tartrates. cit- rates, and acetates, become converted into carbonates within the body, and confer upon the system that alkalinity which appears to be necessary to the integ- rity of the molecular currents. "The state of mal- nutrition, which in its highest degree we call scurvy, appears to follow inevitably on their absence ; and as they exist chiefly in fresh vegetables, it is a well- known rule of dietetics to supply these with great care, though their nutritive power otherwise is small."* Rabuteau observed that the addition of 150 grains of sodium chloride to the daily rations increased notably the amount of urea excreted ; it would seem, therefore, to promote the metabolism of albuminates ; it acts probably simply by stimulating the digestive functions, and possibly increasing the acidity of the gastric juice. It is itself almost wholly eliminated in the urine. The utility of adding phosphates to food with the view of increasing its nutritive qualities has been warmly discussed, and it has been pointed out, as a proof of their inutility, that the soluble phosphates, so given, are eliminated in their totality in the urine, and the insoluble ones in the faeces. But, as has been argued by Dnjardin-Beaumetz, the same happens with regard to chloride of sodium, and it does not follow because of this that it has no influence on nutrition. The favourable action of the phosphates, soluble or insoluble, which is certainly at times observed, is probably due, as he suggests, either to a regulating action on the functions of the alimentary tube, or to the acid elements they convey into the stomach, or to * Parkes' "Hygiene," 8th edition, by Notter, p. 245. 28 FOOD IN HEALTH. [Parti. some other indirect action* " As a rule, we take in with our food a far larger quantity of salts than ia necessary for the replacement of those of the tissues. The excess is excreted with the urine, and only when an increase of the body-weight occurs is any large amount of salts retained in the body." (Bauer.) Water enters into the composition, in greater or less proportion, of most solid and all fluid foods, and it is the essential basis of all beverages. It forms 58-5 per cent, of the human body, from which it is continually passing off by the urine and fpeces, and by the skin and lungs. Water is essentially requisite in the processes of digestion and absorption as a solvent for food substances, and it is also required for the solution of the various substances which have to be removed from the body in the excretions, especially in the urine. Indeed, there is no vital action possible without water. The amount of water needed by the body depends on various circumstances, especially on bodily temperature and bodily labour. The greater the functional activity of the bodily organs the greater the need for water. The temperature and humidity of the surrounding air also exercise an influence, as well as the nature and amount of solid food. The need of the organism for water is usually indicated, when in health, by the sensation of thirst. An insuf- ficient supply of water leads to disturbances in the circulation, and in the distribution of heat, and to the retention in the body of the waste products of meta- bolism. The free ingestion of water promotes an active circulation of the fluids, accelerates albuminous metabolism, and increases the activity of the kidneys tmd the amount of urine secreted. It has been asserted and denied by different observers that an increased consumption of water leads to an increased elimination of urea, and acts, therefore, as an ac- celerator of nutritive changes. The weight of evi- dence and authority are in favour of the affirmative view, but the influence is only temporary. Chap, ii.] STJMULANTS AND CONDIMENTS. 29 The various substances known as stimulants and condiments, although not included in either of the preceding classes, and although they may have no direct nutritive function, undoubtedly exercise an important indirect influence on the processes of nutrition. They stimulate appetite, and give relish to food, and by acting on the peripheral nerves, especially those of taste and smell, they promote the digestive secretions and rouse the digestive functions. It has now been seen that each of these four classes of alimentary substances has a special value in nutrition, and although the members of one group may be competent to serve, to a certain extent, the purposes of those of another, yet in order to accom- plish the best results a combination of all of them is required. An adequate diet must contain a mixture of several articles of food, in which all those classes are represented in due proportion. Some differences of opinion exist as to the relative value of foods of the same class. Albuminates, as has been seen, can be obtained from either the animal or vegetable kingdom ; they have a similar chemical com- position, and they serve the same purposes in the body. It has, however, been suggested that they are probably utilised in a somewhat different manner, or with dif- ferent degrees of rafpidity, and that the man who feeds on meat, like carnivorous animals, " will be more active, and more able to exert a sudden violent effort, than the vegetarian or the herbivorous animal, whose food has an equal potential energy, but which is sup- posed to be less easily evolved." In support of this view it has been urged that the movements of carniv- orous animals, especially in the pursuit of their prey, are far more active than those of herbivorous cattle ; that the form in which they take their food enables them to give out sudden spurts of energy of which the vegetable feeder is incapable. But this view has been questioned by others, who refer to the known activity and speed of the horse, the rapid movements 30 FOOD IN HEALTH. [Parti. of the wild antelope and cow, and even of the wild pig, all animals mostly herbivorous, as inconsistent with the conclusion that vegetable feeders cannot give forth energy as rapidly and continuously, or even more so, than the predaceous carnivora. It is further stated that with the human race also, the East Indian native, if well fed on corn, or even on rice and peas, shows, when in training, no inferiority in capacity for active physical exertion to the animal feeder. It has also been argued that the complicated alimentary canal of the herbivora pointed to a slower digestion and absorption of food ; and with certain kinds of vegetable food this would certainly seem to be the case ; but it has again been contended that this is chiefly intended for the digestion of cellulose, and that the digestion and absorption of albuminates may be as rapid as in other animals. It must, we think, be admitted that all practical observations tend to prove that animal food is digested more rapidly than vegetable food, and it therefore seems highly probable that meat can replace the waste of the nitrogenous tissues more rapidly than meal of any kind, and it is probably true that there is a more active change of tissue in meat eaters than in veget- able feeders, and that the former require more fre- quent supplies of food. Apparent differences in nutritive value in different meals, as in wheatmeal and barleymeal, probably depend on difference of digestibility. The difference in the nutritive value of different fats would seem to depend on the relative facility with which they are digested and absorbed. Animal fats appear to be more easily absorbed than vegetable. And even different animal fats differ much in digest- ibility, and, therefore, in nutritive value. This de- pends partly on chemical composition, and partly on mechanical aggregation or subdivision. Mutton-fat is generally found difficult of digestion, while pork-fat is easily digested. Butter can be readily digested by many per&ons who cannot digest other forms of fat ; chap, ii.j CARBOHYDRATES IK NUTRITION. 31 and the ready digestibility of cod-liver oil is one of its chief advantages. The different carbohydrates are generally supposed to be of equal value in nutrition. Sugar, from its ready solubility, should be more easily absorbed and more quickly utilised than starch, but it is found that when both are procurable a mixture of the two is usually preferred. It will be convenient now to pass in brief review the ORDINARY ARTICLES OF FOOD AND DRINK; the vaiious Alimentary Substances, or "Food-stuffs," as they are also termed. Man, being an omnivorous animal, obtains his food supplies from a variety of sources. The various substances commonly employed in alimentation will therefore now be described, their composition, proper- ties, digestibility, and nutritive value. Those derived from the animal kingdom will be first treated of ; then those derived from the vegetable, kingdom. Those substances used as condiments will also be considered, as well as the various beverages in common use. CHAPTER TIL ANIMAL FOODS. ANIMAL foods, by which is usually meant the flesh cf animals, have certain decided advantages. In the first place, they contain the same chemical elements as the bodies they are destined to feed. They are very rich in albuminous or nitrogenous substances, combined with a certain amount of fat ; they are more easily and completely digested and assimilated than vegetable foods ; they are easily cooked, and develop agreeable flavours in the process ; and they contain important salts (chiefly salts of potassium) and some iron. Animal foods are therefore exceedingly well adapted to minister to the growth and maintenance of the organic structure of the body ; their disad- vantage is the absence of starch, so that they are not so well adapted as non-nitrogenous substances for the production of force. When, however, there is a mixture of a considerable proportion of fat with the muscle tissue, this disadvantage is greatly lessened. In the flesh of all animals we tind, besides mus- cular fibre, blood-vessels, nerves, fibrous connective tissues, and a variable proportion of fat. Analysis of pure muscle shows it to consist, on an average, of 76 per cent of water and 24 per cent of solids. The allmminates amount to about 20 per cent in fresh muscle free from fat ; by far the greater portion of this is in an insoluble form. The soluble albu- minates consist chiefly of myosin, which, after death, undergoes spontaneous coagulation, and cooking causes a further coagulation ; the other soluble albuiniuatcs are in small proportion, the chief in quantity being chap, in.] COMPOSITION OF ANIMAL FLESH. 33 one identical with serum albumen. The colouring matter of muscle belongs to the soluble albumen. Of the insoluble albuminates of muscle but little is known. The analysis of rump of beef made at Netley gave the following results : Water Proteids Fat Ash Flesh alone. Whole ration, exclusive of Bone. 74-0 22-0 2-2 1-6 60-5 21-5 9-1 13 Total 99-8 92-4 The loss of 8 per cent, of total weight in the last column is " due to tough gristle and fibrous tissues not amenable to the ordinary methods of analysis."* The fatter the meat the less water it con- tains, and the smaller is the proportion of albu- minates. It is well known that soon after an animal's death the muscles pass into a state of "rigidity," known as rigor mortis. This is due to the spontaneous coagula- tion of the myosin of the muscular fibre. It sets in within a variable period after death, ten minutes to seven hours, and may last an equally variable period, from one to six days. Its duration varies greatly in different animals. It is not usual to eat the flesh of animals until this has passed off, unless, which is rarely convenient, it can be cooked before its onset. The meat is more tender and has a better flavour after it has disappeared. Hence the practice of "hanging" meat before cooking. * Parkos's " Hygiene," 8th edition, by Notter, p. 262. D 34 FOOD IN HEALTH. (Part i Animal flesh differs considerably in quantitative composition, in flavour, in digestibility, and in nutri tive qualities, according to a variety of circumstances, such as age, sex, state of nutrition, part of the body, etc. etc. Meat containing much fat is gener- ally less digestible and less palatable than leaner varieties. The flesh of young animals is less digestible than that of more mature ones ; veal and lamb are less digestible than beef and mutton ; and in advanced age the flesh becomes tough and uneatable. There is less flavour, less stimulating properties, less nutritive value in the tissues of young animals than in mature ones, and they contain more gelatin. A four- or five- year-old ox yields the best beef, and a three-year-old sheep the best mutton. The flesh of the female has a finer grain and is more delicate than that of the male ; while that of the entire male, during the breeding season, has a coarse and unpleasant flavour. Removal of the testes in the male and the ovaries in the female greatly improves their edible qualities. It is usual in slaughtering animals for food to allow the blood, before or after death, to drain away as completely as possible ; although this practice un- doubtedly involves a loss of nutritive material, and is therefore wasteful, yet it is to some extent justified by the consideration that it improves the appearance of the meat, gives it. delicacy of flavour, and enables it to be kept longer. In civilised life all the animals used for food are vegetable feeders, and the character of the meat is often affected in a recognisable manner by the nature of the food. Pastures containing fragrant herbs, certain roots as turnip and mangold, and oil-cake, will each impart a peculiar character to the flesh. Beef. This is, perhaps, the most extensively consumed and most nutritious of all animal foods. The composition of the flesh, especially with regard to fat. will Viirv much according to the condition of Chap. III.] BEEF ; VEAL. 35 the animal when killed. The following figures refer to three different examples of butcher's beef : Water. Nitrogenous Substances. Fat. From very fat Ox moderately fat Ox ., lean Ox ... 54-76 72-25 76-61 16-93 21-39 20-61 27-23 5-19 1-50 The flesh varies also in quality, according to the part of the animal from which it is taken. The best, or first quality, includes rump, sirloin, fore-ribs ; the second, a portion of shoulder, buttock, middle-rib, etc. ; the third, flank, shoulder, brisket ; and the fourth, cheek, neck, and shin. The difference in composition between different parts of a very fat ox is shown in the following table : Water. Nitrogenous Matters. Fat Neck 73-5 19-5 5-8 Loin 63-4 18-8 167 Shoulder 50-5 14-5 34-0 Hind Quarter, lean part 55-01 20-81 23-32 streaky ,, 47 99 15-93 35-33 Fore Quarter, lean ,, 65-05 19-94 19-97 stroaky,, 32-49 10-87 56-11 Beef fat consists of glycerides of the fatty acids in the proportion of 3 of stearic and palmitic to 1 of oleic. Its melting-point ranges between 41 and 50 C. V^al. Veal has, in Great Britain, always had the reputation of being less digestible and less nutritious than beef or mutton. It certainly contains a larger proportion of gelatin than beef. But it is more highly valued in other countries ; and Bauer maintains that its fibres are tender, and that it is better borne by D 2 FOOD IN HEALTH. [Part I. enfeebled digestive organs than beef. This difference of opinion no doubt depends on the different manner in which veal is killed and prepared in Britain and on the Continent. In England it is a much paler, ex- sanguine, and drier meat than on the Continent. It is probably killed younger, and bled too much before killing. The following table presents the composition of different joints of veal : Water. Nitrogenous Matters. Fat. Lean Veal 78-82 19-76 0-82 Fat . 72-31 18-88 7-41 Loin 76 -2o 15-12 7-12 Ribs ... 72-66 20-57 5-12 Shoulder 76-57 18-10 3-62 Leg 70-30 18-87 9-25 Mutton. Mutton is generally considered to be more easy of digestion than beef. Its fibre is shorter and more tender. It often, however, contains a large proportion of fat, which is harder than beef fat, as it contains more of the glyceride of stearic acid. Such fat mutton is unsuited to invalids. Mutton, however, differs very greatly in quality and flavour ; when of best quality, it is no doubt a most excellent form of animal food. The following table (Konig) gives the composition of mutton : Water. Allmmin- ates. Fat. Moderately fat 75-99 18-11 7-77 Very fat Hind Quarter... 47-91 41-97 14-80 14-39 36-39 43-47 Breast ... 41-39 15-45 42-07 Shoulder 60-38 14-57 23-62 Chap, in.] LAMB; VENJSON ; PORK; BACON. 37 Lamb, like veal, is less digestible than mutton, and is very much richer in fat. Venison. Of other ruminants, only the flesh of the deer is consumed in Britain. On the Con- tinent, the flesh of the goat is also eaten ; it resembles mutton, but has much less flavour, and is much more diflicult of digestion. Venison from young deer is tender, short-fibred, dark-coloured and highly savoury, and is very digestible. It is, however, rather too stimulating and highly flavoured for delicate sto- machs. The following is the composition of venison (Von Bibra) : Water, 74-63 ; albuminates (very little gelatin), 19 '24 ; and fat, 1-3 per cent. Pork. Pork, on account of the large quantity of fat it contains, is the most diflicult of meats to digest. Like all fat meats, it contains proportionately less water. Its fat differs from that of venison, in consisting almost entirely of palmitic and oleic glycerides. The mean composition of fat pork, according to Kb'nig, is: Water, 4740; albuminates, 14'54 ; fat, 37-34. And of lean pork : Water, 72-57 ; albuminates, 19-91 ; fat, 6-81. Bacon is more digestible than the fat of fresh pork. It contains but a small proportion of water, and therefore, weight for weight, is an advantageous kind of food. Its popular use, like that also of boiled pork, with lean meats such as veal, chicken, and rabbit, and also with other articles rich in nitro- genous matter, as eggs, beans, and peas, is founded upon a rational principle, serving, as it does, to estab- lish a proper proportion in the supply of nitrogenous and carbonaceous material. Besides the muscular tissue and fat of animals, some of the viscera, the blood, and even the bones may be utilised for food. By breaking the bones into small pieces, and boiling for many hours, a nutritious extract is obtained, consisting chiefly of gelatin ; 3 Ib. of bone yielding 38 FOOD IN HEALTH. [Parti. about as much carbon as 1 Ib. of meat, and as much nitrogen as 7 Ib. of meat. Bones can therefore be used advantageously in the composition of soup, especially in large public institutions. The brain of animals is of soft consistence, and is no doubt nutritious, but it contains a large per- centage of fat, which renders it difficult of digestion by weak stomachs : the tongue also is tender, but is intimately permeated by fat. The blood of the pig is made into a kind of food known as "black pudding," which contains also fat, groats, and some flavouring condiments. Bullock's blood has also, at times, been pre- scribed for invalids, on the erroneous belief that it is especially nutritious and easy of assimilation. Not only is it repulsive to the palate, but it is probably difficult of digestion. The liver of the pig, the calf, and the lamb is largely consumed as human food. Its richness and closeness of texture render it difficult of digestion. The composition of calf's liver has been given as water, 72-33; albuminates, 2(HO; fat, 5'58; carbo- hydrates (amyloid matter), 045; salines, 1*54. Kidneys are of close, firm texture, and when much cooked become very hard and difficult of digestion. Sheep's kidneys contain about 17 per cent, of albu- minates and 2 per cent, of fat. The muscle of the heart has the same composition as other muscular structures, but it is of close, hard texture, and therefore not easy of digestion. Sweetbread is a reputed delicacy, and is gener- ally considered easy of digestion. There are two kinds commonly eaten one is composed of the pancreas, and the other of the thymus gland of the calf. Simply cooked it is useful food for convalescents. Tripe consists of the paunch or first part of the ruminant stomach of the ox. Its involuntary mus- cular fibre is easy of digestion, but it contains a large proportion of fat which renders it rich and unsuitable chap, in.] POULTRY AND GAME. 39 for delicate stomachs. The following is its approxi- mate composition: Water, 68'0 ; albuminates, 13*2; fat, 16-4; salines, 2-4. Poultry and game. The various kinds of poultry, game, and wildfowl are favourite forms of food, and some of them are especially serviceable to invalids and persons of feeble digestion. Their flesh differs from that of ruminating mammals in not having its muscular fibres permeated by fat, and it is also short-fibred, and therefore more easily disintegrated. Those with white flesh, as the fowl, guineafowl, and turkey amongst poultry, and the pheasant and part- ridge amongst game, are especially tender, delicate in flavour, and easy of digestion ; but the flesh of ducks and geese is clark-c6loured, harder, richer, with a stronger flavour, and is much more difficult of digestion. Of all these, the young well-fed domestic fowl or chicken is perhaps the most valuable to the invalid. The young partridge and hen pheasant also yield very delicate food. The pigeon has less flavour, and the large amount of fat in the duck and goose renders them unsuited for invalids. Deprivation of the sexual organs at an early age is well known to add to the size, flavour, tenderness, and edible qualities generally of certain poultry, as is well seen in the capon and poulard. The flesh of game contains less fat than that of poultry, and has a finer flavour. It is tender and easy of digestion. Keeping develops the flavour of game, as is especially notable in grouse. The absence of fat and the finer flavour will of ten commend it to invalids in preference to poultry. Snipe, quail, and woodcock are delicate in flavour, but they are too rich for invalids. Game for invalids should only be kept long enough to secure tenderness, and the breast is the most suitable part for them to eat. Wildfowl generally have close and firm flesh, of strong and often fishy flavour, not suited to the digestion of invalids. The flesh of a young bare is short-fibred, very 4 o FOOD IN HEALTH. [Part I. tender, and of excellent flavour ; it is nearly as digest- ible as chicken, but more stimulating. The flesh of the rabbit when young is fairly digestible, but when older it becomes dry and hard in cooking, and cannot be said to be easy of digestion. The following table presents the composition of several kinds of fowl : Fat chicken ... Witer. Albumin- ates. Fat. 70-03 23-32 3-15 Fat goose Partridge iS-02 n-96 15-91 25-26 45'59 1-43 FISH. Fish afford a large and important part of human food. The different kinds vary greatly in nutritive value, in edible quality, and in digestibility. The relative proportions of fat they contain are especially subject to variation, and this determines greatly their flavour and their facility of digestion. The lighter kinds, as the sole and whiting, contain least fat, and are of more delicate flavour and easy of digestion. Many contain a large proportion of water, and their nitrogenous matter consists greatly of gelatin. The flesh of many fish has a peculiar odour and flavour. In the brine of herring Trimelhylamin occurs in abundance. The following table gives the composition of some of the more important kinds : Water. Albumin- ates. Fat Salmon 74-36 15-01 6-42 Eel 57-42 12-82 28-37 Herring (fresh) 80-71 10-11 7-11 Bole 86-14 11-94 0-25 Chap, in.] FOOD VALUE OF FISH. 41 Of the great nutritive value of fish no doubt can exist, and whole populations exist entirely upon it. It has been maintained that a fish diet predisposes to cutaneous affections, but this is doubtful. In Siberia dried fish ground into powder is made into a kind of bread. Fish is considered to be less satisfying and less stimulating than the flesh of birds and mammals ; it appears to be digested more rapidly, and therefore requires to be taken at shorter intervals or in larger quantity. For these reasons it forms an especially useful food for invalids whose digestive powers are unequal to cope with the stronger kinds of animal food. White-fleshed fishes, like the sole and whiting, con- tain very little fat ; turbot, brill, cod, plaice, flounder, etc., are of this class. In the salmon, the type of red- fleshed fish, there is, as the above table shows, a much larger pro- portion of fat, which is interspersed amongst the muscular fibres and accumulated under the skin. It is most abundant in the thinner abdominal part of the fish. The pilchard, sprat, herring, and mackerel, as well as the eel, contain much fat mixed with their flesh, and these fishes are, on that account, unsuited to per- sons with delicate digestions. The flounder, like the sole and whiting, is light and easy of digestion, and has a delicate flavour if cooked very fresh. Cod and haddock are not very easy of digestion ; the former varying greatly in quality, and sometimes being hard and tough. When cod is in season, there is a white curdy matter found between the flakes after boiling ; this consists of co- agulated albumen, and is absent when the fish is out of season. Turbot is a fine-flavoured fish, and its flesh is firmer and richer than that of the sole, etc. Brill resembles turbot, but is of inferior flavour. There are many circumstances which influence the 42 FOOD IN HEALTH, [Part i. edible qualities of fish. It is in the greatest perfection just before spawning ; during that process it loses fat and becomes poor and flabby and "out of season." The salmon on its return to the sea, after spawning, is thin and wasted, and is regarded as unfit for food. Immature fishes, not arrived at the spawning age, are always in season. The flavour of sea-fishes caught in deep rapidly- flowing water off rocky headlands, is better than that of fishes found in shallow bays. Fresh-water fishes are best when taken in deep lakes or ponds with clear water and a rocky or stony bottom ; the delicate flavour of the fish caught in Alpine lakes is- well-known. The common ray, and most of the order of cartila- ginous fishes unlike other fish which cannot be cooked too fresh improve by keeping, for their muscular fibre, Avhich is firm and resistant, then yields and becomes tender. Turbot is also considered to improve in flavour and tenderness by being kept for a short time. The roe, or reproductive organ of the fish, is con- sidered a delicacy ; the hard roe is the ovary of the female, the soft roe or milt is the spermatic organ of the male. Caviare is the salted hard roe of the sturgeon. The swimming-bladder of the cod is known as the sound. Fishes that have no scales are generally regarded as unwholesome and indigestible. Fish dried, salted, smoked, or pickled is much less digestible than when fresh. It has been the custom to speak of fish as an " in- tellectual " or " brain food " on account of the phos- phorus contained in it, but much of its reputation in this respect may be due to its being readily digested by persons of sedentary and studious habits. Louis Agassiz spoke of fish as a food " refreshing to the organism, especially after intellectual labour ; not that its use can turn an idiot into a wise or witty man, but a fish diet cannot be otherwise than favour- able to brain development." Chap, in.] CRUSTACEA AND MOLLUSCA. 43 The presumed aphrodisiac effect of a fish diet we are disposed to think not without a basis of experience. There is a remarkable passage in Montesquieu's " Es- prit des Lois " on this point. " The founders of the religious orders," he says, " who desired to subject their unhappy victims to the impracticable law of chastity, wholly missed their end in prescribing for them the habitual use of fish." Crustacea and molliisca (shell-fish). Many of the Crustacea are highly popular' as articles of diet the lobster, crab, craytish, shrimp, and prawn espe- cially. They are, as their composition shows, highly nutritious, but they have also the reputation of being very indigestible ; indeed, in many persons, some of them, the lobster and crab in particular, give rise even to toxic symptoms, such as nausea, vomiting, diarrhoea, giddiness, and frequently to cutaneous eruptions of an erythematous nature. The rheumatic and gouty are considered to be particularly prone to such attacks. The following is Payen'.s analysis of the different parts of a lobster : Soft Flesh. iutefnal awn. substance. ' Water ... 76-618 81-313 62983 Nitrogenous matter 19-170 12-140 21 892 Fittty matter ... 1-170 1-144 8 254 Saline (ash) 1-823 1-749 1-998 Non-nitrogenous (ash) and loss 1-219 0-3.54 4-893 The flesh of the lobster is more delicate and more digestible than that of the crab, and is usually much preferred to it. They both suffer decomposition rapidly, especially in hot weather, and should there- fore be eaten quite fresh. The spawn of the female lobster is much used in making sauces, both for its colour and flavour. It is 44 FOOD IN HEALTH. [Paul. highly nutritious, as is shown by the above analysis. The flesh of the claws is moi*e tender and delicate than that of the tail. The bright red part inside the animal is the ovary. The sea crawfish, or spiny lobster (La Langouste), is by some preferred to the lobster ; others consider its flesh inferior in flavour and tenderness. The flesh of the crab is tougher and more resist- ant to the action of the gastric juice ; the soft part within the shell (liver), on account of its richness and the fat it contains, is more likely to disagree than the flesh of the claws. The river or fresh-water crayfish (VEci-evisse) is the most popular of Crustacea in Paris, where enorm- ous numbers are consumed. Those taken from the Meuse are thought the best. Beixig small, its flesh is much more delicate than that of the lobster. It is credited with aphrodisiac properties, and enters into the composition of Bisque soup. They are usually eaten hot, as they are esteemed more digestible then than when cold. Shrimps and prawns, taken occasionally and in moderation, freshly cooked in sea-water, are stimu- lating and appetising, and capable of exciting appetite in the feeble and anaemic. The oyster is the chief of the edible MOLLUSCA. In England, the mussel, scallop, cockle, periwinkle, whelk, and limpet are also eaten. The oyster, when in season and eaten raw, is esteemed a very digestible form of food ; but when cooked, it is by no means easy of digestion. Analysing the whole contents of the oyster shell, Konig and Krauch found it to contain : Water, 8y-69 per cent.; albuminates, 4-95; fat, 0-37; and extractives, 2 "62. The oyster consists chiefly of a soft and a hard portion. The soft part is the liver; this is very digestible. The hard part is the muscle that binds the shells together, and is not nearly so digestible, and should not be given to invalids of weak digestion. Chap. III.] MOLLUSCA. 45 Of the oyster it has been said, "if its digestibility is great, its nutritive value is small, for ten dozen oysters would be required to yield the nitrogenous substances needed in a day's ration." Oysters vary greatly in delicacy of flavour ; some are large and coarse ; others, like the "native," small and delicate. The mussel is a nutritious bivalve, the consump- tion of which is chiefly confined to the poorer classes of seaport towns. They are usually cooked in their own liquor, and vinegar is added. This mollusc has an evil reputation for causing toxic symptoms, often of great severity. This is said to happen more frequently between May and September than at other seasons. Poisoning by mussels has been studied by Brieger, who succeeded in isolating a toxic principle, which he names Mytilotoxin (C 6 H 5 N0 2 ). He con- siders it to belong to the group of Ptomaines, and to be developed in the liver of these mollusca. It is not necessary to dwell on the other mollusca we have named ; but a few words must be said of the Escargot, or Helix pomatia (vineyard snail), which possesses so high a reputation in France and other parts of the Continent for its nutritive qualities. They are collected in considerable numbers in the vineyards of Burgundy, Champagne, Franche-Comte, and Lorraine. Those are preferable that are found on elevated parts, and where the soil is free from decomposing organic matters. At the end of the winter season they are con- sidered to be most delicate, having had a long period of partial fasting. As they feed often on poisonous plants, especially on the poisonous solanaceae, it is usual to allow a few days to elapse after their collec- tion before cooking them, in order that they may get rid of any poisonous substances they may have eaten. By cooking, the flesh becomes compact and firm, some- what insipid, and not easy of digestion. It contains, however, a large proportion of nitrogenous matters, and is no doubt highly nutritive, and may form a 46 FOOD IN HEALTH. [Parti. useful food for the poor. It has been called " the poor man's oyster." It enjoys a reputation in certain districts of being peculiarly beneficial to the con- sumptive. Selected varieties, seasoned with aromatic herbs and other condiments, form a costly article of luxury for Parisian gourmets. ITIilk and its derivatives cream, butter, cheese, etc. It will be necessary to consider at some length the properties of that very important animal food milk a food which is remarkable as containing all the alimentary substances required for the support and maintenance of animal life, and which is, on that account, termed a complete or typical food. The only other complete food afforded by the animal kingdom is eggs. Not only does milk form the exclusive food, for a time, of the young of all the mammalia, but it is also capable of being advantageously employed as the chief food for adults under various circumstances, which will be fully considered in the second part of this work. In milk we find the four classes of alimentary sub- stances necessary for health combined in proportkns well adapted for the period during which growth is active ; but when applied to the feeding of adults, the proportions of albuminates and fat are in excess as compared with the amount of sugar. The percentage composition of good cow's milk is thus given by Parkes : Specific Gravity, 1029 and over. Water 8G-8 Albuminates Fats . Carbohydrates Salts i 4-0 3-7 4-8 0-7 The albuminates consist of casein and a small quantity of serum, or true albumen, which remains in solution after the casein is thrown down. Cow's milk is said (Parkes) to contain as much as 5'25 grammes of albumen per litre. Casein, the chief nitrogenous" Chap in.] . COMPOSITION OF MILK. 47 constituent of milk, differs from albumen in not being coagulated by heat ; but it is readily coagulated by acids, and also by rentiet, an organic substance ex- tracted from the fourth stomach of the calf. The fat of milk, as is well known, can be separated in the form of butter. It consists of glycerides of stearic, palmitic, myristic, oleic, butyric, and some soluble fatty acids. It is suspended in the fluid or plasma of milk, in the form of milk globules, and these give to milk its white, opaque appearance. The carbohydrate of milk is in the form of lactose, lactiue, or milk sugar. It remains dissolved in the fluid or plasma after the casein and the fat globules have been- separated. It is not so sweet, and is less soluble in water, than ordinaiy sugar. It is nearly insoluble in alcohol and ether ; and it reacts like grape- sugar on the cupro-potassic solution. It is not directly prone to alcoholic fermentation, but under the in- fluence of an organism (the bacillus acidi laclici) introduced from without, it is converted into lactic ttcid, and it is this which causes milk to " turn sour " on keeping. CipHoA. = 4(C 3 H 6 3 ). Lactose. Lactic Acid. The salts, together with the water of milk, supply the necessary inorganic substances required for the nutrition of the animal organism. Potash salts are more abundant in milk than soda salts ; and calcium phosphate is a considerable and important constituent, as it is needed for the bone formation of young animals. These salts are chiefly in the form of chlorides, phosphates, and sulphates. The amount of salts in cow's milk varies, especially with the animal's food, from 0'5 to 0'8 per cent. ; the normal average is 0'7 to 0'75. In poor milk it may be as low as 0'3 per cent. The total amount of solids in cow's milk, of an average specific gravity of 1030, is 13'2 per cent, and J g CO CO 05 r- 50 * 10 S 00 *M O i 1 O i I O 3 O'OCOr-HCOr- iF-i i--50>COOOt^ - O CO IN t^ 00 OO I O eo r-i r-i CM 65 a> o So ^- en o o oo * co S O i~l O CJ 5 O *f t t I Oi rt O CN C* rt 1^1 CO CO K 5 O CO r-i 'C * -S 'i? O 'M 1 o O 00 O 00 * r-l O ejs e t-i t^- o i~- 1 B <;> r-l -M r-l CO CO t (3 O r-i O OO O O fri r-t r-HCO^CO^CCOO O 03 O 5 to co >b i -M >b co ic es oo o t-- co o * O ~r co t o * co a> S "f r-l O O -H 1-1 O OO r-l H H A oS2t &* t t CO ** <^l 5 'M O^3OlO O O O r- JO 3 ,S C-. o ro ^ .- - ? e s t -H o o a r-i o o & ** S3 O OO O r O | SS5SES2S5;S E 3 r-< O * r-l O CO C^ r-l r- 1 _^ CO O ^-1 O I~H o t^ 5 : : : : 2 : : : I I 1 ^ O :- : ^ r g | ' K' S | -1 i : : : :^J : : o t> "^ o'B.s^ g^"a:5rC PMCQiHSl-tP^QOQQO 9 FOOD IN HEALTH. [Parti. Edible fungi. Many species of fungi are suit- able for food, but in England three only are commonly eaten namely, the mushroom, the truffle, and the morelle. Their chemical composition indicates a richness in nutritive, and especially in nitrogenous substances, which should render them of considerable value as foods were they e;isy of digestion, but it seems doubt- ful if they are utilised in the alimentary canal. Some of them contain mannite and grape sugar amongst their non-nitrogenous constituents. Mushrooms are largely consumed in England, but chiefly on account of their agreeable flavour ; and they are eaten either alone or cooked with other kinds of food. They have the property of causing toxic symptoms, in certain persons, in the form of severe gastro-intestinal disturbance. The morelle is usually imported from the Continent, and is employed chiefly for flavouring other dishes. The truffle is esteemed a great delicacy, and is much employed in cooking, for its exquisite flavour. The black variety is the most highly valued, and those obtained from the oak-forests of Pcrigord in France are considered of the choicest flavour. They must be regarded as very indigestible vegetables. The following is the chemical composition of the mushroom, truffle, and morelle as given by Konig. The ash is particularly rich in potash and phosphoric acid : Mush- room. Truffle. Morelle. Water 91-11 72-8 90-0 Nitrogenous Substances Fat 2-57 0-13 8-91 0-62 3-48 0-2-t Grape Sugar and Mannite Other non-Nitrogenous Substances Woody Fibre Ash '. 1-05 3-71 0-67 0-76 7-54 7-92 2-21 0-72 3-95 0-67 0-94 Chap. IV.] FR UITS. Bauer mentions that Iceland moss is used as a food in the Arctic regions, and that after removal of its bitter constituents by repeated washings, a pleasant- tasting bread is made of it, which has been recom- mended by Senator as a substitute for ordinary bread in diabetes. Fruits. A great variety of fruits, both in the fresh and dried state, are consumed as articles of food or as flavouring agents and luxuries. The following are the principal varieties made use of in Great Britain, some being of native growth and others imported : 1. The apple, pear, and quince. 2. The orange, lemon, lime, and shaddock. 3. The plum, peach, apricot, cherry, olive, date (stone fruits). 4. The grape, gooseberry, currant, cranberry, bar- berry. 5. The strawberry, raspberry, blackberry, mul- berry. 6. Melon, pine- apple, fig, banana. The following table gives the average composi- tion of some of the most important of these (after Bauer) : Apple. Pear. Peach. Grape. Straw- berry. Cur- rants. Orange (pulp only). Water 83-58 83-03 80-03 78-18 87-66 84-77 89-01 Nitrogenous \ Matters ... J 0-39 0-36 0-65 0-59 1-07 0-51 0-73 Free Acids... 0-84 0-20 0-92 0-79 0-93 2-15 2-44 Sugar 7-73 8-26 4-48 14-36 6-28 6-38 4-59 Other non- \ Nitrogenous > 5-17 3-54 7.17 1-96 0-48 0-90 0-95 Matters ... ; Cellulose and | Kernel ... } 1-98 4-30 6-06 3-60 2-32 4-57 1-79 Ash 0-31 0-31 069 0-53 0-81 0-72 0-49 FOOD IN HEALTH. (Part I. The following gives the composition of certain dried fruits : Apple. Cherry. Raisin. Fig. Water 27-95 49-88 32-02 31-20 Nitrogenous Matters .. 1-28 2-07 2-42 4-01 Fat 0-82 30 0-49 1-44 Free Acid 3-60 1-21 Sugar ... 42-83 31-22 54-26 49-79 Other non-Nitrogenou a \ Matters ... .. j 17-0 14-29 7-48 4-51 Cellulose and Seeds . . . 4-95 0-61. 1-72 4-98 Ash 1-57 i-63 1-21 2-86 The analysis o? the ash shows these fruits generally to be particularly rich in potash salts. The apple and the strawberry are rich also in soda salts, especially the strawberry. They also contain salts of lime, magnesia, and iron. It will be seen from the above tables that these fruits possess but a low nutritive value, as they con- tain a very large proportion of water, and of their solids only a very small proportion consists of nitro- genous matters. Their chief food value is in the sugar which they contain. This, in some, is consider- able. They also contain important salts of vegetable acids (malates, citrates, tartratca) as well as some free acid. They therefore possess valuable anti-scorbutic pro- perties. As their salts are chiefly combinations of vegetable acids with alkalies, and as these become con- verted into carbonates in the system, they impart alkalinity to the urine, and they are, on that account, valuable in gouty states with a tendency to the depo- sition of acid urates. Many contain small quantities of fat, and waxy and colouring matters. Their agreeable aroma is due to the presence of essential oils and compound ethers. They all contain varying amounts of indigestible chap, iv.] FRLTITS. 93 cellulose and pectin or vegetable jelly. Malic acid is found in apples, pears, peaches, apricots, gooseberries, and currants ; tartaric acid in grapes ; and citric acid in lemons, oranges, etc. When taken in moderate quantity these fruits are useful additions to the dietary : they are cooling and refreshing, of agreeable flavour, and tend to promote intestinal action, and to correct tendencies to constipa- tion. Taken in excess, or when immature, or over- ripe, they are apt to set up gastro-intestinal irritation, often of a severe form. Most of these fruits are so well known that any detailed descriptions of them would be redundant. The apple when cooked, and of good quality, is easy of digestion, cooling, and slightly laxative. Pears of the best quality, when ripe, are better suited for being eaten raw than apples, as their flesh is soft and "melts in the mouth." Oranges are especially valuable for invalids; when ripe and well selected they are pleasant and refreshing, and very grateful for allaying thirst in feverish conditions. The lemon and its congeners the lime and shad- dock are important as yielding a useful anti-scorbutic juice, and for giving an agreeable pungency and flavour to insipid and tasteless foods. Plums should be avoided in the unripe and over- ripe states, and they are more apt than other fruits to prove indigestible and irritating, and to cause diar- rhoea. Dried plums (prunes) are often judiciously added to the daily dietary to remedy habitual consti- pation. Peaches and nectarines are particularly deli- cate-flavoured and refreshing. Owing to the small quantity of sugar they contain, and their soft and delicate flesh (when ripe) they are well suited to the gouty and diabetic. Currants, gooseberries, bilberries, and raspberries are remarkable for the amount of free acid they contain, which makes them very refreshing 94 FOOD IN HEALTH. [Parti. and their juices form an agreeable addition to effer- vescing water. The mulberry is also very refreshing, and has slightly laxative properties. The strawberry is one of the most popular of fruits, and is very wholesome when taken in modera- tion. It is considered to be a useful food for the gouty on account of its richness in alkaline salts (potash, soda, and lime) and its cooling, diuretic, and laxative qualities. There are some physicians who forbid this fruit to the gouty, but it is only in a few rare cases that it is found to disagree. French authors maintain that its flavour is enhanced by the addition of some acid juice, such as orange or lemon juice, or a few drops of good vinegar. The grape is a very important fruit, on account of its richness in sugar, both in the fresh and dried (raisins) form. It is very digestible when fully ripe and most acceptable to invalids. Its properties will be fully discussed in connection with the grape cure. The melon is perhaps the most watery of all the fruits, containing, as it does, more than 95 per cent, of water ; notwithstanding this it is apt to prove very indigestible, and to give rise to gastric disturb- ance. Figs both in the green and dry state contain much sugar, and also a rather large proportion of nitrogenous matters, so that they are more nutritious than most fruits ; in large quantities they are apt to prove aperient. The date is also a highly nutritious fruit, and forms an important food for the Arabs. The banana and plantain are also nutritious fruits, as they contain much sugar and a certain pro- portion of nitrogenous matters. SACCHARINE SUBSTANCES. Grape sugar is largely present in all sweet fruits, and all starchy foods in the processes of digestion become converted into grape sugar or into maltose Chap, iv.] SACCHARINE SUBSTANCES. 95 before assimilation. A form of sugar, lactose, is also present in considerable quantity in that typical food milk. But the importance of sugar as an aliment- ary principle has already been shown, and it is more in its character as a flavouring agent, and as a pleasing addition to food, that we must now regard it. Sugar is not only a food, it is also a very largely adopted luxury, on account of its agree- ably sweet taste. As a food, owing to its ready solu- bility, it needs no previous digestion ; indeed, grape sugar has been termed a " pre-digested " carbohydrate. It is, however, especially when mixed with other food, apt to give rise to acidity and flatulence in some dys peptic persons. It appears, in such cases, to promote acid fermentation in the alimentary canal. Sugar is very largely used in the preservation of fruit, etc.. on account of its antiseptic properties. Cane, or crystalline, sugar is the kind generally used for addition to other foods. It is obtained chiefly from the sugar-cane or from beetroot ; other plants, however, yield it, as certain species of maple, etc. Cane sugar, after extraction, usually undergoes an elaborate refining process, by means of which the im- purities are separated and nearly pure cane sugar is produced. Grape sugar or glucose crystallises less readily, and is inferior in sweetening power. It is usually prepared from starch. Molasses and treacle are more or less fluid residues left after separation of the crystallisable sub- stances in the preparation of cane sugar. Honey is a concentrated solution of sugar mixed with a certain amount of wax, gum, and odorous and colouring substances. It contains a crystallisable and a non-crystallisable sugar the former resembles glucose. Before the discovery of sugar, honey used to be largely employed as a sweetening agent, and it has the same food properties and value as sugar. 9 6 CHAPTER V. BEVERAGES. Wafer. All beverages contain water in certain proportions, and, as may be seen by reference to the various analyses of solid foods, water enters also largely into their composition. The human body is itself composed to a great extent of water, nearly 60 per cent. Everything that is carried into the circulating fluids of the body, or that is eliminated from them, is conveyed by the agency of water. As a solvent it is indispensable in all the functional activities of the body. The consumption daily of a certain amount of water is thus an absolute necessity. Much of this is, of course, taken into the body combined with the solids of the food, but a certain quantity is required in the fluid form, and this is supplied by our various beverages. One of the best ways of supplying water to the body is by drink- ing it in its pure state, when its important solvent properties can be completely utilised. The quantity of water needed daily must neces- sarily depend on the amount of the loss of this fluid which takes place by the lungs, skin, and kidneys, and this will be largely determined by the amount of work or exercise performed by the body, as well as by the temperature to which it is exposed. The quantity required daily must also vary much with the kind of food which enters into our diet ; the drier the solids we eat the more water we shall need, the more succu- lent they are the less we shall require. It has been estimated that on an average an adult will require daily from 2| to 4 pints of water, or some beverage consisting almost entirely of water. Chap, v.] BEVERAGES : WA TER. 97 The purer the water obtained for drinking purposes the better; most, however, of so-called drinking waters, as derived either directly from springs or from wells and rivers, contain dissolved gases and mineral sub- stances. These often improve the flavour of the water, and give it a pleasant freshness, but an excess of mineral ingredients detracts seriously from its solvent properties. Rain water is the purest form of natural water, and resembles distilled water, except that it contains whatever soluble constituents exist in the atmosphere through which it has fallen, so that traces of ammonia and nitric acid are generally to be found in it. If used for drinking purposes it needs to be collected with great care, as it is apt to dissolve any soluble substances with which it comes in contact. It must therefore not be received in leaden cisterns. Distilled water is now largely used at sea, as most passenger ships are provided with condensing appa- ratus. When aerated it is a pleasant beverage. Water used for drinking purposes should, of course, be freed from all organic impurity ; most spring waters, however, although quite pure in this sense, contain a variable quantity of mineral con- stituents, especially of salts of lime, and these, if abundant, may detract from the value of the water for drinking and domestic purposes. Such water may cause digestive disturbance, or promote con- stipation, or may intensify any tendency that exists to calculous disorders. Boiling the water has the effect of greatly diminishing the hardness due to the presence of earthy carbonates, and so rendering it more suitable as a beverage. This it does by driving off the carbonic acid, which is always present in spring water, and which keeps these carbonates in solution ; after boiling they are in part precipitated. Boiling has the further advantage of destroying most organic germs. Water which is not pure may be rendered purer by suitable filtration. H 98 FOOD IN HEALTH. [Parti. A full account of water filtration and filters will be found in the eighth edition of Parker's " Hygiene," edited by Professor Notter. Professor Notter points out that all filters require more or less frequent cleaning. He mentions that Maignen's " Filtre Rapid? " is much used in the Services.* Water, then, is an indispensable beverage ; as a solvent agent it is needed in all the important chemical changes connected with nutrition ; it is a valuable diuretic ; it is absorbed rapidly and eliminated rapidly. It has been justly said that the use of an abundance of water as a bevei'age promotes a sort of " washing " of the various tissues of the body ; that when taken at the end of stomach digestion it carries undigested substances out of the stomach into the small intestine. It has been contended by some that the mineral substances found in spring and river water may usefully supply some of the salts required for the construction and repair of the tissues, and that the existence of lime salts in such water is not altogether disadvantageous. This may possibly be the case with young growing subjects. Iced water, taken in small quantities, is refreshing and cooling, and stimulates the digestive functions, but it is injurious when taken in great amount. Of the useful refrigerating action of cold water as a beverage in acute diseases we shall speak hereafter. Tea, coffee, and cocoa. These aromatic and popular beverages, a 1 , though differing considerably from one another in their common physical characters, agree in containing alkaloids which are either identical or ' closely re'ated. Tea and coffee contain alkaloids, thein and cay'ein, which are identical, and cocoa contains an alkaloid, t/tcobromin, which is closely allied to these. There is a great resemblance in the general effects of tea and coffee, as might be concluded from the fact that they contain the same alkaloid, while the * The " Pasteur -Chamberland" filter is one of the most per- fect, and completely separates micro-organisms. The filtering medium is a solid cylinder of porcelain. Chap, v.i BEVERAGES: TEA. 99 difference in their effects is probably due to the different aromatic principles or essential oils they contain, and to the greater amount of tannin in tea. Cocoa, however, differs greatly in its properties and effects, as well as in its composition, from tea and coffee. We shall consider each of these beverages separately ; and first with regard to Tea. A great many varieties of tea are now im- ported into Britain from Indian and Ceylon, besides the older kinds grown in China. The average composition of dry tea is stated by Bailor to be as follows : Them 1-35 Other Nitrogenous Combinations ... 9 -44 Non-nitrogenous Extractives ... 19 '20 Ash 3'65 Total of Matters soluble in Water. . . 33 '64 per cent. In Parkes's " Manual " the composition of dry tea is thus given : " About 1-8 per cent, of thein, 2-6 of albumen, 9 "7 of dextrin, 22 of cellulose, 15-0 of tannin, 2OO of extractives, 5*4 of ash, as well as other matters, such as oil, wax, and resin." Its aroma is due to a volatile oil. The thein is combined with tannic acid. Some of the best teas yield a much larger proportion of thein than others. Green tea is somewhat richer than black in thein, ethereal oil, and tannic acid, and, indeed, in all the soluble constituents, by about 5 per cent. The as/i contains potash, soda, magnesia, phos- phoric acid, chlorine, carbonate acid, iron, and silica. The principal constituents, and those which give it its characteristic properties, are thein, an aromatic volatile oil, and tannic acid ; of the last it contains, as stated above, about 1 5 per cent. The difference between green and black tea is simply dependent on differences in the time of gather- ing the leaves, and their mode of treatment. The green is prepared from younger leaves, which are H 2 100 FOOD IN HEALTH. [Part I. roasted in pans soon after gathering. Of China teas, Young Hyson is considered the finest kind of green, and Souchong and Pekoe of black tea. Some teas are " scented " in China by mixing the leaves with odorous flowers, such as orange-blossom, jasmine, roses, etc. Both thein and tannin are soluble in boiling water, and when the tea is infused they are dissolved out together ; but some Indian teas if long infused con- tinue to give out tannin after all the thein has been exhausted. Indian and Ceylon teas yield much more tannin in their infusion than good China tea. This is well shown in the following table (Professor Dittmar\ which gives the results of infusing these three/varieties of tea for five and ten minutes respectively : China Five Minnies. Ten Minutes. Thein. Tannin. Thein. Tannin. 2-58 3-06 2-79 3-78 Ceylon Indian 3-15 3-63 5-87 6-77 3'29 3'73 7-30 8-09 It appears that Indian tea, when infused for ten minutes, yields more than twice as much tannin as China tea ; and with China tea there is but little difference between an infusion of five minutes and one of ten minutes. {This 1'esult is therefore strikingly corroborative of Sir William Roberts's statement, that owing to the great solubility of tannin in hot water it is impossible to avoid the extraction of a great amount of tannin, even by the shortest infusion. It is only in the case of a tea so rich in tannin as some of the Indian teas, that prolonged infusion makes any considerable difference in the amount of tannin extracted. Indian teas, on account of the great amount of Chap, v.] BEVERAGES : TEA. 101 tannin they contain, are much more prone to cause gastric and nervous disorders in sensitive persons than the best China teas. In making an inf u,sion of tea the water should be boiling ; for delicacy of flavour it should be neither too hard nor too soft, but for economical purposes the softer the water the better. Parkes suggests that as water containing much lime or iron will not make good tea, such water should be well boiled for fifteen to twenty minutes with a little carbonate of soda before it is used for making tea, and Sir William Roberts also advocates the addition of carbonate of soda to tea for other reasons, as will be immediately mentioned. Soft water extracts more of the soluble principles of the leaves, and makes a darker infusion, but some think that the infusion is, on that account, of less deli- cate flavour. The infusion should not be for more than three or four minutes. Longer infusion lessens the aroma and extracts too much of the soluble matters, thereby diminishing the delicacy of flavour of the beverage. As to the effects of tea as an article of diet much difference of opinion exists, and especially as to the relative value of tea and coffee. It should be recog- nised that there often exist great individual pecu- liarities with regard to the effects of these beverages, and hence the conflict of opinion on this point. Tea appears to act as a stimulant and restorative to the nervous system. It removes fatigue, rouses and clears the mind, and promotes intellectual energy. It diminishes the tendency to sleep, and this effect may be carried to the extent of producing sleeplessness. When taken, as it usually is, hot, the warmth of the infusion no doubt aids its stimulating influence. It increases the action of the skin, and has been said to cause constipation, but it certainly, at times, appears to have the opposite effect, and a cup of hot tea will often accelerate the action of aperients. It deadens the sensation of hunger, and increases the power of IO2 FOOD IN HEALTH. [Parti. fasting. It will cool the body when hot probably by promoting the action of the skin and it warms the body when cold. It will often relieve headache, and proves a useful antidote to alcoholic intoxication, and especially to that mental torpor which even small quantities of alcohol will produce in certain persons. Green tea possesses more active properties than black, and is more likely to be over-exciting to the nervous system. There can be no doubt that for most persons tea, taken in moderation, proves an agreeable, refreshing, and wholesome beverage. It has been found a most useful article of diet for soldiers, increasing remarkably the power of enduring great fatigue, especially in hot climates. When milk and sugar are added to tea it becomes a nutritious and useful food. On the other hand, it is quite certain that tea taken in excess, and in some constitutions, may be- come very injurious. It will not infrequently excite and maintain most troublesome gastric catarrh, the only remedy for which is an entire abstinence from tea for a considerable period. It is often also the cause of troublesome cardiac palpitations, together with muscular tremors, and general nervous agitation. We have noticed that tea will often commence some- what suddenly to disagree with a person, and excite dyspeptic symptoms, coincidently with the occurrence of nervous worry, and that after the cause of nervous anxiety has passed away tea may again be taken, in moderation, with impunity. In irritable states of the stomach tea is also apt to disagree, especially if the coarser teas containing much tannin are taken ; these, when taken in large quantity during or too soon after a meal, will disturb, and often seriously hinder, the digestive process. The ordinary strength of tea, according to Sir W. Roberts,* is 4 to 5 per cent., " that is, four or five parts of the dry leaf to a hundred parts of boiling water. Strong tea runs up to about 7 per cent., and * " Lectures on Dietetics and Dyspepsia." chap.v.] BEVERAGES: COFFEE. 103 weak tea goes down to 2 per cent." This excellent observer found that tea exerted an inhibitory or re- tarding effect on salivary and peptic digestion, and he concludes that this effect is due to the influence of the tannin it contains. He points out that this cannot be avoided by brief instead of protracted infusion : " Tea infused for two minutes was not found sensibly inferior in its retarding power on salivary digestion to tea in- fused for thirty minutes." The best way to minimise the inhibitory effect of tea on digestion is to make it very weak and use it very sparingly, and to drink it after and not with a meal. Adding a little carbonate of soda 10 grains to 1 ounce of the dry tea-leaf had the effect of entirely removing this retarding effect on digestion. Coffee. Coffee is an agreeable aromatic beverage prepared from the seeds, after they have been roasted, found within the fruit of the Coffea arabica. The choicest coffee is Mocha or Arabian coffee. It was introduced into Europe in the seventeenth century, about the same time that tea was also introduced. In roasting, the coffee berries are exposed to a temperature of 200 Cent, or more ; during the process they assume a dark brown colour, the sugar in the berry is converted into caramel, and volatile aromatic empyreumatic pro- ducts are developed which give to coffee its aroma. At the same time certain gases are formed which swell up the seeds, so that they increase in bulk while they lose in weight. Coffee should be roasted only a short time before being used, as owing to the volatile nature of the aroma it rapidly deteriorates by keeping ; for the same reason the roasted berries should not be ground till imme- diately before the infusion is made. The composition of unroasted coffee is stated by Parkes to be 34 per cent, of cellulose, 10 to 13 per cent, of fat, 15 - 5 per cent, of sugar, dextrin, and vegetable acid, and 10 per cent, of legumin, also a solid acid, small quantities of aromatic oil, and the 104 FOOD IN HEALTH. [Pani. alkaloid caffein. The chief ingredients of the ash are potash and phosphoric acid. According to Konig, 21 to 37 per cent, of solids are extracted from roasted coffee by infusion ; or on an average Caffein ,.. 1-74 Oil 6-18 Non-nitrogenous Extractives ... 14 --02 Ash 4-06 Total of Matters soluble in Water... 25'5 per cent. The chief constituents, then, of coffee are a volatile oil, developed by roasting, to which it owes its aroma ; caffeo-tannic and caffeic acids ; and caffein, an alkaloid identical with thein. It has been suggested that the ethereal oils de- veloped during the roasting of coffee are more con- cerned than the caffein it contains in imparting to it its characteristic properties. It is a curious fact that in Europe we make an infusion of coffee, in the East they make a decoc- tion ; the latter, Dujardin-Beaumetz says, preserves its nutritive and tonic properties, while it gets rid of its exciting ones. The value of coffee, as a beverage, is greatly de- pendent on the care and skill manifested in its preparation. Coffee should be made perfectly fresh, from freshly ground and freshly roasted seeds : as all the soluble substances are not extracted by infusing alone, it is desirable, on economical grounds, that a mixed infusion and decoction should be made in the following man- ner : After first preparing an infusion by passing boiling water over the coflee, the grounds left should be boiled in more water, and the boiling decoction thus obtained should be poured over another portion of freshly ground coffee ; this, in its turn, is also boiled with more water, to be used again with fresh coffee in the same manner, and so on. By this method all the chnp. v.] BEVERAGES :-*- COFFEE. 105 soluble matters in the coffee are extracted, and none of the aroma is needlessly dissipated. The effects of coffee on the system are those of a decided stimulant to the nervous centres. It has been termed in France une boisson intellectuelle, on account of its stimulating action on the brain. It lessens the need for sleep after exertion, and diminishes the sense of fatigue ; indeed, it would appear to have the power of augmenting the functional activity of the muscles. It has also a decidedly stimulating effect on the heart ; in small quantities it quickens its action, but in large quantities it slows it, and when taken in excessive amount it will often sen- sibly disturb the rhythm of this organ and cause in- termission. * It increases the secretion of the kidneys and of the skin, and in some persons it will stimulate the peristaltic movement of the intestine, and so act as an aperient. It will sometimes disturb the digestion in dyspeptic persons, and give rise to heartburn, anJ this is more likely to occur when very strong coffee is taken imme- diately after a full meal. Other toxic symptorus occasionally occur from taking coffee in excess, or in too strong infusion, such as muscular tremor, nervous anxiety and dread of impending danger, as well as palpitation, cardiac intermissions, and an indefinite, uncomfortable feeling referred to the cardiac region. Although coffee can exert no direct nutritive action on the system, and it lias been shown that its use tends to increase rather than diminish (as had been stated) the excretion of urea, yet its influence in sustaining the human body under fatigue and privation is very remarkable. Parkes bears strong testimony to its great value in the diet of the soldier : " Not only is it invigorating without producing subsequent collapse, but the hot infusion is almost equally serviceable against both cold and heat ; in the one case the warmth of the infusion, in the other the action 011 the * The author has seen several instances of this toxic effect of coffee when taken inadvertently in excess. 106 FOOD 'IN HEALTH. skin, being useful, while in both cases the nervous stimulation is very desirable." It has been said to afford some protection against malaria. When coffee is taken, as it usually is, together with milk and sugar, as cafe au lait, it then contains a considerable amount of nutritive substances, and forms a highly sustaining food. The valuable properties possessed by coffee are occasionally utilised in the treatment of disease ; as an antidote, for instance, in opium poisoning and alcoholic intoxication. It is also given as a cardiac tonic in heart disease, as a diuretic in dropsies and urinary disorders, and as a nervine in migrain and asthma. Sir W. Roberta's experiments showed that coffee exerted very little retarding influence on salivary digestion, as compared with tea, and this he accounted for by the fact that in coffee tannin "is replaced by a modification of that substance called caffeo-tannic acid." Coffee, however, was found to exercise a greater retarding influence on stomach digestion than tea, on account of its being taken in much stronger percentage infusion. " Strong coffee, the cafe noir of France, is seen to have a very powerful inhibitory effect ; " * hence it should not be taken after a meal by dyspeptic persons. Cocoa or cacao. Cocoa is widely removed by its composition and character from tea and coffee. It, however, contains, as has been stated, an alkaloid closely allied to caffein, viz. theobromin. Cocoa is ob- tained from the seeds of an exotic tree, the Tkeobroma cacao. The seeds are extracted from a pulpy fruit in which they are embedded. These, consisting of kernel and husk, are roasted, after the manner of coffee berries, to develop aroma. The kernels of the roasted seeds, when coarsely crushed, form "cocoa nibs." A decoction of the nibs is made by boiling gently in water for a couple of hours, and then pouring the dark brown decoction off the undissolved residue. * "Dietetics and Dyspepsia." Chap, v.] BEVERAGES: CHOCOLATE. 107 This is, however, very unlike the preparations of cocoa commonly used ; these consist usually of the kernels ground to a paste, and mixed with other saccharine or starchy substances ; one of the objects of such admixture being to lessen the relative proportion of fat in the cocoa. When starchy substances are used for this purpose, the cocoa requires boiling, but when sugar only is used, it can be prepared by the simple addition of boiling water or milk. Chocolate is manufactured cocoa the best kinds from carefully selected and skilfully prepared seeds. Sugar and flavouring substances are added in the manufacture. The composition of cocoa, besides theobroinin, of which it contains about 1'5 per cent., includes a small quantity of a volatile oil, to which it owes its aroma, and which is developed in roasting ; a large amount of fat, known as cacao butter, amounting to 45 or 50 per cent. ; about 15 to 18 per cent, of albuminous sub- stances ; and a small quantity of starch, about 15 per cent. The ash is rich in potassium phosphate. It will be seen from this analysis that cocoa is a highly nutritious food, containing a considerable amount of albuminatcs and hydro-carbons, and a certain proportion of carbohydrates and salts. It re- sembles milk somewhat, as approaching in composition to a complete food. Its defect is the large amount of fat it contains, which renders it prone to disagree with persons of delicate digestions. It is the avowed object of the best preparations of cocoa to diminish the relative amount of fat by the addition of other suitable substances, or to promote its digestibility by the admixture of some alkali. Cocoa and chocolate present a convenient and palatable form of a highly nourishing food, and in South America cocoa and maize cakes are carried by travellers because they provide an agreeable kind of food in small bulk. It will be seen that it is only the decoction of the nibs that can really be likened to tea or coffee as a io8 FOOD IN HEALTH. [Parti. beverage ; the other forms of cocoa containing a large proportion of nutritious solids. The following table, adapted from Konig, gives the average composition of cacao beans (kernels) and the best kind of chocolate : Cacao Beans. Chocolate. Water 3-25 1-53 Nitrogenous Substances Fat 14-76 49-00 5-06 15-25 Starch 13 31 Sugar 63-81 Other Non-nitrogenous Matters Woody Fibre ... Ash 12-25 3-68 3 65 11-03 1-15 2-15 Mate, or Paraguay tea, is prepared from the dried leaves of the Ilex paraguayensis, belonging to the holly tribe. It contains thein, and its infusion is largely consumed in South America as a dietetic beverage. Chicory is prepared from the root of the wild endive (Cichorium intybus) by roasting like coffee, and then reducing to powder. It contains an aromatic volatile oil, which is considered by some to give off an aroma like that of coffee, and its infusion is said to be drunk pure in some parts of the Continent. In Great Britain it has been used either as an addition to, or an adulteration of, coflee. Added to coffee in small quantity it is thought by some to increase its flavour, as it certainly does its colour. Coca. The leaves of the Erythroxylon coca are another stimulant possessing somewhat similar proper- ties to the preceding. Its active principle is cocaine. The leaves may be chewed, or an extract or a tincture made from them. It has a distinctly sustaining effect during muscular exertion, and in weak condi- tions acts as a tonic to the heart. Chap, v.] ALCOHOLIC BEVERAGES. 109 We prefer the simple spirituous tincture to the various coca wines of commerce. Kola. The kola nut has been recommended as a nervine stimulant, and as possessing similar properties to coca. It has been said to contain thein. ALCOHOLIC BEVERAGES. The term " alcoholic beverages " comprises a great variety of familiar drinks, into the composition of which alcohol enters in widely varying proportions : the so-called "ardent spirits" and spirituous liquors may contain as much as 50 per cent., or even more, of alcohol, while the lighter wines scarcely contain 10 per cent., and the weaker kinds of beer not even 5 per cent. Before considering the dietetic properties of these various alcoholic beverages, it will be convenient to describe briefly what is known practically of the effects of alcohol on the human body. A great con- flict of opinion is always maintained in connection with the subject, and this is, indeed, likely to be the case so long as prejudice and dogmatic enthusiasm are allowed to take so large a part in the discussion of a scientific question. It is now generally admitted that only a portion of the alcohol taken into the body is eliminated as such ; a portion, no doubt, especially when taken in large quantity, escapes in the urine and breath ; but a portion, some maintain a considerable portion, dis- appears in the body. What becomes of this ? It is burnt or transformed within the body in the same manner as any other food of similar chemical com- position : this is the answer given by many experi- menters, and it is the one supported by Dujardin- Beaumetz* as the result of his own experiments. "In the blood," he says, "you bring together two bodies, one alcohol, eager for oxygen, the other haemo- globin, ready to give up that oxygen under the feeblest influence ; alcohol, under the influence of haemoglobin, * " L'Hygi&ne Alimentaire. Des Boissons." no FOOD IN HEALTH. is transformed into acetic acid. A portion of the alcohol ingested undergoes combustion at the expense of the oxygen of the haemoglobin of the blood globules. When alcohol is introduced into the economy in non- intoxicating doses, it is in part oxidised, and trans- formed, first, into acetic acid, then into alkaline acetates, and finally into carbonates. Alcohol, then, is a food, un aliment cFepargne, which instead of promoting combustion [of the tissues], on the con- trary retards it by withdrawing a certain quantity of oxygen from the blood corpuscles. It is to this action on the blood globules that it owes its power of lower- ing the temperature of the body, especially notable when toxic doses are administered. In such instances the alcohol is no longer consumed, but it destroys the blood corpuscles and dissolves the oxyhsemoglobin. That portion, however, of the ingested alcohol which does not undergo combustion, acts directly on the cerebro-spinal nervous system, giving rise to the phe- nomena of intoxication, of sleep, and of vaso-motor changes varying according to the amount of alcohol ingested. These three properties of alcohol, alimentary, anti-thermic, and toxic, render alcoholic beverages most powerful remedies in febrile diseases." This opinion has the merit of clearness and definiteness, and is founded on the results of careful experiment. Bauer* is disposed to explain its favourable effects solely on the ground of its exciting and stimulating properties, and he considers its nutritive properties to be insignificant. Pavyt considers the weight of evidence to be in favour of its being regarded as a food, and that when taken in moderate quantities the greater part is utilised in the system, and only a small portion is eliminated. What it is important to note, with regard to its stimulating effects, is that they are temporary, and quickly give place to a sedative, and in some persons, * " Dietary of the Sick." A Treatise on Food and Dietetics." .] ALCOHOLIC BEVERAGES. in even in moderate quantities, to a depressing effect. It produces, then, temporary stimulating effects on the nervous and circulatory systems ; there is, for a time, mental exhilaration and a more rapid flow of ideas, while there is also quickened action of the heart and increased fulness of the pulse. This is followed by a sedative effect on the nervous system, often of very great value. It has also the effect of causing dilatation of the peripheral blood-vessels, in conse- quence of which the face flushes, and there is a sub- jective feeling of warmth following its use. In small quantities, by stimulating the secretion of the gastric juice, it promotes appetite, but in large quantities it has the opposite effect, and is, as will presently be seen, a retarder of digestion. In its action on the nervous system small quantities exhilarate, large quantities (after a brief period of excitement) are sedative and narcotic. It is most important to remember that iJie effects of alcohol vary very greatly in different individuals, and that what may only be suflicient to produce a pleasant exhilaration in one person, will cause toxic depressing effects in another. Indeed, it is mainly on account of the remarkable difference in its effects on different persons that so much misapprehension exists as to its true character. Alcohol is a useful food and an agreeable stimu- lant, or a narcotic poison, according to the close in which it is taken, or the susceptibilities and tissue reactions of the individuals to whom it may be ad- ministered. Experiments as to the effect of alcohol in health have generally been made with too large doses, so that they have only furnished information, valuable cer- tainly so far as it goes, of the effects of alcohol in excess. For instance, to test the effect of alcohol on muscular exertion by giving a man four ounces of brandy every four hours (!)* was useless for the purpose of elucidating the physiological effects of * Experiment quoted in Parkes's " Hygiene." H2 FOOD IN HEALTH. [Parti. moderate doses of alcohol. This was a poisonous dose, and antecedently to its ad ministration it might natur- ally have been expected to produce toxic effects, and therefore to embarrass rather than promote muscular exertion. Experience has taught us that for temperate, healthy persons, unaccustomed to the free use of alcohol, one ounce of brandy or whisky, freely diluted, is as much as should be taken at a time, if it is desired to avoid any of its depressing and toxic effects ; and experiments undertaken with the object of testing the physiological action of alcohol in moderation should be restricted to doses of this amount. It is, indeed, pointed out, in the last edition of Parkes's " Hygiene " that " one to one and a half fluid ounce of absolute alcohol in twenty-four hours is the maximum amount which a healthy man should take ; " whether in the form of ardent spirits, wine, or beer, and with this opinion we are entirely in accord. That alcohol taken in small quantities improves the appetite and beneficially increases the circulatory activity, is almost universally admitted. Of its value as a sedative to the nervous system in certain diseased conditions, there is also nearly a general acknowledg- ment ; as to its influence on the work of the body, physical and mental, it would seem, when taken in the moderate quantity above stated, to be helpful under many circumstances. Taken in larger quantity it would seem, on the contrary, to be almost invariably hurtful ; women appear to be more susceptible to its injurious effects than men, and should take it with even greater moderation, and healthy children should do Avithout it altogether. Alcohol taken in excess is known to lead to very serious morbid changes in nearly all the organs of the body. Chronic inflammatory and degenerative changes, of a granular fibroid and fatty nature, attack the stomach, liver, lungs, kidneys, the brain and its membranes, and especially the blood-vessels. This, however, is not the place to discuss the many and Chap, v.] ALCOHOLIC BEVERAGES. 113 serious morbid conditions which are produced by the excessive use of alcohol. With regard to the influence of alcoholic beverages on the digestive processes, Sir William .Roberts has made some valuable experiments, and the conclusions he has arrived at with regard to spirits may be thus briefly summarised : With respect to ardent spirits, such as brandy, Scotch whisky, and gin, he found that these spirits, used in moderation, and well diluted, promote rather than retard salivary digestion ; that they increase the salivary secretions. " The common practice of adding a tablespoonful of brandy to a basin of arrowroot or sago gruel there- fore promotes its digestion." With regard to peptic digestion, it was found that with 10 per cent, and under of proof spirit, there was no appreciable retardation, and only a slight retarda- tion with 20 per cent., but with large percentages it was very different, and with 50 per cent, the digestive ferment was almost paralysed. In the proportions in which these spirits are usually employed dietetically, not only do they not appreciably retard digestion, but they " act as pure stimulants to gastric digestion, causing an increased flow of gastric juice and stimulating the muscular con- tractions of the stomach, and so accelerating the speed of the digestive process in the stomach." It will be necessary, in the next place, to consider the properties of the various beverages containing alcohol which are in common use. Spirits. The various "ardent spirits" are ob- tained by distillation from fermented liquids, and their odour and flavour depend on the nature and source of the fluid from which they are distilled They are usually met with in commerce of about the strength of proof 'spirit, i.e. 49 parts of alcohol to 51 of water, and having a specific gravity of 0-920 at 60 Fahr. When they contain a larger proportion of alcohol their ii4 FOOD IN HEALTH. [Parti. specific gravity is lowered, and they arc then said to be so many degrees over-proof ; whereas, if they contain a smaller quantity of alcohol their specific gravity is raised, and they are said to be so many degrees under- proof. Practically, these distilled spirits, when pure, may be looked upon merely as mixtures of alcohol and water ; the differences in their flavours and odours depend on the presence of various ethers, or of volatile oils, derived from the various fermented fluids from which they are distilled, or purposely added. Some are sweetened by added sugar, and some are intention- ally coloured by the addition of colouring substances. Brandy, rum, whisky, and gin are the spirits most in vogue in Great Britain. Brandy, cognac, or can de vie, when of the best quality, is distilled from wine or fermented grapes. There is, however, a great quantity of eau de vie fabricated in France, of an inferior quality, from potato-spirit or grain-spirit, i.e. spirit distilled chiefly from rice, maize, etc. The quality of brandy depends on the kind of wine from which it is distilled ; the finest quality conies from the white wines of the Charentes. The colour of brandy is due to its being kept in an oak cask, from which also it extracts some tannin. Caramel is used to colour the inferior kinds. Its aroma and flavour are due to the presence of volatile ethers, which pass over during distillation. Brandy im- proves in flavour by keeping, while it loses in strength. On an average it contains about 42 per cent, of alcohol. Dietetically it is highly valued, when of good quality, for its delicacy of flavour and its purity as a spirit. Runt is distilled, in the West Indies especially, from the fermented products of the sugarcane. When new it is of somewhat coarse flavour, which becomes greatly refined by age. It is the spirit usually served out in the British army and navy. It is of about the same strength as brandy. Chap, v.] ALCOHOLIC BEVERAGES. 115 "Whisky is extensively distilled in Scotland and Ireland from malted grain, usually barley. The smoky flavour is due to the peat and turf fires used in drying the grain. A certain amount of age is necessary to render whisky wholesome. It may be used in the same manner as brandy, and is more likely to be obtained pure than that spirit. Gin and Hollands are corn spirits, distilled from the unmalted grain. It is necessary in this case that the first distillation should be purified by re-distilla- tion. Gin is flavoured subsequently by the addition of juniper and other flavouring agents ; it is also sweetened by the addition of sugar, so that gin may be obtained either " diy " or " sweet." Dry Plymouth gin is one of the most wholesome kinds. It is more diuretic than other spirits, on account of the juniper it contains. Arrack is a spirit distilled from a fermented infusion of rice. Kirsch, or Kirsch-wasser, is a spirit largely drunk in Germany and on the Continent. It is dis- tilled from cherries. Spirits distilled from grain or from the potato are apt to be contaminated with ami/lie and other alcohols of injurious quality. As arnylic alcohol, or fusd-oil) is less volatile than ordinary or ethylic alcohol, by redistillation the latter can be separated from the former, which is left behind in the still. Dujardin-Beaumetz has shown that the toxic character of alcohols increases with their atomic weights, and each of the alcohols in the following series presents more and more poisonous properties as its atomic weight increases : Ethylic Alcohol C.,H 6 O Propylic C~H 8 Butylic C 4 H 10 Amylic C s Hj 2 The higher the alcohol in the series the more toxic it becomes. i 2 n6 FOOD IN HEALTH. [Parti. Brandy distilled from wine contains only very small quantities of these toxic alcohols, but eau de vie distilled from potatoes or from grain contains a much larger quantity of propylic, butylic, and amylic alcohol. As to the influence on the digestive processes of the various spirits in common use, Sir W. Roberts found gin preferable to either brandy or whisky ; in his experiments he noticed that brandy and Scotch whisky interfered with the digestive processes, " pre- cipitated the starch more readily," altogether out of proportion to the amount of alcohol they contained, and brandy was worse than whisky ; and this circum- stance appears to be due to certain ethers and volatile oils in them ; and brandy contains a trace of tannin, which has an intensely retarding influence on salivary digestion. Little need be said of the various alcoholic liqueurs in ordinary use. They owe their sweetness to added sugar, and their characteristic flavours to various aromatic substances. Curaqoa is flavoured with orange peel ; Noyeau with the kernels of the peach and apricot ; Maraschino with a flavour derived from cherries ; Kiimmel with cumin and carraway seeds ; Anisette with aniseed and coriander. Cltartreuse and Benedictine, etc., are distilled from a mixture of various aromatic substances. Absinthe is bitter, being flavoured with wormwood. It is usually taken mixed with water, before a meal, to stimulate appetite. Wines. We have seen that alcohol and the ardent spirits are obtained by distillation from saccha- rine fluids that have undergone fermentation. The juices of all saccharine fluids can be made to undergo the alcoholic fermentation. This is usually set up by the agency of the yeast fungus, which causes the sugar to break up into ethylic alcohol and carbonic acid. The most ancient and most popular of these fer mented drinks are those which have been obtained, Chap, v.] BEVERAGES: WINES. try since the earliest times, from the juice of the grape ; and it is to the fermented juice of the grape that the term " wine " usually applies. This term is, however, also applied to the fermented juice of other saccharine fruits, as that of the orange, elder, gooseberry, currant, etc. The characters and properties of wines are deter- mined not only by the variety of the vine on which the grapes are grown, but also by circumstances of soil, of climate, of season as influenced by weather, of degrees of ripeness when the grapes are gathered, and of modes of manufacture and preparation. "In the manufacture of white wines, the grape juice, after having been left for several days in contact with the crushed skins, in order that the soluble con- stituents of these may be extracted, is pressed out, and the must (the name given to the expressed juice) so obtained is submitted to fermentation, which sets up of itself on mere exposure to air, by means of the yeast germs everywhere present. To make a red wine, the juice of black grapes is fermented together with the skins and stones (and sometimes the stalks), and the colouring matters as well as the tannin contained in these are dissolved out into the wine."* Konig gives the following as the average per- centage composition of grape must : Water 74-49 Nitrogenous Substances 0-28 Sugar 19-71 Acid 0-64 Other Non-nitrogenous Substances ... 4-48 Ash 0-40 Great fluctuations are observed in the proportions of sugar and acid as determined by the circumstances mentioned above. Even in the same localities, difference of season will cause the sugar to vary from 12 to 24 per cent. ; and the acid from 0'5 to 1-2 per cent. * Bauer. n8 FOOD IN HEALTH. [PartL The ash consists chiefly of potash and phosphoric acid. The must, of course, undergoes great changes in composition during the processes of fermentation and preparation. The sugar is, in great part, con- verted into alcohol, glycerin and succinic acid being at the same time formed. The fermentation, however, in many wines is arrested before the whole of the sugar has been exhausted, and the proportion of sugar thus left in the wine gives it one of its distinctive characters. The tannin, which gives astringency to wine, is only found in any considerable amount in red wines, and is derived from the stones, the skins, and the stalks. The aroma of wines is usually developed during fermentation and after it has been in bottle ; but in some instances, as in the Muscat, it depends on the grape itself. The chief acids of must are malic and tartaric. Malic acid is found principally in the unripe grape. They both diminish in amount as the fruit ripens, while the proportion of sugar at the same time increases. Good wine should not contain more than 0'5 per cent, of tartaric acid. Owing to the variability of climate and seasons in the north of Europe, and the consequent imperfect ripening of the grape in certain years, the Rhenish and Moselle wines ai - e apt at times to contain an excess of acid. The amount of sugar in wine depends much on climate, the grapes grown in hot climates contain- ing much more saccharine matter than those grown in colder regions. It also depends on the degree of ripeness of the fruit when gathered, and so also upon the season, for in cold, wet seasons the grapes will not ripen thoroughly, and will therefore con- tain less sugar. The amount of sugar will vary in different wines from 10 to 30 per cent. In order to make good wine the must should contain not less than 20 per cent, of sugar. Warm and dry summers are advantageous, and influence favourably Chap, v.] BEVERAGES : WINES. 119 the wine produced. In the preparation of some of the richest and choicest wines, such as Chateau d'Yquem and Tokay, only fully ripe, or even over- ripe, grapes, rich in saccharine substances, are selected. The colour and astringency are extracted from the skins and stalks during fermentation, to a great extent by the combined action of the alcohol generated during this process and the acids ; at the same time the exhausted organic ferment, with other organic sub- stances and "cream of tartar," are deposited as lees, Certain wines are " fortified " by the addition of spirit, especially the wines grown in hot countries, as in Spain, Portugal, Madeira, etc. The spirit is added for the purpose of checking fermentation before all the saccharine matter is exhausted. Such wines possess much "body" and " fruitiness, " on account of the amount of saccharine and extractive matters retained in them. In cooler climates, as in France and Germany, the fermentation, which proceeds more slowly, is allowed to terminate spontaneously, and the saccharine matter is almost wholly exhausted. Such wines are " drier," mature more rapidly, and acquire a finer aroma or bouquet. This bouquet or aroma depends upon the ethereal products formed by a combination of free acid with alcohol, and therefore appears more constantly in the acid wines of the north. The cream of tartar thrown down in the lees is deposited in proportion as the alcohol is formed, as it is very sparingly soluble in spirit. A further deposit of this insoluble salt takes place after the wine has been drawn off into casks ; it then assumes a crystal- line form, and is known as "argol." The fining of wine consists in adding to it white of egg, isinglass, or some similar substances, which, being coagulated and precipitated by the action of the wine, entangles and carries down with it the suspended organic and other impurities. The wine is thus rendered clear, bright, and durable. i2o FOOD IN HEALTH. [rani. Plastering is the term applied to the practice that prevails in Spain, Portugal, and the south of France, of either dusting plaster of Paris (sulphate of lime) over the grapes before they are crushed, or adding it to the must. This leads to the deposition of the greater part of the natural tartaric acid in combination with lime, and to the substitution of sulphate of potash in its place, an altogether undesirable change so far as wholesomeness is concerned, but the keeping proper- ties of the wine are probably improved. In the preparation of spai'kling wines like cham- pagne, a second fermentation is set up by the addition of syrup, and some of the carbonic acid is prevented from escaping, so that an effervescing character is given to the wine, while a special flavour is imparted by the addition of " liqueur." Little that is of practical value can be learnt from the minute chemical analysis of a wine ; the palate and the stomach are the most reliable tests of its quality aud wholesomeness. Dujardin-Beaumetz well remarks that " it is a pro- found error to regard wine as merely a mixture of water and alcohol. It is a complete, living whole . . a living being " of very complex constitution. " It has," he goes on to say, " its youth, its maturity, and its old age. Some growths, like those of Burgundy, have a short life and a precocious old age ; others, like Bordeaux, have a much longer life, and are even made to travel to hasten their maturity. They have also their diseases, diseases which result most com- monly from bad manufacture or faulty fermentation giving rise to the presence of impure products." Be- sides water and alcohol, wines contain glycerin, sugar, tannin, essential oils, ethers, colouring matters and extractives, acids, and salts ; and a wine will contain these constituents in different proportions in different periods of its existence. The proportion of alcohol in wine varies from 6 to 25 per cent. ; and it is stated that a natural wine derived from the normal fermentation of the grape Chap, v.] BE VER AGES: WINES. 121 cannot yield more than 17 per cent, and that any amount beyond thi$ must be added. It is also said that a pipe of 1 1 5 gallons of port wine has never less than 3 gallons of brandy added to it, and some of the richer wines have as much as 13 to 15 gallons added ; and that to 108 gallons of sherry, there are added 6 to 8 gallons of brandy. Some of the finest wines do not contain more than 6 to 10 per cent, of alcohol. The following table of the average percentage by volume of alcohol in some of the best-known wines is collated from the tables published by Bauer, Dujardin-Beaumetz, and Parkes: Per c-e;it. of Alcohol. Sherry 22-90 Port 21-91 Marsala '20-44 Madeira 19-11 Tokay 12-74 Grave 12-30 Champagne (Sparkling) 11-75 Rudesheirner ... ... ... ... 11 '60 Zeltingcr 11-20 Buster 11-08 Macon \ -r> -, . , , nft Volnay } B "*ffundios H'OO Joharmisl>erg ... ... ... ... 10-00 Voslauer 9'89 Larose 9-85 St. Julien 9-28 Leoville 9-10 Chateau Margaux ,.. . ... ... ... 8-75 Lafitte 8-73 Chahlis 788 It is only in the sweet liqueur-like wines and in those to which sugar is added in the manufacture, that this substance exists in any considerable amount. According to Bauer, Ruster contains 21 '74 per cent, of sugar, Tokay 1499, Malaga 16-57, Champagne 11-53, Sparkling #oc&, 8'49, Port 6-42, Marsala 3.48, Madeira 3-46, Sherry 1-88. In the Rhenish and Moselle wines there is but a 122 FOOD IN HEALTH. [Parti. very small quantity of sugar. In Johamnsberg only 0'42 per cent., in Rudesheimer O39, in Zeltinger 0*13, and in Stein-Reisling O01. In Clarets and Burgundies it is either absent, or present in very small quantity. The amount of tannin found in different wines varies greatly. As it is derived chiefly from the coloured skin of the grape, it is absent, or in very small quantity, in white wines. New ports contain it in greatest quantity. On keeping, the tannin becomes deposited in combination with cream of tartar and colouring and extractive matters, and forms what is known as the "crust." Most wines contain some free acid, as well as the acid bitartrate of potash. The free acid is chiefly tartaric, with smaller quantities of malic and acetic acids. The white wines contain most free acid, the Rhenish and Moselle wines from 1-14 per cent. (Marschberg) to 0'33 (Rudesheimer), Champagne 0-58, port and sherry about O45, clarets about 0-60. The bouquet and aroma of wines depend chiefly on the presence of compound ethers and volatile oils. The ethers, the chief of which is termed cKnant/tic ether, are developed in the wine as it ages, and become especially noticeable after it has been long in bottle. They are formed by the reaction of the acids in the wine on the alcohol, and are therefore more remark- able in the more acid wines as in those of the Rhine and Moselle. These, then the alcohol, the sugar, the tannin, the free acid, and the ethers are the chief constituents of wine from a dietetic point of view. Some authors divide wines into four classes : (1) Spirituous or liqueur wines ; (2) red or astringent wines ; (3) white or acid wines ; and (4) sparkling wines.* The liqueur, or spirituous wines, such as Sherry, Port, Madeira, Marsala, Malaga, etc., are wines which * Dujardin-Beaumetz : "Des Boissons/' op. cit. Chap, v.j BEVERAGES: WINES. 123 contain more than 1 5 per cent, of alcohol. They are called dry when nearly all the sugar of the grape is converted into alcohol, as in dry sherries ; and sac- charine when the fermentation is arrested before all the sugar has been exhausted, as in Malaga, fruity Ports, etc. Some of these are termed in French, vin cuits, or " cooked wines," because the fermenta- tion is arrested, and the saccharine matters retained by heating them to a certain temperature. Most of them contain added alcohol. The red wines are most of them slightly astringent and tonic from the tannin they contain. The most esteemed and useful are the French wines the clarets or Bordeaux wines and the Burgundies. The cheaper kinds are, however, so largely adulterated in France that, as they are imported into Great Britain, they are often mixtures of various worthless wines artificially coloured. Sound, well-made clarets and Burgundies are amongst the most wholesome of wines,, taken in moderation and somewhat diluted with water, as is usual in France. The Burgundies contain more alcohol than the Bordeaux wines, and are considered more "heady," but they are valuable when a somewhat stronger and more tonic wine is needed. The red Hungarian wines, such as Carlowitz and Ofner, form good substitutes for French wines. The white or acid wines contain less tannin and more free acid than the preceding. They are some- times more diuretic, and are wholesome and refresh- ing, especially when diluted with some alkaline table water, which removes the excess of acidity without injury to the other qualities of the wine. Most of these wines are grown in northern countries, and come from the banks of the Rhine and Moselle. France also has several white wines, such as Barsac, Vin de Grave, and the Sauternes, from the Bordeaux district; and Chablis, from Burgundy. Many of the Sauternes, however, are strong saccharine wines, and 124 FOOD IN HEALTH. [Pani. cannot be said to resemble greatly the white acid wines of the north. Some, also, of the white Hungarian wines, as Ruster, are rich in saccharine constituents. The type of sparkling wines is champagne. This wine, when pure and sound, is most valuable as a .rapidly-acting restorative and stimulant, and is often of great service from its power of allaying irritability of the stomach by means of the carbonic acid it contains. With regard to the influence of wines on the digestive processes, Sir W. Roberts has made some instructive observations. He found that even very small quantities of the stronger and lighter wines sherry, hock, claret, and port exercised a powerful retarding influence on salivary digestion. He. con- siders this to be wholly due to the acid not the alcohol they contain ; for if this acid be neutralised, by mixing with the wine some alkaline water, the disturbing effect on salivary digestion is completely removed. "The use of 'alkaline table waters' as an addition to wines is/' Sir "W. Roberts observes,* "highly commendable," as they "greatly mitigate or wholly obviate the retarding influence of these wines on the digestion of starch." It was also found that they likewise retarded peptic digestion to an extent altogether out of proportion to the quantity of alcohol they contained. Port and sherry exercised a great retarding effect. " Even in the proportion of 20 per cent., sherry trebled the time in which digestion was completed." This, then, is a most unsuitable wine for persons of feeble digestive powers. "With hock, claret, and champagne, it was also ascertained that this retarding effect on digestion was out of proportion to the alcohol contained in them ; but champagne was found to have " a markedly less retarding effect than hock and claret ; " indeed, in the proportion of 10 per cent., champagne had a distinct, * " Dietetics and Dyspepsia." Chap, v.] BEVERAGES: CIDER AND PERRY. 125 though slight, accelerating effect, and this superiority of champagne appears to be due to the " mechanical effects of its effervescing qualities." The final con- clusion arrived at by Sir W. Roberts is that, while large quantities of these wines exercise a considerable retarding effect on peptic digestion, small quantities do not produce any appreciable retarding effect, but act as pure stimulants ; that sparkling wines impede digestion less than the still ones, and, when taken in moderate quantity, "act not only as stimulants to the secretion of gastric juice and to the muscular activity of the viscus, but may, at the same time, slightly accelerate the speed of the chemical process in the stomach." In the dietetic use of wines, as the author has elsewhere observed,* those wines agree best and are most useful which are absorbed and eliminated from the system with the greatest rapidity, as tested by the increase of the renal secretion, and he has been led to the practical conclusion that this is the best criterion of the suitability of any particular wine to any parti- cular constitution. If the effect of different wines on notoriously gouty persons be carefully observed, it will be found that some can drink champagne (in modera- tion, of course) with impunity, especially if a small quantity of an effervescing alkaline water be added to it, while claret will at once provoke some mani- festations of gout ; others who are unable to drink champagne without provoking a gouty paroxysm, will often be able to drink a mature, fine, soft claret with advantage ; others will support hock well, and a few can drink fine sherries and ports in small quanti- ties ; but in all it will be found that the test of the suitability of the particular wine to the particular constitution is its susceptibility to rapid elimination, and vice versa. Cider and perry. These fermented beverages, obtained respectively from the saccharine juices of * "Food Accessories: their Influence on Digestion." tcentk Century, February, 1886. 126 FOOD IN HEALTH. [Parti. the apple and the pear, have much in common with " wines ;" and, indeed, in Germany cider is known as "apple-wine." They are usually made in districts where those fruits abound. Their "alcoholic" strength varies. In England o o and in Germany it lias been estimated at from 5 to 9 per cent. ; but some of the sweet ciders of France do not contain even 2 per cent, of alcohol. They contain also acids, chiefly malic, extractives, and salts. The alkaline salts, malates, carbonates, and phosphates impart diuretic properties, and those of potash some slight aperient effects. It has been suggested by Denis-Dumont, of Caen, that the diuretic properties of cider render it a useful beverage for the gouty and those who suffer from uric acid deposits. Made into " cup " with soda-water, it is, no doubt, a refreshing and wholesome beverage ; but as it is apt to undergo acetous fermentation, care must be taken that it is " sound," or it may give rise to colic and diarrhoea. Beer. This popular and ancient beverage is, as is well known, a fermented infusion of malt flavoured with the bitter extractive of the hop. In the process of " malting," barley is caused to* germinate under the influence of warmth and moisture ; a ferment diastase is developed during germination, and this ferment converts the starch of the grain into dextrin and sugar ; it is thus rendered capable of yielding a saccharine infusion suitable for alcoholic fer- mentation. The malt must be dried, and this drying is effected at different temperatures. When dried at a comparatively low temperature, e.g. below 140 F., a pale malt is produced which is used in brewing ale. Malt dried at a higher temperature, and so blackened and burnt, is used for brewing porter and stout. It is unnecessary here to describe the process of brewing. It is sufficient to say that the infusion of malt is termed " wort," and contains in solution sugar, dextrin, albuminates, diastase, and salts. To Chap. V.] BEVERAGES : BEER. 127 this "sweet wort "hops in suitable quantity are added, the liquid is then boiled, cooled, and placed in vats for fermentation with yeast. The alcoholic strength of the beer depends on whether a strong or weak wort is used. The more concentrated the wort the stronger will be the beer brewed from it. In the preparation of beer other starch-containing substances capable of being converted into sugar by the action of diastase may be used, such as wheat, rice, and potatoes. Alcohol and carbonic acid are formed during the fermenta- tion of the wort. The greater part of the latter escapes, but enough is retained to give an agree- able flavour to the beverage. There are other details necessary to be attended to in the preparation of the various kinds of beer with which we are not concerned. The chemical composition of beer is somewhat complex ; besides water and alcohol, it contains sugar, dextrin, albuminates, aromatic, bitter and colouring matter, salts, and a varying amount of acetic and carbonic acid. The following analysis of German beers is adopted from Ko'nig : Carbo Water. nic Alcohol Albu- Extrac- Ash. Acid. Mild (Winter) Beer 91-81 0-23 3-21 0-81 4 '99 020 (Summer) 90-71 0-22 3-68 0-49 5-61 0-22 Strong (double 88-72 0-25 4-07 0-71 7-23 0-27 Porter 88-52 0-21 5 16 0-73 6-32 0-27 By keeping, the amount of alcohol gradually in- creases and that of extractives diminishes ; " old ales " are therefore, as a rule, strong ales. The colour of beer depends on the temperature at which the malt is dried, also the longer the wort is boiled the darker it becomes. The average percentage amount of alcohol, extrac- 128 FOOD IN HEALTH. [Parti. tives, and ash in various well-known beers is thus given by Dujardin-Beaumetz after Girard and Pabst.* Alcohol. Extractives Ash. English Beer (for exportation) 7-3 5-9 0-35 London Porter . 5-2 64 0-32 Strasbourg Beer. 4-7 4-65 0-32 Bavarian 4-5 1-1 0-29 Saxony 3-7 5-8 0-2o Bohemian 3-6 4-7 0-20 Vienna 3-5 6-1 0-20 The amount of alcohol by volume in different beers may vary by as much as from 1 to 10 per cent. Scotch (Edinburgh) alecontainsas much as 8 -5 per cent, of alcohol. The free acidity (chiefly acetic acid with small quantities of lactic, malic and gallic acids) ranges from 18 to 45 grains per pint. Most beers contain a small amount of albuminous substances, not more on an average than 0'5 per cent. The salts consist of earthy phosphates and alkaline chlorides and phos- phates. Some of the dark beers and porters contain caramel. Free carbonic acid exists in beer in about the proportion of If cubic inch per ounce. It has been calculated that on an average a pint (20 oz.) of beer contains Alcohol Extractives- Free Acid Salts -Dextrin, Sugar 1 oz. l-2oz. 25 grains. 13 grains. The peculiar aromatic and bitter flavour of beer is due to the hop extractives it contains. The extractive matters derived fro. .I the malt, and consisting chiefly of sugar and other carbohydrates, vary from 5 to nearly 15 per cent., and are most abundant in stout, porter, and sweet ales, and least so in light, bitter beer. * " L'Hygiene Alimeutairc des BoisiouE." Chap, v.] BEVERAGES: BEER. , 129 Beer is not merely a tonic and stimulating alcoholic beverage, it also contains a certain amount of nutri- ment in the form of extractives, chiefly carbohydrates, with a small quantity of albuminates ; so that, when taken habitually, it tends to induce a state of fulness and plethora of the system, and a disposition to grow fat. It has been suggested that this is to some extent due to its exercising a slight interference with the metabolism both of the fatty and nitrogenous tissues. Dujardin - Beaumetz considers that it assists the digestion of alimentary carbohydrates through the influence of a certain amount of diastase in it. Light beers in which the bitter principles predominate and the extractives are small in amount, no doubt act as stomachics and tonics. It has been remarked that great beer-drinkers are subject to heaviness and drowsiness, and these effects are referred to the narcotic principles in the hops (lupulin) ; but Ranke has suggested that it is caused in part by the potash salts in it. It is believed that the habitual excessive consumption of beer may inter- fere with due oxidation and elimination to such an extent as to lead to the accumulation in the system of imperfectly oxidised products such as oxalic and uric acids, and so engender biliousness and goutiness. To avoid such possible evils the quantity consumed daily should not exceed a pint of the stronger beers or two pints of the weaker ones. Porter appears to be easier of digestion than beer. Sir William Roberts's observations on the effects of beer on salivary and peptic digestion showed that "malt liquors hamper salivary digestion exactly in proportion to their degree of acidity. Sound English beers have not nearly so much acidity as wines, and they interfere comparatively little with the digestion of starch ; but ' turned ' beer is highly inhibitory." With respect to peptic digestion, malt liquors exerted a retarding effect " altogether out of proportion to their percentage of alcohol." In large quantities they are powerful retarders of stomach digestion, in J 130 FOOD JN HEALTH. [Parti. particular of farinaceous foods. " But in more moderate quantities a tumbler or so especially of the lighter beers," they assist digestion, and this is particularly the case when the beer is " well up," i.e. when it contains a considerable amount of free carbonic acid. It is greatly to be regretted that in the interest of temperance amongst the poor, no generally accept- able cheap beverage, somewhat of the same char- acter as beer, has been provided for common con- sumption. We add a recipe for such a beverage, which we obtained from the wife of a country doctor, after partaking of some of her brewing, which appeared excellent : Take 6 Ibs. of raw sugar, 5 ozs. of hops, 4 ozs. of ginger, boil these together for two hours (the hops and ginger being enclosed in bags) in 9 gallons of water. Then place in a pan to cool, and while still warm add 2 tablespoonfuls of yeast ; next morning skim off the yeast and put into a barrel, and allow it to " work " two days and two nights ; then add f oz. of isinglass and bung up the barrel. After standing for three days it will be fit for use. The addition of a little burnt sugar (caramel) would give it an attractive colour. CONDIMENTS. Condiments are employed for the purpose of giving flavour and relish to food, to excite appetite and to promote digestion. They greatly increase the pleasures of feeding, and by their stimulating properties they promote the digestive secretions and excite the muscular contractions of the alimentary canal. Many are distinctly antiseptic and carminative. The most important and most extensively used is common salt. Sir William Roberts asks the question, '' Why do we use so much salt with our food 1 Animals in a state of nature require none." He concludes that it is because in our elaborate methods of cooking and preparing food they are deprived Chap, v.j CONDIMENTS. 131 of most of their saline ingredients. " Salt must therefore be supplied artificially to make up the defect, and to restore to the food so treated that sapidity and salinity of which it has in part been deprived." Besides giving relish to food, salt aids digestion by promoting the secretion of gastric juice, and thereby furthering the solution of albuminous substances. According to Voit, the pre- sence of salt favours the disintegration of albumen in the body, and accelerates the interchange of juices and augments the renal secretion. Vinegar is also an important condiment extensively used to give an acidulous flavour to many articles of food, and also, for its antiseptic properties, to preserve food. Sir William Roberts found that it had a very powerful retarding effect on salivary digestion, and he cautions persons with weak digestion to be very sparing in its use. Bauer also cautions against an excessive use of vinegar as it " leads to a high degree of anfemia and emaciation, since the acid lessens the alkalinity of the blood and the number of the blood corpuscles."* Many substances used as condiments contain small quantities of ethereal oils and other aromatic substances as mustard, pepper, horse-radish, ginger, nutmeg, cinnamon, cloves, allspice, saffron, vanilla, mint, thyme, fennel, sage, parsley, garlic, etc., etc. Many of these, by conferring agreeable flavours and by their warm carminative properties promote appetite and assist digestion ; but their excessive use is calculated to excite irritation and disorder of the Digestive organs. * "Dietary of the Sick." J 2 132 CHAPTER VI. THE ANNEXATION OF FOOD : ITS DIGESTION, ASSIMI- LATION, AND UTILISATION. IN this chapter we shall proceed to consider the pre- parations and transformations which the different varieties of alimentary substances must undergo within the body in order that they may be assimi- lated, annexed, or otherwise utilised according to their several functions in nutrition. The first change which the food experiences in order to fit it for annexation and utilisation is in the mouth, where it undergoes mechanical subdivision in the process of mastication, as well as admixture with the secretion of the salivary and other glands of the mouth. The mechanical division which the food undergoes in the mouth is an exceedingly important preparatory step to the further action of the digestive juices upon it, as it multiplies the surfaces of contact and increases its permeability to the digestive fluids. By simultaneous commingling with the frothy saliva a certain amount of air is blended with the food, which also renders it lighter and more porous and. more accessible to the gastric and intestinal juices. Admixture with the saliva is also attended by a chemical action on the carbohydrates or starchy food substances. Through the agency of a diastasic fer- ment contained in the saliva, to which the name of ptyalin is given, the insoluble starch is converted into soluble dextrin, and subsequently into maltose, a form of sugar which is distinguished from grape-sugar by containing one molecule less of water. In the small intestines the maltose is converted into glucose. chap, vi.] ACTION OF THE SALIVA. 133 Ptyalin belongs to the group of unorganised fer- ments, and, even when present only in very minute quantity, it causes starch to take up the elements of water and become soluble, undergoing itself no essen- tial change in the process. Saliva acts but slowly on raw, unboiled starch, because the starch-grains consist of granulose, or starch enclosed in coats of cellulose, and cellulose appears to be unaffected by saliva. When the starch is boiled, the starch-grains swell up, the cellulose envelopes are ruptured, and thus the diastasic action of the ptyalin can take effect. Hence the necessity of thoroughly boiling all starchy food or raising it to a high temperature. During the early months of infant life the salivary glands are very imperfectly developed, and it is not therefore, advisable to give starchy food to young infants. Saliva acts best in an exactly neutral medium ; but it also acts in an alkaline and even in a slightly acid fluid. Its action is, however, arrested or prevented by a strong acid ; so that when the con- tents of the stomach are decidedly acid, and especi- ally when it contains free hydrochloric acid, the action of the saliva on starch is arrested when the food reaches that organ. If the acidity be neutral- ised, the action is resumed. Bauer suggests that the chemical action of saliva in digestion is infinitely less than might at first sight be supposed, as the food remains so short a time in the mouth, and the transformation of starch into sugar is arrested by the acid gastric juice, and that its chief use is to soften, moisten, and aid in the mechanical subdivision of the food-mass, and also, by covering it with mucus, to enable it to be easily swallowed. Substances soluble in water are dissolved by the saliva, and the sapid matters are thus brought into contact with the end-organs of the nerves of taste. Sir William Roberts observes with regard to salivary digestion that, as the time for it is brief, " to be of any avail the action must be r.ipid." He thinks 134 FOOD IN HEALTH. [Pani. that " the exceptional richness in diastase of human saliva " is remarkable, and that it has " special rela- tion to the habit man has acquired of cooking his food. Salivary diastase is powerless on raw starch, but it acts energetically on starch which has been changed to a state of jelly or mucilage by previous boiling or baking. And if we consider how large a part of our food consists of bread and other cooked farinaceous articles, the importance of an exceptional salivary power will at once appear." The initial act is the transformation of this "solid or semi-solid coherent starch-jelly into a running liquid. Such articles, as bread, pastry, and doughy puddings are altered considerably even by a brief contact with saliva. Their texture is rendered loose and more penetrable, and this change greatly facilitates the subsequent task of the gastric juice."* In febrile and other morbid states the saliva may assume an acid instead of the normal alkaline reac- tion. This is due to fermentative changes set up by low organisms in the mouth. The salivary secretion is often also diminished, and the mouth becomes " dry and parched ;" or the mucus becomes viscid and tenacious and the mouth "clammy." This condition is favourable to the development of acid and foetid decompositions. The conclusions deduced by Sir William Roberts, from his experiments on the influence of certain fami- liar " food accessories " on salivary digestion, may be suitably summarised here : First, with regard to ardent spirits, such as whisky, gin, and brandy, he found, when used with moderation and well diluted, that they promoted, rather than retarded, salivary digestion by causing an increased flow of saliva. But the proportion must not exceed 5 per cent., and gin seems to be preferable to either brandy or whisky. In whisky and brandy there are certain ethers and volatile oils, and in the latter a trace of tannin, and these appear to exert an intensely * "Dietetics and Dyspepsia. ' Chap, vi.] GASTRIC DIGESTION. 135 retarding influence on salivary digestion. And the stronger mixtures of all these decidedly retard salivary digestion. With regard to wines, it was found that even small quantities of such wines as sherry, hock, claret, and port exercised a powerful retarding influence on salivary digestion, due, not to the alcohol, but to the acid they contain ; for when this was neutralised by the addition of some alkaline effervescing water, the disturbing effect on salivary digestion was completely removed. The influence of acids in arresting or retarding salivary digestion is important in connection with the dietetic use of vinegar, pickles, salads, etc. In the case of vinegar, it was found that 1 part in 5,000 sensibly retarded this process ; so that when acid salads are taken together with bread, the effect of the acid is to prevent any salivary digestion of the bread. As to 7iialt liquors, if they are free from acidity they interfere but little with salivary digestion ; but it is otherwise if they are acid. Pure water charged with carbonic acid exercises a considerable retarding influence on salivary digestion ; but if it contains an alkaline carbonate, the presence of the alkali removes this retai'ding effect. Tea was also found to exert a powerful retarding influence on salivary digestion, due to the tannin it contains ; coffee and cocoa a compara- tively feeble one. The food when it reaches the stomach encounters the acid gastric juice, and by the agency of this digestive fluid the insoluble albuminates become converted into soluble peptones. This change is effected by the agency of a " hydrolytic " ferment, termed pepsin, which the gastric juice contains, together with free hydrochloric acid. The acidity of the gastric juice is, in health, not so great as is generally believed ; indeed, its acid reaction is but slight, as the hydrochloric acid it con- tains enters into combination, for the time being, with pepsin and albuminates, and then no longer gives an acid reaction. The amount of free hydrochloric acid in 136 FOOD IN HEALTH. i,Parti. gastric juice has been estimated at 0'2 to - 3 part in 1,000.* (Landois.) Lactic acid is also found in gastric juice, but this arises from the fermentation of carbohydrates ; for there are two other ferments yielded by the gastric juice a lactic acid ferment and a milk-curdling ferment. The carbohydrates undergo still further conversion into dextrin in the stomach through the continued action of the saliva swallowed, but whether their con- version into sugar is or is not arrested in the stomach is as yet undetermined. The finely divided mixture of food and gastric juice found in the stomach is spoken of as chyme. The action of gastric juice on albuminates is first to cause them to swell up, and finally to dissolve them more or less completely. There would appear to be certain stages in this process. The large and complicated proteid molecule is split up by a process of hydration into simpler one& The first stage is the formation of syntonin or acid- albumen, or para-peptone. This has the property of being soluble in acids, but it is again precipitated on neutralising the solution. The next step is the forma- tion of hemi-albumose or pro-peptone. This is not coagulated by heat and is soluble in water. It is precipitated by nitric acid, but the precipitate is dissolved on heating and falls down again on cooling. Finally, by the continued action of the gastric juice, the pro-peptone passes into true soluble peptone. Its formation is due to the taking up of a molecule of water, under the influence of the hydrolytic ferment pepsin. The greater the amount of pepsin, within certain limits, the more rapidly does the solution take place. The pepsin suffers scarcely any change ; it would seem, however, that some of it is used up in the process of digestion, but the chief loss is due to its passing, from time to time, with the chyme into the small intestine. Sir William Roberts, from obser- vations on peptic digestion, out of the body, infers that * Richet's estimate is much higher, iiamely, 017 per cent. " Du. Sue Gastrique." Chap. vi. i PEPTONES. 137 " the speed of digestion is roughly proportionate to the amount of pepsin in the digesting mixture. The more pepsin, the greater is the speed of digestion without any limit on either side. And we should probably see ... if it were possible to arrange the experiment so as to eliminate all interfering conditions, the speed of peptic digestion would be found to be exactly proportional to the quantity of pepsin con- tained in the digesting mixture." Albuminous sub- stances entering the stomach in solution are not first coagulated, as used to be taught, before they are converted into syntonin, except in the instance of casein, which is first coagulated and afterwards dissolved. It has been suggested that coagulated albumen may be regarded as the anhydride of the fluid form and the latter as the anhydride of peptone ; this view, therefore, represents the peptones as the highest degree of hydration of the albuminates. The true peptones have remarkable characters and properties by which they differ greatly from ordinary soluble albumen. They are not coagulated by heat, or by nitric acid, or by acetic acid, and potassium ferro-cyanide. They diffuse easily through animal membranes. They have a cheesy taste, while albumen and albumose are tasteless. The destination of the peptones, after absorption into the blood, is doubtless to replace the albuminous substances consumed in the organism. Gelatin and gelatin-yielding substances are also digested by the gastric juice, and gelatin loses its property of solidifying in the cold. The gelatin-peptones are quite different from the true peptones, although they share with them the properties of solubility in water and dilfusibility through membrane. It is interesting and important to notice the changes that milk undergoes in the stomach. On entering the stomach the casein coagulates and en- tangles with it some of the fat globules. The free hydrochloric acid, by neutralising the alkali which 138 FOOD IN HEALTH. [Parti. keeps the casein in solution in milk, is adequate to produce this effect, but the gastric juice contains also, besides pepsin, a milk-curdling ferment which pre- cipitates casein either in neutral or alkaline solutions. It is this ferment, under the name of rennet (an in- fusion of the fourth stomach of the calf in brine), which is used to coagulate casein in the manufacture of cheese. The casein is in the stomach subsequently converted into syntonin, and finally into a true peptone. There is also a lactic acid ferment in the stomach which changes a portion of the milk-sugar into lactic acid. A part of the milk-sugar is converted in the stomach and intestine into grape-sugar. It is necessary for the proper performance of gastric digestion that the food should be kept for a considerable time in the stomach submitted to the sort of churning movement imparted to the food-mass by the contraction of its muscular walls. In this way the food is thoroughly mixed up with the gastric juice, the chyme being prevented from escaping into the duodenum by the contraction of the pylorus ; this after three or four hours relaxes, and the acid chyme passes out of the stomach into the small intestine. Do fats undergo any change in the stomach ? They are said to undergo partial decomposition with the formation of a small quantity of fatty acids which are of use in emulsifying the rest of the fat ; but their real digestion takes place lower down in the alimen- tary canal. Peptones can be produced outside the body by dissolving albuminous substances in artificial gastric juice. Such products often possess a disagreeable bitter taste, the cause of which is not thoroughly understood. It has been suggested that it is due to the formation of an alkaloid of the nature of a ptomaine developed during the decomposition of albuminous matter. These artificially-produced pep- tones have been regarded as calculated to render great service in invalid feeding. Whether they can fulfil Chap, vi.] PEPTONES. 139 all the functions in the body of albuminous sub- stances, and contribute, like them, to the repair of the nitrogenous tissues, has been warmly discussed. It is admitted that there is no necessity that dissolved albuminous substances should be transformed into peptones in order to be absorbed ; they can certainly be absorbed without undergoing such transformation. It is also known than an increased secretion of urea appears after the administration of peptones, just as it does after the ingestion of unaltered albumen, and that the chemical composition of peptones differs little from that of ordinary albuminous bodies. But Brucke has maintained, in opposition to those who assert that peptones perform all the functions of proteids, that the absorption of some unchanged albumen is necessary and that only this is capable of forming organic albumen, and that the peptones after undergoing a re-conversion into albumen are wholly metabolised as such. This is the view to which Bauer seems to lean.* "An organism," he says, "could with peptones alone, and combined only with the necessary non-nitrogenous food stuffs, be kept alive only for a limited, albeit a fairly long space of time; but for its continued maintenance the addition of so much unaltered albumen as is necessary for the repair of the tissues would be required. At the same time it is not improbable that a given weight of peptone is perfectly equivalent for purposes of metabolism to an equal amount of albumen, so that its albumen- sparing action far exceeds that of gelatin. " It is clear also that the peptones, even if in further researches they should be found not to be available for tissue formation, may yet bo very valu- able nutriments for the sick, being capable of re- placing albuminous nutrition for months together, aud presenting the manifest advantage of being easily and immediately absorbed. A relatively small addi- tion to the food ot unaltered albumen would be neces- sary in order to obviate the waste of albumen in the * "Dietary of the Sick." 140 FOOD IN HEALTH. [Parti. body as well as to attain an increase of weight. All clinical experience in peptone feeding in the past is capable of the same interpretation." It is a curious and interesting circumstance that when pep tones are injected into the general circula- 1'ttion they act as poisons, and this fact has naturally led to the inquiry why it is that, in health, the pep- tones in the intestine do not pass into the general circulation and exert their poisonous influence on the nervous system. To this inquiry no satisfactory answer can at present be given. As a rule, the peptones disappear from the portal blood before it reaches the general circulation ; indeed, very little, if any, peptones can be found in it before it reaches the liver. Although it has not yet been discovered where the peptones undergo this remarkable change which renders them fit for appropriation as nutriment, it has been suggested that the liver may, to some extent, serve the purpose of preventing any peptones from reaching the general circulation which may have escaped transformation in the blood of the portal system. Dujardin-Beaumetz calls attention to the difference observable in the various peptones that are found in commerce ; "some are acid, some neutral ; some are liquid, some solid ; and their chemical reactions even are different." He regards the question of peptones as a " very complex " one. The dry peptones he considers preferable to the liquid ones. He calls at- tention to their disagreeable taste being obje -tionable to many invalids, and he suspects the more agreeable- tasting preparations of being largely adulterated with gelatin. Instead of promoting the secretion of gastric juice, he has found that they retard it. Their chief value is, he maintains, in rectal alimentation. Attempts have been made from time to time to estimate the relative digestibility of different kinds of foods in the stomach ; but this is a question extremely difficult to resolve, as it is complicated by a variety of changing circumstances. The activity of Chap, vi.] DURATION OF GASTRIC DIGESTION. 141 the digestive organs is subject to great variations at different times and in different individuals. The various modes of cooking or otherwise preparing the food may cause it to offer very varying degrees of resistance to the action of the gastric juice at different periods. One of the most important conditions is, no doubt, the state of mechanical subdivision to which the food is reduced when it reaches the stomach Fish and chicken (the more delicate parts, as, e.g. the breast) are more digestible than mutton, and mutton is more digestible than beef ; and these differ- ences are due to the different degrees of resistance their fibres offer to disintegration. The flaky mus- cular masses of the more digestible kinds of fish are made up of short fibres, easily torn apart and sepa- rated ; the flesh of the chicken is composed of shorter and more delicate fibres than those of mutton, and mutton of shorter and smaller fibres than beef. The muscular fibres of different parts of an animal differ also greatly in their size and delicacy and mode of aggregation. The short and delicate-fibred muscles of the chicken's breast are more easily digested than the larger and tougher-fibred leg muscles. Dr. Beau- mont's observations on the rate of digestion of various substances, as noted by him in the celebrated case of Alexis St. Martin, who was the subject of a gastric fistula, have been repeatedly quoted. His general conclusions were in accord with those of common experience. Animal foods were more easily digested than vegetable ; the latter were often observed to leave the stomach in an undigested state. Fats were highly indigestible in the stomach. The digestibility of animal flesh was seen to be dependent, to a great extent, on its tenderness and facility of disintegra- tion ; game, for instance, was the most digestible of foods. Salt and vinegar appeared to promote diges- tion. The rapidity with which a meal was digested depended on the quantity as well as the quality of the food and the condition of the stomach at the time. Three and a half hours was the average time 142 FOOD IN HEALTH. [Parti it took to digest a moderate meal of bread and meat. Saturation of the ingesta with fat materially inter- feres with the action of the gastric juice upon it. The tender cellulose of young vegetables is much more digestible than when it has been rendered woody by age. Cooked meat is more digestible than raw, the gastric juice penetrating with greater ease between the fibres. Hard-boiled eggs appear to offer mechanical conditions most unfavourable to the action of the gastric juice. Animal gelatin is very readily dissolved in the stomach. The duration of gastric digestion appears to vary between very wide limits, and to depend on indi- vidual peculiarity and many other circumstances. The most common circumstances which retard gastric digestion are : excessive quantity of food, a catarrhal condition of the gastric mucous membrane, the pre- sence of the febrile state, hypersemia and anaemia of the mucous membrane of the stomach (both of which interfere with the free secretion of the gastric juice); certain morbid states of the nervous system also diminish the secretion of gastric juice. A de- ficiency of free acid seems even of more importance than a deficiency of pepsin ; and it is probable that this is a common condition in cases of acute and chronic gastric catarrh. It is also noteworthy that, although the quantity of the normal acid needed for active digestion may be deficient, yet there may be sour eructations and other symptoms present pointing to the abnormal formation of other acids, due to abnormal fermentative processes. Food, of course, may be abnormally retained in the stomach by any obstruction at the pylorus, or by defective propelling power in the stomach walls associated with dilatation of its cavity and a paretic condition of its muscular coats. Sir William Roberts's experiments on the influence of certain food accessories on peptic digestion led him to the following conclusions : Ardent spirits retarded digestion according to their degree of concentration. Chap, vi.] INTESTINAL DIGESTION. 143 With 10 per cent, and under of proof spirit there was no appreciable retardation, and only a slight retarda- tion with 20 per cent. ; but with large percentages it was very different, and with 50 per cent, the digestive ferment was almost paralysed. Wines and beer retard peptic digestion altogether out of proportion to the quantity of alcohol they contain. Port and sherry exercised a great retarding effect. Tea and coffee exercise a remarkably retarding effect on stomach digestion ; strong coffee had a very powerful retarding effect. Beef tea had a powerful retarding effect on peptic digestion, apparently due to the salts of the organic acids contained in it.* The food, reduced to the condition of chyme, when it passes out of the stomach into the duodenum, en- counters two other digestive fluids the bile and the pancreatic juice. The acid chyme, meeting with these alkaline fluids, loses its acidity, and the further action of the pepsin on the albuminates is suspended. The pancreatic juice is one of the most important digestive fluids in the body, and it is the most ener- getic and most general in its action of all the digestive juices, and contains no less than four hydrolytic fer- ments : (1) Amylopsin, which seems to be identical with the ptyalin of the saliva, but is much more energetic than it, and can transform raw as well as lioiled starch into sugar. At the temperature of the body the change is effected almost at once. Even cellulose is said to be dissolved by it, and gum changed into sugar. This ferment is absent, accord- ing to Korowin, from the pancreas of new-boru children. (2) Trypsin,^ which digests albuminates, changing them, first, into a globulin-like substance, then into pro-peptone or album ose, and finally into * " Dietetics and Dyspepsia." t It is a remarkable circumstance that the juice cf the green fruit of the papaya tree, or Carica papaya, possesses digestive properties, due to the presence of a peptonising ferment closely related to trypgin, and termed caricin orpapain. 144 FOOD IN HEALTH. [Parti. true peptone like the pepsin-peptones, and sometimes termed tryptone. Trypsin is destroyed when it en- counters pepsin and hydrochloric acid together ; so that it is useless administering trypsin by the mouth, as it would be destroyed in the stomach. (3) A. fat- splitting ferment, steapsin. This causes neutral fats to appropriate a molecule of water and split into glycerin, and their corresponding fatty acids, as, e.g. : Tristearin. Water. Glycerin. Stearic Acid. and (4) a milk-curdling ferment. The pancreatic juice has the power of forming & fine permanent emulsion with fats. In this process the fats are subdivided into exceedingly minute par- ticles, in which form they can be taken up by the lacteals. The fatty acid, set free by the fat-splitting ferment, enables the alkaline pancreatic juice at once to produce an emulsion, for the presence of a free fatty acid causes emulsification to take place very rapidly. Putrefactive bacteria appear to find in the pro- ducts of pancreatic digestion an extremely favourable soil for their development, and under certain circum- stances, when pancreatic digestion is prolonged, will give rise to the production of most foul smelling substances, the chief of which is Indol (C 8 H 7 N). This may readily be produced during pancreatic digestion out of the body ; and the same thing, no doubt, occurs occasionally inside the body, and would fre- quently occur were it not for the antiseptic action of the bile. When, therefore, the flow of bile into the small intestine is for any reason hindered or interrupted, there is obvious danger of such putre- factive decomposition occurring; and since during putrefactive decomposition within the body poisonous organic alkaloids may be formed, there is the risk of actual poisoning by the absorption of such alkaloids from the alimentary canal. It is seen, then, that the pancreatic juice exerts a C'np. Vt.) f-'V.\'CT/OXS OF THE BlLE. 14$ solvent digestive action on all classes of alimentary substances, the albu ruinates, the carbohydrates, and the fats. Like the saliva, it converts starch into dextrin and sugar, and like the gastric juice, it con- verts insoluble albuuiinates into soluble peptones. It has, however, been proved that the bile exerts an important influence in the absorption of fat, and that large quantities of fat can be absorbed without the presence of pancreatic juice in the bowel, pro- vided only there be a free inflow of bile ; but if bile be absent, then the absorption of fat is to a very great extent interfered with, notwithstanding the abundant presence of pancreatic juice ; and so far from pancreatic juice being the sole agent in the digestion of fat (as was once taught), it is only when associated with bile that it is of any real value. " So far as we know at present," says Bauer, " the pan- creatic juice alone, without the presence of the bile, can effect the absorption of but a fraction of the ingested fat ; nevertheless, it is conceivable that the action of the bile in the assimilation of fat may be but imperfectly performed without the co-operation of the pancreatic juice. Perhaps the true state of the case may be, that while a moderate admixture of fit with the food may be absorbed by means of the bile alone, larger quantities cannot be without the aid of pancreatic juice at the same time." The bile is, then, an important agent in the diges- tion and absorption of fat. It aids the pancreatic juice in emulsifying fat, and it has a remarkable power in facilitating the passage of fat through animal membrane. If bile be absent from the intestine, a large proportion of the fatty matters of the food pass away undigested in the evacuations. The whitish colour of the stools in cases of obstructive jaundice is not only connected with the absence of bile pigment, but is also due to the presence of a large quantity of undigested fat. Bile promotes the absorption of fats 1st, by emulsifying them, so that the fatty par- ticles pass more readily into the lacteals ; 2nd, by K 146 FOOD IN HEALTH. [Parti. moistening or wetting both the fat granules and the pores of the intestinal villi so that they become easily permeable ; it is found that fat filters through a membrane moistened with bile or bile-salts under less pressure than when moistened with water or saline solutions. It allows diffusion to take place between a watery fluid and a fatty fluid by acting as a sort of soap, so that the intervening membrane can be moistened by both fluids.* It is said (Landois) that bile also contains a diastasic ferment capable of transforming starch into sugar and also glycogen into sugar. Another function of the bile is that it stimulates the peristaltic movements of the muscular wall of the intestine, and so acts as a sort of natural aperient ; this effect is also furthered by the amount of fluid it adds to the faeces. The bile acts also as an antiseptic, and prevents putrefactive changes in the intestine which the presence of the bacteria of putrefaction would otherwise bring about. Throughout the whole of the intestinal canal, from the duodenum to the termination of the large intes- tine, the contents continue to present an alkaline reaction, and the action of the pancreatic ferments is maintained. Besides the bile and pancreatic juice, the food when it reaches the small intestine encounters also the so-called " succus entericus," or intestinal juice, secreted by the glands that are found embedded in the intestinal mucous membrane. These are mainly Brunner's glands which are confined to the upper part of the small intestine, and Lieberkiihn's follicles, which are closely packed throughout the whole length of the small and large intestine. Since in the small intestine the food encounters simultaneously so many digestive secretions, it is * Mayo Kobson infers from the results of his observations in the case of biliary fistula that "increase of body weight and good health are quite compatible with the entire absence of bile from the intestines," that its "antiseptic properties are unimportant," and that it is "probably chiefly excrementitious. " On Gall Stones, "p. 32. Chap, vi.] ABSORPTION OF FOOD. \ 47 almost impossible to limit accurately the particular part that each one plays in the processes of digestion. Experiments made out of the body cannot be arranged under precisely the same conditions as those which obtain within the alimentary canal, and conclusions drawn exclusively from such observation are exposed to obvious sources of error. The succus entericus is said to be able to convert maltose into grape-sugar, and so to continue the diastasic action of the saliva and pancreatic juice ; it is also believed to be able slowly to peptonise fibrin. It is probable that portions of the food may continue to be dissolved in the lower half of the small intes- tine under the influence of the various digestive fer- ments that have been mixed with it. In the large intestine the digestive processes cease, and putrefactive changes alone continue ; the absorption of fluid, how- ever, goes on so that the contents of the large intestine increase in consistency as they advance along it. The food has now been traced from its entrance into the mouth to its complete digestion in the small intestine ; here the dissolved food substances pass into the blood-vessels and lymphatics, and so enter the general circulation. The peptones immediately on entering the blood-vessels appear to undergo certain changes. They are taken up, to a great extent, by the red blood-corpuscles, and by a process of dehydration are converted back again, so to speak, into a larger and more complex albuminous molecule, that of ylobulin. " The blood corpuscles thus form, as it were, a store of albuminous material, which they convey to all parts of the body, and give off where it is wanted." A portion, however, of the peptones appear to have another destination : they are con- verted in the liver, where they are arrested, into glycogen. In the liver also the sugar absorbed from the intestinal canal is dehydrated and converted likewise into glycogen. There it is stored up for a time, and given out as required by the organism. K -' 148 FOOD IN HEALTH. [Parti. The liver, therefore, is a great storehouse of carbo- hydrates, and it serves them out to the economy as they are required. The chief amount of the fats is absorbed in the form of a milk-like emulsion, and a small portion, in the form of soluble fat-soaps. The fats themselves are not chemically changed, but remain as undecomposed neuti'al fats. The villi of the small intestine are the chief organs concerned in the absorption of the fatty emulsion, and in these the lacteal vessels originate which convey the chyle, containing the fatty granules, towards the thoracic duct on its way to join the general circulation. Sir W. Roberta's observations led him to the conclusion that the effects of food-accessories (for reasons he sets forth) on pancrtatic digestion are practically nil. " In no case did I find evidence of the possibility of that embarrassment and arrest which occurred in the case of salivary and peptic digestion."* The usefulness of various articles of diet in nutri- tion must depend upon their digestibility and upon the proportion in which they can be and are dissolved and absorbed in the alimentary canal. The real nutritive value, therefore, of any food-stuff cannot be accurately determined simply by reference to its chemical composition, but can only be properly estimated by actual observation as to the extent to which it is appropriated by the organism. It must, at the same time, be remembered that there are limits to the digestive and absorptive capacities of tlm alimentary canal, which vary with regard to different forms of food, and that any overloading of the digestive organs with food-substances it cannot com- pletely digest is most injurious. In the case of a complex feeder like man it is undoubtedly extremely difficult to ascertain to what precise extent any particular component of his diet is utilisable ; a certain amount of approximately accurate information can, however, be obtained in various * 'Dietetics and Dyspepsia." Chap. VI. UTILISATION OF FOODS. 149 ways which will afford considerable assistance in the solution of these questions. It is well known how much the digestibility and full utilisation of the food of man depend on its being presented to him in sufficient variety, and that a monotonous sameness of dietary ends by becoming repulsive, and leads to actual derangement of the digestive organs. Particular methods of preparing and cooking food also greatly determine the extent of its utilisation. Individual peculiarities, habits, and various external circumstances, such as different climatic conditions, also influence the digestion and assimilation of different articles of diet. One of the most marked and most notable differences in the utilisation by man of habitual food-substances is that which is observed between animal and vegetable foods. The human digestive organs can assimilate vegetable foods far less completely than animal foods. The seeds of certain cereals when submitted to a special mode of preparation and cooking form the only exception to this rule. This difference in the power of utilising animal and vegetable foods is well illustrated in the following table of Fr. Hofmann quoted by Bauer. It gives the percentage proportions digested and undigested of several animal and vegetable alimentary substances : Weight f Foo- tible of mechanical subdivision. The lessened cohesion and increased mechanical divisibility which cooking imparts to food, greatly favour its digestibility, by 156 FOOD IN HEALTH. [Parti. enabling the digestive juices to come into intimate contact with it, and to penetrate readily into its sub- stance. Cooking thus leads to important mechanical and chemical changes in food, which greatly facili- tate its digestion. The exposure of food to a high temperature affords the further safeguard of destroying parasitic or other minute living creatures or germs which may acci- dentally be present in it. The effect of a certain degree of heat on animal flesh is that the albumen is coagu- lated, and the fibrous connective tissues are converted into gelatin. Nor is the warmth that cooking imparts to food a matter of indifference, for in many instances it promotes the digestive action of the stomach upon it, and increases its stimulating effects. Boiling^. One of the simplest and most con- venient modes of cooking animal food is that of boiling. One of the first effects of plunging meat into water is that some of the soluble constituents of the meat pass out into the water, a portion of the soluble albumen, of the extractives, and of the salts. To what extent these soluble constituents shall be extracted by the water, or be retained in the meat, will depend on the manner in which the process of boiling is carried out. In prolonged boiling more or less of the connective tissue is converted into gelatin, and is dissolved in the water ; some of the fat, of course, melts at this high temperature and floats on the surface. The water in which the meat is boiled is termed broth, or in French bouillon. When the object is to retain as much as possible of the soluble constituents in the meat, the process of boiling must be conducted differently from what it is when the contrary is desired, viz. to extract as much as possible of the nutritive constituents of the meat in the broth. In the first case, the meat, which should be in one large piece, is plunged into the water which is already boiling, and it is then kept on the boil for about five minutes. By this means the albuminous matter in the external layers of the joint is rapidly coagulated, so as to form Chap. VIM METHODS OF BOILING. 157 A protective layer on its surface ; this retains the juices and soluble constituents in the interior of the meat, and prevents their escape into the water. The meat is thus kept juicy and palatable throughout its interior, and the broth is thin and poor. After boiling briskly for five minutes, the cooking should be completed at a temperature of 160 to 170 F. If a lower tempera- ture than this be employed, the albuminous matter in the interior will not be properly coagulated, and the joint will cut with a raw and uncooked appearance ; and if this temperature be much exceeded, the muscular fibre tends to shrink and become hard and indigestible. Many cooks employ too great heat in boiling, and so cause the meat to be hard and shrunken. Liebig re- commended a temperature of 158 U to 160 F., and Parkes says after the first five minutes of boiling " the heat can scarcely be too low," and he points out that the <; temperature of coagulation of the albuminous substances differs in the different constituents ; one kind of albumen coagulates at as low a heat as 86^ F., if the muscle serum be very acid ; another albumen coagulates at 113 F. ; a large quantity of albumen coagulates at 167. The hamiato-globulin coagulates at 158 to 162, below which temperature the meat will be underdone. In boiling, ammonium sulphide is evolved with odoriferous compounds, ami an acid like acetic acid." If, on the other hand, the object is to make a rich and nutritious broth, and therefore to extract as much as possible of the soluble constituents of the meat into the water, a different method is followed. The meat, cut into small pieces, is put into cold water, and the temperature should then be gradually raised to about 150 or 160. Actual boiling should be avoided in making strong broth, in order to avoid the coagulation and precipitation of the albumen. But in the pre- paration of soups, prolonged boiling is needed in order fully to extract the gelatin. It is the gelatin, in- deed, which forms the basis of soups, for the coagulated albumen floating in the fluid is usually removed by 158 FOOD IN HEALTH. [Parti. straining. Boiled in this manner the nutritive prin- ciples of the meat pass out as completely as possible into the water in which it is cooked, and impart to it the flavour and much of the nutritive qualities of the meat, while only a tough, tasteless, stringy solid residue is left. We thus see that either the joint must be sacrificed to the broth, or the broth must be sacrificed to the joint. Of course, inferior parts of meat, and bones, may be largely utilised when our object is simply to make strong broth or soup. Parkes states that beef gives the weakest broth, containing in a pint about 150 grains of organic matter and 90 grains of salts. Mutton broth is a little stronger, and chicken broth strongest of all. About 82 per cent, of the salts of beef pass into the broth, i.e. all the chlorides and most of the phos- phates. Broth can also be made without the appli- cation of heat by digesting half a pound of finely- minced beef with a pint of water, to which four drops of hydrochloric acid have been added. This is richer in soluble albumen than when heat is employed. By using rather more hydrochloric acid, but no salt, heat can be applied up to 130 F., and by this method nearly 50 per cent, of the meat can be obtained in the broth. The effect, then, of boiling on the joint (cooked for its own sake, and not for the broth) is to coagu- late the albumen, to loosen the muscular fibres, and to abstract a portion of the water and some of the soluble extractives. There is, therefore, a con- siderable loss of weight in the process of boiling, variously estimated at from 20 to 30 and even 40 per cent. The clear broth, after skimming from it the melted fat, together with the coagulated albumen which collects on the surface with the fat, contains very little nutritive substance. It contains the salts of flesh, some gelatin and soluble extractives, and forms a fluid stimulating to the digestive organs, although not, perhaps, directly nutritious. According Chap, vii.] METHODS OF ROASTING. 159 to Bauer, 500 grammes of meat will suffice to prepare a litre of strong broth, which should be flavoured with a few aromatic vegetables. Roasting. This method of cooking retains the ' ' nutritive juices and the extractives more completely than boiling. In order to retain the juices as much as possible, the joint should be at first exposed to a strong heat, and afterwards cooked very slowly. By this method the surface layers are at once coagulated, water is evaporated, and a sort of crust is formed, which presents a barrier to the subsequent escape of the juices of the meat. The joint is removed to a greater distance from the fire, and the lower tempera- ture is allowed to penetrate slowly to the interior. By this means the albumen and the coloured juices of the flesh are slowly coagulated without any great shrinking and hardening of the muscular fibre. A certain amount of the meat juice, however, escapes during roasting, and this, together with the melted fat, forms the "gravy," to which some gelatin be- comes added when the high temperature is long maintained. Continual basting with the melted fat is an important part of the process, as it tends to diffuse the heat uniformly over the joint and to pre- vent scorching and too great hardening of the surface. As the surface becomes browned by the influence of a higher temperature, several new odorous and sapid substances are developed, which give to roast meat its characteristic odour and taste. If too strong a heat is employed, the fat is apt to undergo de- composition, and fatty acids are developed, attended with the disengagement of volatile products having a most penetrating and disagreeable odour, and often proving irritating to the digestive organs. If the tern- perature of the interior of the joint does not rise above 130 F., it remains reddish, blood-tinged, and "underdone." For beef, mutton, and game this temperature is sufficient, and gives the tenderest meat and the best-flavoured ; but for veal and poultry a higher temperature 158 to 160 F. is needed. 160 - &oob IN HEALTH. [Parti. The colouring-matter of the blood, as we have seen, coagulates at this point. If the temperature is allowed to exceed this, the muscular fibre becomes hard and tasteless. In roasting small joints, in order to keep them juicy and savoury and " underdone " throughout, they must be put for a short time in very hot fat, as in cooking steaks ; so, also, in order to avoid the formation of a hard, dry crust on lean meat, it should be freely basted with added fat. The loss of weight in roasting is due chiefly to loss of water, and is estimated variously by different writers. Bauer puts it at a much lower percentage than that by boiling, viz. 20 to 24 per cent. ; Parkes gives 20 to 35 per cent. about the same as in boil- ing ; but probably much depends on the method of roasting. The loss in baking is said to be rather less. In other methods of cooking meat, the changes it undergoes are essentially the same as in boiling and roasting. One of the most popular is Slewinjy. In this process the meat is usually cut up into small or moderately-sized portions, and placed in just enough water to cover it. It is then allowed to simmer gently for a considerable time. The meat should be cooked slowly ; and the water should not be allowed to boil, for if boiling occur, the meat will become tough and hard. Much of the nutritive matters of the meat passes out into the surrounding liquid, which becomes thick, rich, and greasy, to which sliced vegetables and other flavour- ing ingredients are usually added. When properly stewed, tl;e texture of the meat becomes greatly loosened, so that it breaks down readily under pressure, and should be thus rendered easy of diges- tion ; but the other substances and the sauces so frequently added to stews often interfere greatly with their digestibility ; and it is probable that when, as is not uncommon, the stewed substances are kept for a very long time at a high temperature, toxic products may be developed by decomposition of chap, vii.j BRAISING. 161 some of the albuminates. Stewing is an economical method of cooking meat, as the loss is much less than in boiling or roasting, viz. about 20 per cent., and is chiefly due to the water evaporated. The whole of the stew is eaten meat, vegetables, and gravy so that there is no loss of nutritive constituents. When this process is applied to previously-cooked meat it is termed a "hash." In this the meat is often hard, dry and tasteless. Braising. Sir Henry Thompson has called at- tention to the neglect in England of the method of " braising " in cooking. He refers to it as a valuable process in the preparation of animal food, and as " superior in some respects to that which the term ' stewing ' denotes. In braising, the meat is just covered with a strong liquor of vegetable and animal juices (technically called braise or mirepoix) in a closely covered vessel, from which as little evapora- tion as possible is permitted, and is exposed for a considerable time to a surrounding heat just short of boiling. By this treatment tough, fibrous flesh, even if old, whether of poultry, of cattle, or meat unduly fresh, such as it is difficult to avoid during the sum- mer heats in town, is made tender and easily digestible. Moreover, it becomes impregnated with the odour and flavour of fresh vegetables and sweet herbs, while the liquor itself, slowly reduced in the process, furnishes the most appropriate, fragrant, and delicious sauce with which to surround the portion when served at table. Thus also meats which are dry, or with little natural flavour, as veal, become saturated with juices, and combined with sapid substances, which render the food succulent and delicious to the palate. Small portions sufficing for a single meal, however small the family, can be thus dealt with. . . The first principle essential to a braise is that the meat so to be treated must be very slowly cooked in a closely covered vessel, and with a small quantity of liquid. The second principle is that the meat shall be impregnated in this process with the flavour of vegetables, herbs, etc., L 1 6z FOOD IN HEALTH. [Parti. and of some spices and, if desired, with wine. This is to be done by placing in the braise-pot around the meat slices of ham or bacon, cut carrots, parsnips, turnips, onions, various herbs, a bay -leaf, cloves, and other spices, and a little wine ; together with a small quantity of good meat stock. . . The third principle is not generally considered absolutely essential to the process, although it is undoubtedly the last refinement necessary to produce a first-rate braise. It is that of partially browning or half roasting the portion also, and this may be accomplished in two ways. The legitimate or original way of doing this is to have well-fitted to the braise-pot a sunk copper or iron cover, in which some hot coals or charcoal are placed, in order to transmit downwards a scorching heat to the top of the portion which is uncovered by the liquid in the pot below. In this case it is usual to cover the portions, especially of a fowl, with a piece of white paper, which serves to shield a delicate morsel from a too fierce heat. The other and inferior way is very lightly to roast the meat before putting it into the pot to braise, and so dispense with th coals on the cover ; but this hardens it and prevent the juices from penetrating." * Broiling or grilling is the same as roasting, only it is applied to smaller portions of meat, and is therefore a much more rapid process, and a far larger surface is exposed to the direct action of a high temperature. In order to preserve the juices within the meat the same principle must be applied as in roasting. It is a method which develops the flavour of the meat very completely, and has the further advantage of being rapid and convenient. The flavour of baked meat is inferior to that of meat roasted before an open fire, for when cooked at a high temperature in a confined space, the volatile fatty acids generated in the process are unable to escape, and they are therefore retained in contact with the joint, which acquires a rich, strong flavour, and is * " Food and Feeding." chap, vii.] FRYING. 163 unsuited for the consumption of persons of delicate digestions. Frying is also a mode of cooking meat ill suited for* the purpose of increasing its digestibility. Usually the meat, cut into thin slices, is put into boiling oil or fat with which it becomes more or less saturated, and is thus rendered somewhat impermeable to the digestive juices. Fatty acids, developed during the action of a high temperature on the fat, are also apt to remain in contact with the meat, and to lead to disturbance of the digestive process, attended with the formation of irritating acid substances in the stomach.* Whatever method of cooking meat be adopted, one great rule should always be attended to, viz. to cook the meat slowly and with as little heat as possible, so that the loss may be chiefly due to the water evaporated. t Too great heat is commonly employed in cooking on a large scale, and the meat, instead of being juicy and full of flavour, is often sodden and tasteless, and the muscular fibres are hard, shrunken, and indigestible. * Some critical remarks on the process of frying, by Sir Henry Thompson, may be studied with advantage. "The art of frying," he says, "is little understood, and the omelette is almost entirely neglected by our countrymen. The products of our frying-pan are often greasy, and therefore for many persons indigestible, the shallow form of the pan being unsuited for the process of boiling in oil that is, at a heat of nearly 500 F. This high temperature produces results which are equivalent indeed to quick roasting, when the article to be cooked is immersed in the boiling fat. Frying, as generally conducted, is rather a com- bination of broiling and toasting or scorching ; and the use of the deep pan of boiling oil or dripping, which is essential to the right performance of the process, and especially preventing greasine=s, is a rare exception and not the rule in ordinary kitchens. The principle on which success depends is, that at the moment of con- tact with the almost boiling oil, a thin film of every part of the surface of the fish or other object to be fried is coagulated, so that the juices with their flavours, etc., are at once locked up within, and no quality can escape. The bath of oil should therefore be in quantity sufficient, and also be hot enough to effect this result in an instant ; after which, and during the few minutes requisite to cook the interior, the heat is often slightly lowered with advantage." t Parkes states that the loss to the soldier from cutting up, from bone and from cooking, amounts to 6 or 7 out of 12 oz. L2 164 FOOD IN HEALTH. {Pani. In cooking salt meat, which is invariably boiled, the heat should be applied very slowly and for a long time ; the addition of a little vinegar is said to have a useful softening effect. Fish is cooked for the same purpose as meat, and is usually either boiled, grilled, or fried. It is most easily digested when boiled ; the next best method is grilling. Fish requires to be thoroughly boiled, so that it can readily be detached from the bones ; but it requires a shorter time than meat. The harder the water in which it is boiled the firmer is the flesh of the fish. Fish boiled in sea-water, or in water to which salt has been added, is firmer and of finer flavour than when boiled in soft water, because of the solvent effect of the latter. Fish fried in fat is not a suitable food for persons of delicate digestion. The preparation and nutritive value of soups, broths, and the various meat extracts, will be more conveniently considered hereafter. The Cooking of Vegetable Foods must next be considered. Many vegetable substances used for food by man are absolutely inedible in the raw, unprepared condition, while others are rendered more palatable and digestible by cooking processes. Mechanical sub- division and the action of a high temperature are the chief processes applied to the preparation of vegetable foods. By these processes the vegetable structures are softened and the intercellular substance is loosened, so that they are more readily amenable to the pro- cesses of mastication ; by rupture of the cell walls, the nutritive cell contents are set free, while by the action of heat on the starch granules, the principal alimentary constituent in vegetable tissues, important physical changes occur which greatly aid the digestion of starch. Heat causes the starch granule to swell up, its outer envelope is ruptured, and its contents are set free, so that they can be readily acted on by the digestive secretions. Unless submitted to this chap, vii.] BKEAD-MAKING. 165 influence, the outer envelope of the starch granule offers great resistance to the action of the digestive juices on its contents. Besides this action on the starch granules, cooking, as in the case of animal food, coagulates any soluble albuminous substances in the vegetable tissues or juices ; and in boiling, the soluble, gummy, saccharine, colouring and saline matters are, of course, to a great extent extracted in the water. Undoubtedly, Bread-making is one of the most important cooking processes that are applied to the preparation of human food, and it is practised amongst all civilised nations. The art of bread-making consists in converting flour or meal into a firm and porous substance, which can be readily masticated, and which, while it retains a certain amount of water,, is not noticeably moist or sticky. The first step in this "process is the formation of a dough or paste by mixing the flour with a certain quantity of water and kneading this together by the hands or by machinery. The next step is to impart the necessary property of porosity by intimately mixing carbonic acid with the dough, either by generating it within its substance, or forcing it in from without. The first of these methods may be effected either by fermentation or by the use of so-called "baking powders"; and the second by Dauglish's process for forcing carbonic acid into the dough by pressure. Owing to the tenacity of the gluten of the meal, the vesicles of gas are held together, and a light, spongy mass is formed. It is then exposed, in suitable portions, to the" heat of the oven, and by the process of baking it is solidified and converted into a firm and permanently porous bread. Leavened bread is the term applied to bread in which the carbonic acid has been generated by fer- mentation. - The ferment used is either yeast or leaven, that is, old dough in a state of fermentation. The yeast furrgus, Torula or Sacdiaroinycetes cerevisice, 166 FOOD IN HEALTH. [Parti. is the active agent in either case. This converts the sugar in the dough into alcohol and carbonic acid. It is usual in making bread by fermentation to mix a certain quantity of the flour with the ferment, some salt, and lukewarm water. These are kneaded into a stiff paste or dough, which is placed aside in a warm situation for an hour or two. The mass gradually swells up, from the evolution of carbonic acid gas, or, as the baker, terms it, the sponge rises. When the sponge is in active fermentation it is ^thoroughly kneaded with the remainder of the flour, salt and water, and again set aside for a few hours in a warm situation. Fermentation extends throughout the whole, and, at the proper moment, the dough is made into loaves and introduced into the oven. Herein constitutes one of the chief points in the -taker's art. Unless fermentation lias been allowed to proceed far enough, a heavy loaf is the result; and if allowed to proceed too far, an objectionable quality is given to the bread by the commencement of another an acid fermentation. This is said to be more likely to occur, with the formation of acetic, butyric and lactic acids, when " leaven " has been used as the ferment, and that bread so made has, as a rule, a more or less sour taste. The alcohol is driven off by the heat of the oven in baking. The best-flavoured bread is said to be that made with brewer's yeast. The necessary porosity may also be given to the dough by the use of baking powder for the evolution of carbonic acid gas. Berwick's baking- powder con- sists of a mixture of~carbonate of soda and tartaric acid ; and Liebig's, which is by some considered more wholesome, of a mixture of the acid phosphate of calcium with carbonate of soda and chloride of potassium ; or carbonate of ammonia may be mixed with the dough, and hydrochloric acid added. The bread thus made has a less agreeable taste than that made by fermentation, and it is a process rarely employed by bakers. Dauglish's process, which is now largely carried Chap, vii.] BREAD-MAKING. 167 out by the Aerated Bread Company, consists in forcing carbonic acid through the dough by pressure, and it claims as one of its recommendations that the manipu- lation of the dough by the hands of the baker is avoided. It is also considered to have the advantage over fermentation, that it is impossible for the con- version of starch into dextrin, sugar, and lactic acid to go too far. About twenty cubic feet of carbonic acid, derived from chalk and sulphuric acid, are used for 280 pounds of flour, and about eleven cubic feet are actually incorporated with the flour. It is said to keep sweet and good much longer than fermented bread, but it has a peculiar taste, and lacks the pleasant flavour of the best fermented bread ; more- over, it is always drier, and in keeping even for a short time becomes very hard and brittle. Salt is usually addjed to bread to improve its flavour and appearance, giving it greater whiteness and firmness. The effect of the heat applied in baking, on the constituents of the flour, is to increase their digesti- bility, the nitrogenous constituents are changed, the starch granules are ruptured, and a portion of the starch is converted into dextrin and grape sugar. Bread varies much both in its digestibility and nutritive properties, just as it differs also in its physical appearance and chemical composition. These differences depend partly on the mode of preparation and partly on the kind of meal employed. Badly-made bread is often the cause of dyspepsia ; the fermentative changes continue in the stomach with generation of carbonic acid gas, and consequent flatulence, heartburn, and acid eructations. This has been attributed to the use of unwholesome yeast ; and it has been urged in favour of aerated bread made by the Dauglish method that it is free from such risks; but bread may certainly be badly imi'le, and on that account indigestible, without the fault being necessarily in the yeast. It is undoubtedly a 1 68 IN HEALTH. (Part I. great drawback to the use of the coarser meals and of whole meal for making bread that such bread is often indigestible and heavy, and productive of dyspepsia in some persons of feeble digestion. This is probably, in great measure, due to the diminished porosity of such bread, for it seems to resist aeration and vesicu- lation to the same degree as is common in the best qualities of white bread. Bauer observes of bread made of coarse, adhesive meal : " Such adhesive breads are very imperfectly utilised by the human organs of digestion, since the irritation they cause to the mucous membrane of the alimentary canal leads to a rapid progress and early evacuation of its con- tents " a property, however, often " usefully em- ployed to overcome habitual sluggishness of the bowels." Dujardin - Beaumetz also protests against the common error that the coarser kinds of household bread are more nutritious than the very fine white "fancy " breads (pains de luxe). In the first place, it must be remembered that such bread is prepared and baked with unusual care and skill, and is thoroughly aerated and light, and thereby rendered more easy of digestion. In the second place, it would seem to be richer in nitro- genous constituents. The following figures, comparing the percentage proportion of nitrogen in three quali- ties of bread seconds, firsts, and " fancy " bread are quoted by Dujardin-Beaumetz from Violet (" Sur le Pain ") : PERCENTAGE OF NITROGEN. 1st Specimen 2nd 3id Average Seconds. Firsts. '' Fancy." 0-92 ro-5 0-99 I'll 1-36 T02 1 -89 2-06 1-2-5 0-99 1-16 1-57 Chap. VII.] BREA o-MA KING. 169 The composition of some different kinds of bread is thus given by Bauer :* in 100 parts ii a- M 4) I 3 . C m C M | c ^ ^ ja j Id Sex; i2 u S ?i5 ^ "S ^^ m to 12 -5s 5 "^ g"' 'S ^ Fine Wheaten Bread 38-51 6-82 0-77 2-37 40-97 0-38 1-18 English 37-00 8-10 1-60 3-6 47-40 2-30 (Joai-st; ,, ,, 41-02 6-23 0-22 2-13 48-69 0-6-2 1-09 Rye Bread 44-02 6-0 ( J 0-48 2-54 45 33 030 1-31 A great deal has been written, without very much reflection and without any very great regard to accu- racy, about the evils attending the separation of the "bran," or outer coat of wheat, from the flour of which bread is made. It has been urged that not only is this practice very wasteful, but that it leads to the loss in the bread made from such flour of much of the most important nutritive constituents of the grain ; and, indeed, it is admitted that the bran is rich in nitrogenous (15 per cent.), fatty (3-5 per cent.), and mineral substances (6'7 per cent., chiefly phosphates). But, as has been pointed out by Parkes and others, if the " bran " is used, much of it is probably entirely undigested, and it can therefore yield but little nutriment, and that, unless ground very fine, the outer envelopes of the grain are very irritating, and especially unsuited to sick persons with any tendency to intestinal irritation ; indeed, according to Parkes, " dysenteries have been found most intractable merely from attention not being directed to this simple point." The method, now extensively adopted, of decorticating the grain that is, of removing the two or three outer highly silicious envelopes and leaving the fourth or inner envelope has certainly more to recommend it, and it * Abstracted from a larger table in his "Dietary of the Sick." 170 FOOD IN HEALTH. [Parti. no doubt yields a meal very suitable for bread-making, especially for young and growing persons with sound and active digestions; but we have seen some other- wise very pleasant bread made from such decorti- cated whole-wheat meal prove very indigestible to adults leading sedentary lives. It makes a bread which is usually heavier, moister, and of closer texture than that made from the finest white flour. Sir Henry Thompson advocates strongly that the bread of the labourer should be made from entire wheat meal ; " but it should not be so coarsely ground as that commonly sold in London as ' whole meal.' This coarse meal does not readily produce light, agreeable bread when made in the form of ordi- nary loaves : a solid, mass of this meal, being a bad conductor of heat, will have a hard, flinty crust if baked sufficiently to cook the interior ; or it will have a soft, dough-like interior if the baking is checked when the crust is properly done. Con- sequently the form of a flat cake, resembling that of the Ordinary tea-cake, is preferable, since it admits of the right amount of heat operating equally through- out the mass. The following recipe will be found successful, probably after a trial or two, in pro- ducing excellent, light, friable, and most palatable bread : To 2 Ib. of coarsely-ground or crushed whole wheat-meal, add half-a-pound of fine flour and a sufficient quantity of baking powder and salt ; when these are well mixed, rub in about 2 oz. of butter, and make into dough with half milk and water, with skimmed milk (warm), or with all milk, if preferred. Make into flat cakes like 'tea-cakes,' and bake with- out delay in a quick oven, leaving them afterwards to finish thoroughly at a lower temperature. The butter and milk supply fatty matter, in which the wheat is somewhat deficient. A palatable addition is made, in my opinion, by exchanging the half-a- pound of flour ordered in the foregoing recipe for the same quantity of medium-fine Scotch oatmeal. Chap vii.] BREA D-MA KING. 1 7 1 The change adds to the brittleness and lightness of the product" The baking powder is made by mixing well to- gether Tartaric acid, 2 oz. ; bicarbonate of soda, 3 oz. ; common arrowroot, 3 oz. Keep perfectly dry in a wide-mouthed bottle. The advantages of bread as an article of diet are familiar to everyone. It contains a large amount of albuminates and carbohydrates ; the nitrogen is in the proportion of 1 to 21 of the carbon, so that the addition of some nitrogen would be necessary to make it a perfect food. It is deficient in fat and, if the outer coverings of the grain are entirely removed, in mineral substances. But man never tires of its use, probably because of the great variety of its constituents. A further cooking of bread in the form of toasting is often resorted to, and it appears to increase its digestibility ; there is a further loss of water, and the surfaces are scorched, and the bread is made tinner and crisper. It should be toasted in slices thin enough to be made crisp all through ; when they are thick the central part becomes soft like new bread. New bread is well known to be less digestible than stale ; the former being soft and moist is more difficult of mastica- tion and insalivation, as it tends to clog together in heavy adhesive masses which are not porous enough to allow of the free access of the digestive juices. Bread, when stale, has the peculiar property of becoming soft and like new bread on re-baking or exposing for a short time to a high temperature ; this has been accounted for on the hypothesis that when bread gets dry by keeping, the water enters into chemical com- bination with the solid constituents, for if it were due to evaporation of the contained water, it would be impossible to make it appear fresh and new by re-heating. Wheat flour, and the meal of other cereals, is also cooked in various other ways besides being made into bread. Biscuit, as the name signifies, is made of dough which is bakrd much longer, and is harder 172 FOOD IN HEALJH. [Part i. and drier than ordinary bread, so that it can be preserved for a much longer time. In tlie French army, besides the pain de munition, or ordinary bread, which is reckoned to keep from five to eight days, according to the season, they have when on active service pain biscuite, which will keep forty to fifty days. They have also pain demi-biscuite, which can be preserved twenty to thirty days. The simplest kind of biscuit is made of flour and water only, or a very little butter is added to prevent it from becoming too dry and hard. Such is the ordinary "ship" or sailor's biscuit. The advantages of biscuit of this kind are that it contains but little water, and is therefore, bulk for bulk, more nutritious than bread, three-quarters of a pound of biscuit being equivalent to one pound of bread ; it occupies less space, and is more transportable. Its disadvantages are, that it tends, by keeping, to get very hard and dry, and to become, after long restriction to its use, unpalatable and indigestible, and it is found better for the health of troops to issue a bread ration when- ever possible, and to use biscuit only when bread cannot be procui'ed. Parkes calls attention to the value of "unfermented cakes" made simply with water and salt, as a substitute for biscuit in war time. They are palatable, nutritious, and readily made ; and he thinks every soldier should be taught to make them. "The Australian damper is simply made by digging a hole in the ground, filling it with a wood fire, and when the fire has thoroughly burnt up, removing it, placing the dough on a large stone, covering it with a tin plate, and heaping the hot ashes round and over it. In a campaign every soldier, if he could get flour and wood, would soon learn to bake a cake for himself. The only point of manipu- lation which requires practice is not to have the heat too great ; if it be above 212 F., too much of the starch is changed into dextrin, and the cake is tough. Ex- posed to greater heat and well dried, the unfermented cakes become biscuit." Chap, vii.] MACARONI, VERMICELLI, ETC. 173 Various other kinds of biscuit are prepared in which sugar, eggs, milk, etc., enter as constituents, and sometimes baking powder or carbonate of ammonia (on account of its volatility) is added to the dough to give them porosity and lightness. Puddings, pastry, sweet cakes, etc., are made of flour mixed with butter, eggs, sugar, and other sub- ' stances. These are cooked at a high temperature, being usually baked or boiled, and the flour undergoes . similar changes to those which occur in making bread. They are, however, generally rich, and apt to cause < stomach disturbances, particularly in the dyspeptic. Pastry is especially unwholesome on account of the 4 changes which the heat of the oven causes in the fats . mixed with it ; and boiled pudding or paste is in- ' digestible because it usually forms a solid tenacious mass, not porous like bread, and is penetrated with difficulty by the digestive fluids. Macaroni, Vermicelli, Pate d'ltalie, etc., are all preparations of flour usually made from hard Italian wheat, rich in gluten. A stiff paste is made with flour and hot water, and this is pressed through holes in metal plates, or stamped into various forms, heat being applied at the same time. They have the advantage of keeping well and being very nutri- tious in small bulk, and so are convenient for trans- port. Of macaroni Sir H. Thompson observes: "It is certainly to be lamented that so little use is made in our country of Italian pastes. Macaroni in all its forms is, in fact, an aliment of very high nutritious power, being formed chiefly of gluten, the most valu- able part of the wheat from which the starch has been removed. Weight for weight it may be regarded as not less valuable for flesh-making purposes, in the animal economy, than beef or mutton. Most people can digest it more easily and more rapidly than meat ; it otters therefore an admirable substitute for meat, par- ticularly for lunch or mid-day meals. . . Macaroni might with advantage be prepared at restaurants as a 174 FOOD IN HEALTH. iParti. staple dish in two or three forms, since it sustains the power without taxing too much the digestion. One of the best forms for serving it is that known as macaroni a I'Jtalienne." * Many kinds of farinaceous foods are prepared by boiling with milk, eggs, etc., and served in semi-fluid form easy of digestion, and very suitable for invalids, young children, and persons of delicate digestion. Oatmeal gruel, rice-milk, and milk puddings made with sago, arrowroot, tapioca, macaroni, etc., afford very useful foods, especially appropriate to states of convalescence, and as a transition from fluid to solid foods. Rice requires to be cooked carefully, or the grains will remain hard and indigestible ; thorough steam- ing, so that the starch granules shall be completely swollen, is the best process to adopt. Peas and beans also require thorough boiling, slowly, and for a long time, in order to be made diges- tible. If old, no amount of boiling will soften them ; they must then be soaked in cold water for twenty-four hours, crushed and stewed. The potato, a vegetable rich in starch, also requires cai-eful cooking. Steaming is the best method, as there is then no loss of salts, but the heat should be moderate. If boiled, it should be in their skins to prevent the loss of salts, and the boiling must be thorough or the starch granules will remain indiges- tible ; and also slow, otherwise the cellulose and albuminates will be hard. " Mashed potatoes " is a useful method of serving this vegetable, as it effectually gets rid of the hard indigestible masses into which a badly cooked or imperfectly masticated potato is apt to reach the stomach. Most fresh green vegetables and edible roots are boiled in water according to definite culinary rules, and their digestibility and wholesomeness depend greatly on their being well and carefully cooked. * A recipe for making this will be found in the Appendix. chap, vii.] PRESERVATION OF FOOD. 175 They should be selected young and tender, and boiled sufficiently to acquire the necessary softness. Their digestibility is greatly increased, and their irritating properties avoided by reducing them into the form of purees whenever this is possible. Vegetables of the cabbage tribe give a peculiarly disagreeable odour to the water, " green-water," in which they are boiled, so that they must be boiled alone and the water thrown away. Salads are prepared both with cooked and un- cooked vegetables, and are usually " dressed " with a mixture of oil, vinegar, and other condiments. They are useful for stimulating appetite, and giving relish to other food, but they do not constitute suitable food for invalids, as they are somewhat difficult of digestion. Many fruits are also submitted to a cooking process, in order to soften them and make them more easy of digestion. The preservation of food. Various means have at all times been adopted by the human race to prevent or retard the decomposition of food sub- stances, so as to render them transportable from place to place, or to store them up when procurable in abundance, for use in periods of scarcity, or to pre- serve them from one season to another. By the application of the various means available for preserving foods, the produce of different countries becomes interchangeable, and the over-abundance of one region supplies the deficiencies of another ; and, indeed, a great part of the world's commerce consists in the transport of food supplies between distant countries. Foods that contain very little water, such as various cereal grains and the pulses, only require to be kept dry and clean, in order to remain sound and in a good state of preservation for long periods, but all kinds of food, both animal and vegetable, into the composition of which water enters largely, can only be pi-evented from undergoing decomposition for any 176 FOOD IN HEALTH. [Parti. considerable time by special methods of preservation. These methods are mainly four in number : 1. The method of drying food, or getting rid of the greater part of the water contained in it. 2. The exclusion of atmospheric air ; or, what amounts to the same thing, covering the food with an impermeable coating. 3. Exposure to cold. 4. Treatment with antiseptic chemical agents. 1 . Some of these methods are frequently combined. Drying by exposure to the air is a very ancient and very primitive method of preserving animal food, and is practised largely in savage or half-civilised communi- ties. In countries where the air is dry and pure, and the solar radiation intense, it is a ready and con- venient method; the meat is simply cut into slices and exposed to the air. The Kaffirs thus preserve large masses of beef that have been sun-dried. The Egyptians also preserve meat by exposing it to the sun and north wind. Charqui is the name given in South America to strips and slices of beef, freed from fat and dried rapidly by sun heat, and sprinkled with maize. Tasajos is also a preserved meat prepared in South America, by cutting it in thin slices, then dipping it in brine and partially drying. Pemmican, a food used by Arctic travellers, consists of a mixture of the best beef and fat fried together, and is very nutritious, but costly. Sugar is sometimes added to it, as well as raisins and currants, which increases its value when fresh vegetables are not procurable. Meat may also be dried at a very low heat ; it gets very hard from having lost the greater part of its water, and requires careful cooking. There is a preparation of dried meat by M'Call, of London, which retains 12 per cent, of water, and is flavoured with pepper and salt. It is sold in 4 oz. packets, and is said to be very good and nutritious. Chap, vii.] PRESERVATION OF FOOD. 177 The French use powdered dried meat largely for adding to invalids' foods. La poudre de viande Rousseau is one of the most popular ; it is said to keep for any length of time, to be of an agreeable odour and taste, and to be readily digested. There are also the Poudres de bifteck et de viande Adrian, the former being prepared from French beef, the latter from American. HassalVs flour of meat is analogous to these pre- parations. It is said by Parkes to be composed of good fresh meat, freed from visible fat, and carefully dried at a very low temperature, and pulverised by machinery, so as to form a very fine, smooth powder. This is mixed with about 8 per cent, of arrowroot, 2^- per cent, of sugar, and 3 per cent, of a mixture of salt, pepper, spices, and colouring matter. The object of the arrowroot is to assist its suspension in water. It keeps well in tins, but it should not be exposed to the air for long at a time. Bread is also preserved by drying ; the " pain biscuite" of the French army is bread dried by heat, and bread from which the water has been partially pressed out by hydraulic pressure will keep good for years. Potatoes, too, are preserved by drying. They are either in slices or granulated. This preparation is easily cooked (should be steamed, after soaking in cold water) and is very palatable. Analyses made by Pro- fessors Attneld and De Chauinont showed that one pound of preserved potatoes contained the solid matter of three and a half pounds of ordinary fresh potatoes. Other vegetables can be dried arid compressed, such as peas, cauliflower, carrots, etc., and so successfully, that those of Masson and Challott, if properly cooked, are almost equal to fresh vegetables. They must lie cooked very slowly. Professor Attneld's analysis showed that dried compressed cabbage contained th" solids of seven times its weight of fresh cabbage, and the mixed vegetables five and a half times the solids of the fresh vegetables. The experience of the American war showed that as anti-scorbutics they 1 78 FOOD IN HEALTH. (Parti. were much better than nothing, but inferior, however, to fresh vegetables. Vegetables preserved in bulk, without drying, are much better as food, and as anti- scorbutics. Milk can also be preserved by drying, and is sold as a powder. Eggs can be dried, but the yolk does not keep well. Mixed with flour, ground rice, etc., both yolk and white can be dried and preserved. The drying of fruits is a very well-known means of preserving them. A combination of drying, salting, and smoking is a very common domestic method of preserving several kinds of animal food. 2. The exclusion of air is another largely employed method of preserving food. The immersion of fish (previously somewhat salted) in oil, the covering of potted meats with a layer of melted fat, are familiar illustrations of this process. By simply exposing the surface of meat to a strong heat, so as to coagulate the outside albuminous layers, it can be, on this principle, kept for some time. Any means by which foods can be covered with an impermeable coating, and so protected from the action of the air, will usually preserve them for a long time ; in this way by coating eggs with a solution of bees' wax in warm olive oil (one-third of bees' wax to two- thirds of olive oil) they may be preserved for two years. Eggs are also preserved by packing iu sawdust or salt, or by covering them with gum, butter, or oil, indeed anything which excludes air. A modification of this method is one described by Parkes. " Meat being cut into smaller portions and placed in a large vessel, heat should be applied, and while hot, the mouth of the vessel should be closed tightly with well- washed and dried cotton-wool ; the air is filtered, and partially freed from germs." Covering the whole surface of meat with a coating of paraffin, or embedding it in powdered charcoal, is also a preservative measure representing applications of this method. Tinned and Chap, vii.] PRESERVATION OF FOOD. 179 bottled provisions are all preserved on the principle of the exclusion of air. The food to be preserved having been introduced into a suitable vessel, heat is applied so as to generate steam, in order to drive out the air, the opening of the vessel is then closed and made air-tight. What is known as Appert's process consists simply in the complete exclusion of air. M'CalPs process consists in partial exclusion of air, and acting on the residue by sodium sulphite ; this latter process avoids the application of so high a temperature as is needed in the former. Another method is to draw off the air and substitute a mixture of nitrogen and a little sul- phurous acid in its place. Meat, fruit, vegetables, and all kinds of provisions may be preserved for a great length of time by application of this method. Milk may be kept in the same way, but the butter is apt to separate, and this may be prevented by con- centrating the milk and adding some sugar. It is usual to add about 80 grammes of cane sugar to one litre of milk, and evaporate the whole to one-fifth of its volume, and it is sealed up while hot in air-tight tins ; when given to children a suitable proportion is first dissolved in cold water and then boiled. By LoefBund's process it is preserved unsweetened. 3. Another method is the application of cold. It is a well-known domestic expedient to keep perishable food substances on ice, and fish is invariably packed in ice to convey it to market, and to preserve it fresh until cooked. In ice, meat can be preserved for an unlimited period, and the supposed tendency to rapid decomposition after thawing appears to have been exaggerated. It is, however, certain that frozen meat loses about 10 per cent, more in cooking than freshly- killed meat. Large quantities of meat are now im- ported from America and Australia in refrigerating chambers. The refrigerating chamber is now an essential part of the equipment of ocean-going steamers, and thanks to it passengers can now be provided with fresh provisions all through the voyage. v 2 180 FOOD IN HEALTH. [Parti. 4. And lastly, there is the method of preservation by antiseptic chemical agents, a method which is often combined with one of the others. Salting and smoking, associated often with drying, represent the earliest efforts in this direction. Salting is one of the oldest methods of preserving meat ; a small quantity of salt- petre is usually added to the common salt to preserve a red colour in the flesh. Smoking is usually applied after salting. The creosote and other constituents of the smoke penetrate the substance exposed to it, and exercise a highly antiseptic and preservative action upon it. A certain amount of drying and coagulation of the albumen on the surface occurs at the same time. One of the great objections to salting is that a portion of the salts and extractives, and a considerable amount of the albuminates, pass out into the brine. Analysis of the brine has shown that it contains much of the nutritious principle of the meat, both organic and mineral. Liebig estimated the nutritive loss at one-third or more. Kuhne has found that myosiii is soluble in a 10 per cent, solution of chloride of sodium \ hence a large quantity of this substance necessarily passes into the brine. The muscular fibre is also hardened by the salt, and rendered indigestible. Parkes considers salt beef to be of rather less than two-thirds the value of fresh beef. Whitelaw was able to obtain by dialysis a large quantity of flesh extract from the brine of salt beef ; from two gallons of brine a fluid was obtained which, on evaporation, yielded one pound of extract. Brine has sometimes been found to be poisonous ; this occurs when it has been used over and over again. A large quantity of animal substance passes into it and appears to decompose, but no special poisonous agent has been isolated. Another important con- sideration is that the long-continued use of salted meat leads to a deterioration of health, and the development of scurvy. The flesh of the hog, however, seems especially adapted to salting and smoking, and its digestibility Chap, vii.] PRESERVATION OF FOOD. 181 and wholesomeness are increased rather than diminished thereby. Bauer speaks of " smoked bacon as one of the wholesomest forms of meat. Whether boiled or eaten raw, it seems as a rule to be more easily digested by weak organs than almost any other. It appears to me not improbable that the flesh becomes more digestible in the process of smoking." Fish, such as salmon, herrings, cod, haddock, sprats, and many other kinds, are preserved in vast quantities, by salting and smoking together, or by salting alone. Immersion in vinegar, alcohol, or strong syrup, the application of sugar to the surface, are also common expedients for preserving both animal and vegetable foods. There are many other antiseptic agents used for preserving food, such as the vapour of sulphur, the meat being placed in a close vessel in which sulphur is burnt ; or charcoal, which is dusted over its surface ; or strong acetic acid ; or calcium disulpkide-; or weak carbolic acid. Injection of alum and chloride of aluminum into the blood-vessels will preserve meat for a long time ; water should be injected first and the antiseptic solution afterwards. Borax, boric acid and salicylic acid have all been used for the preservation of food. Aseptin, a powder, and Aseptin amykos, a liquid Swedish nostrum, used in the preservation of food, both owe their antiseptic properties to boric acid. This acid is also used largely in England and other countries for preserving milk. It is regarded by most authorities as harmless. A substance termed Boro- glyceride, a preparation patented by Barft' in England and Le Bon in France, is made by heating together boric acid (62 parts) and glycerine (92 parts). It forms a tough, deliquescent mass, readily soluble in water and alcohol ; and in solution in water in the proportion of one to forty it is extensively used as an antiseptic for the preservation of meat, fish, milk, and other food. Another substance termed G'lacialin has 1 82 FOOD IN HEALTH. [Parti. been recommended for the same purpose ; this consists of borax, boric acid, sugar and glycerine. Much discussion has taken place, especially on the Continent, as to the propriety of allowing salicylic acid to be used for the preservation of wine, beer, milk, fish, meat, fruit and other food substances ; and the decision has been almost universally against its use as being distinctly injurious to the healthy organism. In addition to the preced ing general account of the different methods of preserving foods, it may be useful to describe the measures usually adopted for preserving particular important articles of diet. Milk may be preserved by various means. 1. It may be boiled, then placed in a bottle which should be completely filled and at once corked up and sealed so as to be air-tight. The milk lessens in bulk, a vacuum is formed on its surface, and in this way it will keep for some time. It will keep longer if a little sugar be added. If it is heated in a close vessel to 250 F., it will keep for years. The butter may, how- ever, separate. 2. The passing of sulphurous acid gas through milk .after boiling, or the addition of sodium sulphite to it, will preserve it for some time. 3. The addition of a little carbonate of soda and sugar, with or without boiling, will keep it for ten or twelve days. 4. The addition of boric acid and the other antiseptics already mentioned. The method of preserving concentrated milk in tins has been de- scribed. Desiccated or dried milk is milk mixed with a little sugar and dried at a low temperature. It is said to form an excellent milk when dissolved in water. Butter. The tendency of butter to become rancid, especially in hot weather, is well known. This is due to the presence of some of the albuminous constituents of the milk, which, acting as a ferment, cause the setting free of the fatty acids. Washing the butter thoroughly, so as to separate these sub- stances completely, contributes greatly to its subsequent preservation. Indeed, it may be preserved for some Chap, vii.] PRESERVATION OF FOOD. 183 time, but at the cost of some loss of flavour, by melting and shaking with boiling water so as com- pletely to remove these substances. Butter also that has become rancid may be again rendered eatable by melting and agitating it repeatedly with boiling water, which removes the fatty acids ; while melted it should be poured into ice-cold water. Salt is used very largely in the preservation of butter ; it checks the decomposition of the casein which is present and so preserves the butter from decay. Sugar will also exert the same influence, and butter immersed in syrup is said to keep even better than when salted. Butter may also be preserved by excluding it from air, so that merely immersing it in cold water, which should be changed daily, will keep it fresh for a week or more. It is said that a weak solution of tartaric acid or water acidulated with acetic acid (3 grammes to a litre) is far more efficacious, and that butter has been kept fresh for two months by its means at a temperature of 60 to 68. It should be kept in a closely-covered vessel. Potatoes. According to Parkes, sugar, in the form of molasses, is the best substance for preserving potatoes on a large scale ; a cask is filled with alternate strata of molasses and peeled and sliced potatoes. On a small scale, boiling the potatoes for a few minutes will keep them for some time. Free exposure to air, turning the potatoes over and at once removing thoso that are bad, are useful plans. Preserved potatoes have already been described. Licbig's Extract is a form of preserved and condensed meat. It is prepared by subjecting meat entirely freed from tendons and fat to a moderate heat for some time until a viscid dark extract is obtained which contains the salts, creatin, and other organic nitro- genous substances. Mixed with warm water, it forms a nutritious and palatable fluid. One pound of mutton gives about two-fifths of an ounce of extract. It has no tendency to decomposition and will keep 184 FOOD IN HEALTH. [Parti. unaltered for years. Other extracts of meat resemble it more or less in composition. Liebig's extract has been found remarkably restorative after the fatigue of great exertion and to increase cardiac power. It has been used with great effect mixed with wine to rouse wounded soldiers who have passed into a state of collapse. It does not, however, represent a true nutritive albuminate, as it contains no albumen or fibrin, its nitrogenous constituents being in the form of creatin and soluble extractives. It is believed to increase the power of the stomach to digest vegetable food, and while not capable of acting as a substitute for meat, yet assists also in digesting meat so that less meat is needed. It should not be taken in large quantities, as it has been known to cause heaviness and torpor, probably owing to the excess of nitrogenous extractives introduced into the system. It is a useful addition to poor soup. A great number of condensed fluid meat extracts are prepared, most of which are of value as nutritious restoratives, but none of them can be said to be capable of completely taking the place of meat. Meat biscuits can be made in a very simple way (Parkes) " by mixing together, cooking and baking 1 Ib. flour, 1 Ib. meat, -| Ib. suet, | Ib. potatoes, with a little sugar, onion, salt, pepper, and spices. A palatable meat biscuit, weighing about 1^ Ib., containing 10 to 12 per cent, of water, is thus obtained, which keeps quite unchanged for four months." The celebrated Erbswurst, or pea sausage, of the German army contains pea-flour and fat pork, with some salt. It is ready cooked and can be quickly made into a soup. It was used largely in the Franco- German war, and was much liked for a few days, but it is said the men got eventually tired of it, and that in some it produced flatulence and diarrhoea ; but it is obvious that however useful such a form of preserved food might be, it is one which should be varied with other foods, and not trusted to exclusively, or for long at a time. i8 5 CHAPTER VIIL THE SCIENTIFIC BASIS OP DIETARIES AtfD RATIONS. THE object of food is, as we have .seen, to repair the waste, and to administer to the growth of the bodily organs : to maintain a nutritive equilibrium between the bodily income and expenditure under all the varying conditions and circumstances to which the human organism may be exposed ; to maintain all the functions of the body in healthy activity, and to prevent any loss of the normal body-weight. In the determination of a dietary or dietaries adequate to all these purposes, in the selection of suitable kinds and sufficient, but not excessive, amounts of food, experience lias shown that it is not altogether safe to trust merely to the sensation of hunger or to the voluntary choice or desires of individuals. Such a reliance might lead to injurious over-indulgence on the one hand, and serijus insufficiency on the other. It is therefore necessary that we should be provided with some accurate scientifi j data, which shall furnish a secure basis for the construction of the various diet scales and rations appropriate to the many varying periods and conditions of human life. The practical considerations associated with this investigation are of the greatest general importance and interest, for they include the determination of such questions as the food of the soldier at home and in the field ; the food of convicts in strict confinement and engaged in hard labour ; of the inhabitants of various public institutions, such as schools, asylums, hospitals, etc. ; the appropriate food in childhood, growing youth, and maturity in the different sexes ; 1 86 FOOD IN HEALTH. (Parti. in sickness and in health ; in different occupations, climates, etc. A certain amount of valuable information can undoubtedly be obtained by reference to the long- established customs and habits of different classes of persons as founded on the teachings of a lengthened experience ; but it is an advantage to be able to bring to the support of the conclusions founded on such data more precise experimental proof. To provide this is admittedly a difficult and complex problem. The elaborate series of experiments undertaken by Voit and Pettenkofer had for their object the estima- tion of the influence which various foods or mixtures of foods had on metabolism. To do this it was needful to ascertain accurately the total bodily income and output, so as to discover under what circum- stances a given amount of food either exactly main- tained the nutritive eqiiilibrium, and therefore the body- weight, or was attended with either loss or gain. By this means these observers were enabled to determine, with precision, the amount of the three chief classes of alimentary substances thealbuminates, fats, and carbo-hydrates, which were respectively necessary to satisfy the wants of the organism, and also to ascertain what was the fate of any excess of these. One fact, as might have been expected, soon became evident, viz. that the amount of alimentary substances consumed in the body, even under ordinary conditions, was very variable, and depended on the general nutritive condition of the body, on the amount of work performed, and on certain external circumstances ; so that in order to estimate the amount of food needed by different persons, it became necessary to take the averages of a great number of experiments adapted to the experience of ordinary daily life, as well as to special conditions. It was found that the two most important factors which determined the amount of food required by chap, viii.] DIETARY EXPERIMENTS. 187 different persons were : first, physical development and body-weight; and second, the amount of work performed. In short, as might readily be supposed, a strong, well-developed man in active work required much more food than a small feebly-developed man leading an idle life. The three following tables are abstracted from those given by Bauer as representing the results of Pettenkofer's and Voit's experiments to show the daily incoming and outgoing in the case of a powerful man weighing 69 - 5 kilos. (1) in a state of rest ; and (2) during work ; and (3) for purposes of comparison in a small and ill-nourished man with a liberal diet during rest. 1. INCOME AND OUTPUT WITH AN ABUNDANT DIET DURING REST.* Income. Meat ... ... 139 - 7 grammes. White of Egg 41'5 Bread 450-0 Milk 500-0 Beer 1025-0 Suet 70-0 Butter 30-0 Starch... 70-0 Sugar 17-0 Salt 4-2 Water 286'3 Oxygen from Air 709-0 Total 3342-7 Output. Urine 1243-1 grammes. Fzeces 114-5 Breath 1739-7 3197-3 Balance + 14.V4 * Bauer, " Dietary of tbe Sick." It has not been thought neces- sary to reproduce all tbe details of the chemical analysis of the various foods consumed. t88 FOOD IN HEALTH. [Parti. In this experiment a summary of the results of chemical analysis gives the following figures : Albumen . . , Fat Carbo-hydrates Taken in. j Consumed. 137 117 352 137 52 352 Stored up. 65 2. INCOME AND OUTPUT WITH AN ABUNDANT DIKT DURING WORK. Income. Meat ... 151-3 examines. White of Egg 48-1 Bread 450-0 Milk oOO-O Beer 1065-9 Suet 60-2 Butter 30-0 Starch 70-0 Sugar 17-0 Salt 4-9 Water 489-1 Oxygen from Ail 1006-1 Total 3892-6 Output. Urine 1261-1 grammes. Faeces 129-0 Respiration ... 2545-5 Balance 3935-G - 43-0 It was found on chemical analysis that during hard ivork whereas only the same quantity of albumen (137 grammes) was consumed as during rest, on the other hand, 173 grammes of fat were consumed, as compared with 52 during rest. The amount of carbo-hydrates was the same in both instances 352 grammes. Chap, viii.] DJETARY EXPERIMENTS. 189 INCOME AND OUTPUT IN A SMALL ILL-NOURISHED MAN, WITH AN ABUNDANT DIET DURING REST. Income. Meat ... ... 151 '1 grammes. White of Egg .... ... 61'8 Bread 450'0 Milk 509-6 Beer 1012-7 Suet 58-8 Butter... ,.. 30-0 Starch 70-0 Sugar 17-0 Salt 4-3 Water 41-4 Oxygen from the Air ... 600'" Total 3007-4 Output, Urine ... 1069-6 grammes. Faeces 137-1 ,, Respiration 1597'8 2804-5 Balance + 202-9 As the result of these experiments, Voit fixed for the average daily needs of a moderate worker 118 grammes of albumen (nitrogen 18-3 and carbon 63) and 265 grammes of carbon, either in the form of fats or carbo-hydrates, making a total of 328grammes of carbon. The estimate given by Dujardin-Beaumetz* agrees According to Dujardin-Beauiaetz, a man loses, in connection with the processes of nutrition, nitrogen, carbon, water, and salts. In twenty-four hours these losses, on an avcraye, amount to 20 grammes (300 grains) of nitrogen, 310 grammes (4,650) grains of carbon, 30 grammes (450 grain?) of salts, and 3 litres (about C pints) of water. The chief part of the nitrogen (14 "5 grammes) passes away in the urine in the form of urea and uric acid, and the remainder (5'5 grammes) in the faeces, perspiration, and mucous discharges. Of the carbon, 250 grammes are consumed in the lungs, 45 grammes are eliminated by the kidneys, and 15 grammes in the other secretions. The water passes off by the skin, lungs, kidneys, and bowels. A man's food must contain the elements necessary to repair these incessant losses. " L'Hygu-ne Alimentaire. '' FOOD IN HEALTH. [Part I. closely with this : " An adult man submitted to moderate labour loses 20 grammes of nitrogen daily, and 300 grammes of carbon ; these 20 grammes of nitrogen represent 124 grammes of dry proteicl matters, and as these contain 64 grammes of carbon, on sub- tracting these 64 grammes from the 300 grammes neces- sary for nutrition, there remain 236 grammes of carbon to be derived from starch substances or from fats." Moleschott's estimate is, for an adult working man, 130 grammes of albumen, 84 grammes of fat, 404 grammes of carbo-hydrates, and 30 grammes of salts. The following table by Forster gives the analysis of the habitual diets of several persons of different occupation, with the relative amounts of nitrogen and carbon in each : Albumen. Fat. Carbo- hydrates. Nitrogen. Carbon. Labourer, age 36 133 i 95 422 21 321 Joiner ... 131 68 494 20 342 Young Surgeon . . . 127 89 362 20 297 134 102 292 21 280 Powerful old Man 116 68 345 Landois (" Text-book of Human Physiology ") thus analyses the average income and expenditure of an adult doing a moderate amount of work : INCOMK. Albumen, Fats, Starch, 120 grammes = 90 = 330 = C. H. N. O. 64-18 70-20 146-82 8-60 10-26 20-33 18-88 28-34 9-54 162-85 281-20 39-19 18-88 200-73 chap, vii j.) BODILY INCOME AND OUTPUT. 191 To thi* should be added : In Air respired Water Salts 744-11 grains of oxygen. 2818-0 32-0 The whole is equal to 3^ kilos. = 7 lb., i.e. about ;h of the body-weight. OUTPUT ou EXPENDITURE. Water. Carbon. H. N. 0. By Kespiration 330 248-8 p 631-1.5 ,, Perspiration 660 2-6 7'2 Urine 1700 9-8 3-3 15-8 11-1 Faeces 128 20-0 3-0 3-0 12-0 2818 281-2 6-3 18 8 661-4.5 To this is to he added : 298 grammes of water formed in the body by the oxidation of hydrogen. These 298 grammes of water = 34-59 H. and 263 41 0. 26 grammes of salts are given off in the urine, and 6 by the faeces. So that about 6 per cent, of the water, about 6 per cent, of the fat, and about 1 per cent, of the albumen, and about 0-4 per cent, of the salts of the body, are daily transformed within the or- ganism. At the time when it was believed that the amount of mechanical work performed by the organ- ism required the consumption of a corresponding amount of albuminates, a due supply of albumen was regarded as of the first importance in enabling the body to develop functional activity or muscular force ; and it was a matter of common observation that persons who were habitually called upon for great exertion were accustomed to take large quanti- ties of albuminous food. But since it has been established that the most strenuous muscular labour 192 FOOD IN HEALTH. [Parti. does not increase in the smallest degree the meta- bolism of albuminates in the body, we know that it is the non nitrogenous alimentary principles the fats and the carbo-hydrates whose consumption is increased by muscular activity. This conclusion is not, how- ever, inconsistent with the common observation that during active exertion the body requires a more liberal supply of albumen than when at rest, for in order to perform sustained and laborious physical efforts it is necessary to have well-developed and well-nourished muscles, which means the existence in the body of a large proportion of nitrogenous tissue, for the maintenance of which a corresponding pro- portion of albuminous food is needed. But a physic- ally weak person will not be enabled to perform an increased amount of muscular work simply by sup- plying him with a larger amount of albumen in his food. It would be necessary, in the first place, to produce an increased muscular development by raising his nutrition to a higher standard. Life can, no doubt, in certain circumstances, be maintained on a much smaller amount of food than an active labouring man requires, as is exemplified in the so- called " subsistence diet " of Playfair. The annexed table gives (in grammes) the amounts of the different classes of food, together with the relative proportions of carbon in each, required, according to Playfair, for mere subsistence, as well as in varying circumstances of muscular effort : Albu- men. Fat. Carbo- hydrates. Carbou Minimum ("subsistence") diet 57 14 340 190 Rest 71 28 340 210 3 1 oderate exercise ... ... 119 51 530 337 Hard work ... ... ... ! 156 71 567 380 Intense exertion ... ... 184 71 567 405 chap, viii.] STANDARD DAILY DIETS. '93 Voit has expressed surprise at Play fair's estimates of the quantity of albumen (57 and 71 grammes) in the first two cases, and he considers them far too low, unless for individuals of unusually small physique. Parkes also points out, with regard to the sub- sistence diet of Playfair, that, while calculated as sufficient for the internal mechanical work of the body, it may be doubted if an average man could exist on it without losing weight, as it supposes absolute repose; and he regards the "rest" diet as probably the minimum for an adult male of average size and weight (150 Ib. == 67 kilos). Comparing the estimates of various authorities, Parkes has drawn up the following table of STANDARD DAILY DIETS FOR A MAN IN ORDINARY WORK. Proteids ... Fats Carbo-hydrates Salts Total water-) free food ... $ Moleschott. Pettenkofer and Voit. Ranke. Means. oz. av. grms. oz. av. grins. oz. av. grins. oz. av. grms. 4-59 2-90 14-26 1-06 130 84 404 30 4-83 4-12 12-40 1-00 137 117 352 30 3-52 3-52 8-4(5 0-89 100 100 240 20 4-31 3-53 11-71 1-00 122 100 332 28 582 22-87 648 22-41 630 16-39 465 20-55 If we compare these with Playfair's diets, we notice a great discrepancy in the estimation of the requisite amount of fats. Either Playfair's must be defective, or the others excessive in this alimentary principle. It is true that in the working diets of Playfair the deficiency in fats is attempted to be compensated for by an excess of carbo-hydrates ; but it is doubtful if the carbo-hydrates can advantageously take the place of fats to this extent in ordinary diets. The constituents of the above diets are estimated as absolutely water-free ; so that, assuming the water N 194 FOOD iff HEALTH. [Parti. free food to be 23 oz., and a man's weight to be 1501b., each pound-weight of the body receives in twenty-four hours (H5 oz., or the whole body re- ceives nearly one-hundredth part of its own weight. But ordinary solid food contains usually between 50 and 60 per cent, of water ; and if we add this to the water-free solids, the total daily amount of so-called dry food (exclusive of liquids) is about 48 to 60 oz. But from 50 to 80 oz. of water in the liquid form is iisually taken in addition, and this would make the total supply of water = 70 to 90 oz., or half an ounce for each pound of body-weight. Allowing for the modifying influence of varying conditions, we may fix the usual average daily range in different males as from 40 to 60 oz. of ordinary solid food, and from 50 to 60 oz. of water. Under great exertion men require an increased amount of food, especially in the form of albuminates and fats, and a total of 66 to 77 oz. of solid food (1-970 to 2*180 grammes) may be estimated as an average requirement under such circumstances. AVERAGE DAILY WATER-FREE DIET REQUIRED FOR AN ADULT MAN IN VERY LABORIOUS WORK (Parkes). Proteids ... 6'0 to 7'0 oz. or 170 to 198 grammes. Fats 3-5 4-5 99 ,, 128 Carbo-hydrates IG'O 18-0 454 610 Salts 1-2 1-5 , 34 43 Total water-free Food 26 -7 31-0 757 879 The following table (from Parkes) may be used as "an approximate basis for the calculation of diets according to size and work " : Chap. viii.] TABLE FOR CALCULATING DIETS. 195 1 lof. .!!! d Iff, 0>a34jfclt-'S3O C O O5 ^ CO Si ' O i i O ^ o p o o i o o o o 50 CO till O Sp 1 s >. r- O ~ ~ 'S C4 PH O O O g s3 c~ >>Z? .fj ><* -* rt >o B _ ^Ufc-^^w^ O O O O ~ aj^r^'2^-2 tl > 0000 o 11 6 "gi *^ * o o o o ,4 poop O o o o o o p * s i-s bj *s ifel co *-* oi o p p p p (M US m o< ^ O O M 1 i>*5 ^*< C^ O CO O5 c fe 5 c^j ^ p i O 5O i g <= tef "S p Tf p rt

& * o o o o at : : : : : I : i : : I : : J 1 JMi fl S O do 1 196 FOOD IN HEALTH. [Part I. Beyond 300 foot-tons (or 100,000 kilogramme- metres) the additions would require to be greater. S E.^ 3 E 5*31* I s E P o 1 Chap, viii.j TABLES FOR CALCULATING DIETS. 197 The following is another useful table (from Parkes also), " compiled from, in most cases, several analyses by different authors," for calculating diets. From such tables of mean composition the four classes of alimentary principles in any diet, the articles of which are known, may be calculated. Such tables are, of course, merely approximative ; " they ai % e very useful as giving a general idea of diet, although they are not accurate enough to be used in physiological inquiries." Articles. In 100 parts. Water. Albu- miii- atett. Fats. Car- bo-hy- drates. SaltH. Meat of best quality, with ) little fat, like Beef-steaks j 74-4 20-5 3-5 1-6 Uncooked Meat of the kind j supplied to soldiers, Beef > 75 15 8-4. 1-6 and Mutton ) Uncooked Meat of fattened j cattle, calculated from / Lawes' and Gilbert's ex- ( periments. These num- f bers are to be used if the \ 63 14 19 3-7 meat is very fat . . . j CookcdMeat,roast,nodrip- j ping being lost. Boiled > f>4 27-6 15-45 2-95 assumed to be the same ) Corned Beef (Chicago) ... 52-2 23-3 14 4 Salt Beef (Girardin) 49-1 29-6 0-2 21-1 Salt Pork- 44-1 26-1 7-0 22-8 Fat Pork (Letheby) 39-0 9-8 48-9 2-3 Dried Bacon ,, 1 5 -0 8 '8 73-3 2-9 Smoked Ham (Konig) ... 27-8 24-0 36-5 10-1 Horseflesh 74-3 2T7 2-6 1-0 White Fish (Letheby) ... 78-0 18-1 2-9 1-0 Poultry 74-0 21-0 3-8 1-2 Bread, White Whuaten, of | 10 3 1*5 49 '2 ' 1'3 average quality ... j ^ V Wheat Flour, of average ) 15 11 2 71-2 0-8 quality j Biscuit 8-0 15-6 1-3 ' 73 4 1'7 Rice . 10-0 50 0-8 83-2 0'6 198 FOOD IN HEALTH. [Part I. In 100 parts. Articles. Albu- Car- Water. rn in- Fats. bo-hy- Salts. ates. drates. Oatmeal (Letheby) 15-0 12-6 5-6 63-0 3-0 Maize (Poggiali), cellulose i excluded ( 13-5 10-0 6-7 64-5 1-4 Macaroni (Konig) 13-1 9-0 0-3 76-8 0-8 Millet (Konig), cellulose ^ excluded ... ... j 12-3 11-3 3-6 67-3 2-3 Arrowroot... 15-4 0-8 83-3 0-27 Peas (dry)... 15-0 22-0 2-0 53-0 2-4 Potatoes ... 74-0 2-0 0-16 21-0 1-0 Carrots ( cellulose ex eluded ) 85-0 1-6 0-25 8-4 1-0 Cabbage ... 91-0 1-8 0-50 5-8 0-7 Butter (Bell) 7-5 ro 90-5 1-0 Egg ( 1 per cent, must be \ deducted for sbell from | 73-5 13-5 11-6 1-0 weight of Egg) . . . ) Cheese (Single Glo'ster)... 36-0 31-0 28-5 4'5 Milk (sp. gr. 1-029 and over) 80-8 4-0 3-7 4-8 0-7 Cream (Letheby) ... 660 2-7 26-7 2-8 1-8 Skimmed Milk (Letheby) 88-0 4-0 1-8 5-4 08 Sugar ... 3'C 96-5 0-5 Pemmican (Do Chaumont) 7'2 35-4 55-2 1-8 The gelatin of meat is reckoned with the albu ruin- ates. It is not certain what deduction should be made on account of its lower nutritive value, which is about one-fourth that of albumen, according to Bischoff. " The mode of using the above table is very simple. The quantity of uncooked meat or bread being known, and it being assumed or proved that there is no loss in cooking, a rule of three brings out at once the proportions. Thus, the ration allowance of meat for soldiers being 12 oz., 2'4 oz., or 20 per cent., is deducted for bone, as the soldier does not get the best parts. The quantity of water in the remain- 9'6 oz. will be 76 x 9-6 100 =r 7 '2, and the water-free Chap, viii.] TABLES FOR CALCULATING DIETS. 199 solids will be 2-4 oz. The albuminates will be 1-44 oz., the fats -8064 oz., and the salts -1536 oz. (Parkes.) It is difficult to estimate the value of salt beef and pork, as much of the nutritive matters passes out into the brine. This has been estimated at as much as from one-third to one-half. It appears that myosin is soluble in a 10 per cent, solution of chloride of sodium ; therefore a large proportion of this substance necessarily passes into the brine. " Analyses show, it is true, a large percentage of fibrous and cellular tissue in salt meat, but this is made up of indigestible nitrogenous substances, which afford, probably, little real nutritive material. Perhaps salt beef may be reckoned as equal to two-thirds the quantity of fresh beef; this estimate is certainly quite high enough." (Parkes.) If we again refer to the table of " standard daily diets "we shall be able to ascertain the relative pro- portion of the nitrogenous to the non-nitrogenous substances in them ; it will be found to be about 1 part of nitrogenous to 3| to 4 of non-nitrogenous substances, e.g. ; Molesehott. Pettenkofer and Voit. Kanke. Mean. Proteids 100 100 100 100 Fats 65 87 100 84 Carbo-hydrates ... 315 258 240 271 Salts 23 22 25 23 If it is required, as may sometimes be the case, to calculate the amount of nitrogen and carbon, as well as that of hydrogen and oxygen in the constituents of any diet, Parkes gives two methods by which this may be done. " 1. Calculate out the dry albuminates, fat, and 200 FOOD IN HEALTH. [Parti. carbo-hydrates in ounces, and then use the following table : Water-free Constituents. Nitro- gen. Carbon. Hyd \ Glucose ) " " - 175 "The total amount of carbon in one ounce of proteids is 233 grains, but of this 30 grains are con- verted into urea, and are therefore oxidised only as far as carbon monoxide; making allowance for this, we have a net total equal to 212 grains of carbon fully oxidised. " 2. In the following table, the calculation of these ingredients per ounce has been made ; the substance being supposed to be in its natural state, and to have the composition already assigned to it in the former table : One ounce (= 437'5 grains) contains iu its natural state in grains Substance. Water. Nitro- gen. Carbon capable of being Hydro- gen capa- ble of Sulphur capable of being Salts oxidised. being oxidised. oxidised. Uncooked Meat ) (Beef) of the [ 326 14-3 55 3-2 1-2 7 best quality . . . ) Uncooked Meat \ as supplied to > 328 10-5 60 5-2 0-9 7 soldiers ... ) chap, vin.j TABLES FOR CALCULATING DIETS. 201 Substance. One ounce (= 437'5 grains) contains in its natural state in grains- Water. Nitro- gen. Carbon capable Of being oxidised. Hydro- gen capa- ble of being oxidised. Sulphur capable of being oxidised. Salts Uncooked Fat i Meat (Beef) ... J Cooked Meat ... 276 236 9-8 19-3 94 110 10-2 9'6 0-8 1-7 16 13 Corned Beef (Chi- \ cago) } Salt Beef 228 215 16-3 20-7 96 63 8-6 2-5 1-4 1-8 17 92 Salt Pork 193 18-0 79 5-1 1-6 100 Fat Pork 170 6-9 185 24-3 0-6 10 Dried Bacon G6 6-2 265 39-9 0-5 12 Smoked Ham . . . 122 16-8 174 19-4 1-4 44 Horseflesh 325 15-0 55 2-9 1-3 4 White Fish ... 341 12-6 48 2 8 1-1 4 Poultry... Bread 324 173 14-7 5 '5 57 116 3-5 1-3 1-3 0-5 5 6 Wheat Flour ... 66 7-7 166 1-9 0-7 4 Biscuit 35 10-9 180 1-8 0-9 7 Rice 44 3-5 175 0-8 0-2 2 Oatmeal 66 8-8 168 3-7 0-8 13 Maize 59 7-0 169 4-0 0-6 6 Macaroni 57 6-3 169 0-9 O-o 3 Millet 54 7-9 166 2-6 0-7 10 Arrowroot 57 0-6 162 o-i . Peas (dried) Potatoes 66 324 15-4 1-4 156 45 2-8 0-3 1-3 o-i 10 4 Carrots ... 372 1-1 20 0-2 0-1 4 Cabbage Butter 398 33 1-3 0-7 17 299 0-3 43-G o-i o-i 3 4 Eggs 322 9-4 68 6-7 0-8 4 Cheese 157 21-0 161 17-2 1-9 20 Milk (sp. gr. } 1-029 and over) ) Cream ... 380 289 2-88 1-9 30 100 2-1 13-0 0-2 0-2 3 8 Skimmed Milk... 385 2-8 24 1-2 0-2 3 Sugar 13 178 2 Pemmican 31 24-8 260 29-8 2-1 8 It has been stated that the standard daily diet of an adult man in ordinary work should contain 202 FOOD IN HEALTH. [Parti. 20 grammes of nitrogen and 300 grammes of carbon , this would be equal to 308'6 and 4,629 grains. In order to use the above table Parkes gives the following estimate in grains, founded on Moleschott's standard: Nitrogen 321 grains. Carbon 4,737 Hydrogen 179 Sulphur 28 Salts 464 Some range, however, is necessary to adapt a diet to different persons under varying circumstances. For adult men the usual range is from 250 to 350 grains (17 to 23 grammes) of nitrogen, and the extreme range 140 (mere subsistence estimate of Playfair) to 500 grains (very great exertion), or 9 to 33 grammes. El-fed London needlewoman, according to B. Smith's observations, had 135 grains of nitrogen, and 8,271 of carbon. Irish farm labourers ... 349 ,, 6,185 And operatives during) Cotton famine in Lan- > 180 200 8,900 to 4,300 cashire ) Prisoners on light la- ) . . ,.. bour (Wilson) ... f 224 ' 4 ' 651 Prisoners on bard la- ) - nan bour (Wilson) ... f m ' 5 > 9 (On this diet they lost weight.) Military prisoners with ) 001 . _-,, hard labour ... f m 6 ' 873 (On thisdiet they also lost weight.) Military prisoners in ) onn K arm India j- 800 6,800 (These did not lose weight.) The amounts of carbon range in various diets from about 3,500 to 6,000 grains. Pettenkofer's and Voit's observations on two healthy men, on several occasions, in ordinary exercise, showed a daily consumption of 1 9 '82 grammes = 305 - 8 grains of nitrogen, and Parkes's experiments on four healthy average men in common work showed that they could be maintained in perfect health and uniform weight on a daily allowance of 293 to 305 grains of nitrogen. In the best diets the chap, viii.j CALCULATION OF DIETS. 203 proportion between the nitrogen and carbon is nitrogen 1 to carbon 15. Advanced age necessitates a considerable reduction in the amount of food allowed, for not only are all the organs, and especially the voluntary muscles (except in certain exceptional instances of unusually vigorous old age), more or less wasted, but the digestive and assimi- lative functions are far less active, and are unable to digest and utilise the same amount of food as formerly. In an institution for the widows of beneficed clergymen, Forster found that a number of old ladies wei*e content with an average allowance of 67 grammes of albumen, 38 of fat, and 266 of carbo-hydrates, while others required rather more viz. 80 grammes of albumen, 49 of fat, and 266 of carbo-hydrates ; but both these diets are much richer in albuminates and fats than Playfair's " subsistence diet." Dujardin-Beaumetz regards the following as a fair basis for the estimation of the average daily dietary of an adult man : 124 grammes of albuminates, 430 grammes of carbo-hydrates, 55 grammes of fat ; this would correspond with a bread and meat ration of 819 grammes (about 28 oz.) White Bread. 259 (about 9 oz.) Meat. Economical reasons may occasionally require that we should cut down the dietary to the lowest level compatible with the maintenance of healthy existence ; but it is always advisable when practicable to allow a certain excess over and above the strict physiological necessities. The effects of a deficient diet are usually not slow to make their appearance. They are loss of weight ; a lowered capacity for exertion and functional activity ; often an unhealthy, cachectic aspect, and a diminished power of resistance to unfavourable in- fluences, so that during periods of famine or enforced privation the rate of mortality rises enormously. The consequences of immoderate feeding and of habitual 2O4 FOOD IN HEALTH. [Pani. excess are frequently also sufficiently conspicuous. In many cases an unusual, unequal, and unsightly de- position of fat takes place in connection with the abdominal and other organs, together with disturb- ances in the functions of the liver and other organs of digestion. But apart from the deposition of fat, which is not an invariable consequence, excess of food leads to retarded metabolism and imperfect nutritive changes, indicated sometimes by the presence of uric acid deposits, of oxalates in the urine, of an excessive excretion of urea. The disturbances of metabolism which lead to these deposits are as yet, however, only imperfectly understood ; but there is a vast deal of evidence which points to immoderate feeding as one of their common antecedents. Not only is it important to have due regard to quantity in the construction of dietaries, but it is also equally necessary to have regard to the pi-oportionate composition and quality of foods. A particular food- stuff may contain all the constituents necessary for the nutrition of the body, but may yet be quite un- suitable to form the sole food of the oi-ganism, on account of the unfavourable proportions in which they may exist in it. Or another food-stuff may contain some or all of the necessary elements of nutrition but they may not all be digestible and utilisable. These considerations show the necessity of mingling or combining different articles of food in due and proper proportions in the construction of diet- tables. The following table, which is modified from one by Voit, shows in a striking manner the unsuitableness of many common articles of food to be employed as the sole constituents of liuman diet, and the great wastefulness 011 the one hand a::d insufficiency on the other which would be involved in the at- tempt. In order to yield the necessary daily ration of nitrogen and carbon, the following quantities of the undermentioned articles would be required ; for Chap, vin.] SUITABILITY OF DIFFERENT FOODS. 205 " experience has shown that the diet best suited for the body must contain one part of nitrogenous foods to three and a half or at most four and a half of the non-nitrosrenous " : To To yield 18'3 yield 328 grammes grammes Nitrogen. Carbon. Cheese 272 Bacon 450 Peas 520 Maize 801 Lean Meat . . . 538 Wheat Meal 824 Wheat Flour 796 Rice 896 Eggs (18) ... 905 Peas 919 Maize 989 Cheese 1,160 Black Bread 1,430 Black Bread 1,346 Rice 1,868 Eggs (43) ... 2,231 Milk 2,905 Lean Meat . . . 2,620 Potatoes . . . 4,576 Potatoes 3,124 Bacon 4,796 Milk 4,652 Cabbage . . . 7,625 Cabbage ... 9,318 Turnips 8,714 Turnips 10,650 Beer 17,000 Beer 13,160 It would be scarcely possible for any individual to consume and digest daily 2,620 grammes (i.e. about 90 ounces) of meat, the quantity necessary in order to yield the daily requirement of carbon, while the waste of nitrogen would be prodigious ; on the other hand, it would require 4,575 grammes or about 10 Ib. of potatoes to yield the daily requirement of nitrogen. And milk, which is the food of Nature's own selection for the infant, would be most wasteful as the sole food for the adult, as he would require 4,652 grammes or 10 pints to furnish the daily supply of carbon he requires, and a considerable proportion of the nitrogen would be wasted. Whereas in a mixed diet of meat and potatoes, less than 538 grammes of the former together with less than 3,124 grammes of the latter would yield respectively the amount of nitrogen and carbon required. The carbon necessary for nutrition can be pro- vided, as we have seen, either in the form of fats ol 206 FOOD IN HEALTH. [Parti. of carbo-hydrates. If in the form of fat, then, accord- ing to Voit's calculations, an average working man would require for his daily consumption 346 grammes if in the form of starch, 596 grammes. But it is no doubt better to obtain the carbon that we require in our food in part from both classes of aliments from a mixture of fat and farinaceous foods. This appears to suit the digestive capacities of man as well as his nutritive requirements best. Carbo-hydrates are not able to minister as com- pletely as the fats do to the functions of tissue growth and repair ; while, on the other hand, a large propor- tion of fat in the food is not, as a rule, well tolerated by the digestive organs for long at a time, unless under exceptional conditions of climate, as amongst the inhabitants of Arctic regions, where food possess- ing a relatively large capacity for heat-production is especially needed. It is not uncommon, moreover, to find individual peculiarities with regard to the capacity for taking fats, some persons being incapable of digesting but very small quantities ; in such cases the deficiency must be supplied by a proportionate allow- ance of carbo-hydrates. The force-value of various foods. Two chief conditions determine the possible amount of force that can be manifested in the body 1st, the amount of potential energy contained in the food, and this may be readily ascertained and expressed in units of heat or of motion ; and 2nd, the degree in which the assimilative processes in the body are able to liberate and make use of this energy. An ounce of albumen if burnt in oxygen will yield a certain amount of heat, but no such complete oxidation can occur in the body, for about one-third of the constituents of the albumen is excreted, incompletely oxidised, in the form of urea. It is different with some of the carbo-hydrates, and a soluble carbo-hydrate, like sugar, is completely oxidised within the body and converted into carbonic acid and water, so that its actual energy in the body is equal to its theoretical energy. Chap, viii.] FORCE VALUE OF FOODS. 207 It has been calculated (Parkes) that One ounce of dry Proteids yields 173 Fat 378 Starch 138 Cane Sugar 131 Lactin or Glucose 124 that sars^sr One grain of Carbon in conversion into C0 2 yields 0-710 Hydrogen H. 2 O 3-000 Sulphur S0 2 0-205 Phosphorus P a 3 0'510 Carbon (forming Urea) 0'198 The following table embodying Dr. Frankland's experimental results displays a close agreement with theoretical results, and is useful as showing what can be obtained from food. It would, however, be an error to suppose that the value of food is in exact relation to the possible energy it can yield. To pro- duce this energy, not only must it undergo suitable preparation and digestion within the body, but the setting free of energy must take place where and how it may best serve the purposes of nutrition. " The mere expression of potential energy cannot fix dietetic value, which may be dependent on conditions in the body unknown to us." Gelatin, for instance, cannot completely supply the place of albumen, although its potential energy is but little less, and it is readily oxidised in the body; yet, owing to some unknown conditions, its energy has a different direction from that of albumen. According to Frankland, Heat Units. One gramme of dry Isinglass when burnt in Oxy- \ A.-OQ gen will develop ... ... ... . . . J One gramme of dry boiled Ham when burnt in i .I-QIQ Oxygen will develop ......... . . . ) One gramme of dry Beef when burnt in Oxygen ) - 010 will develop ............... ) which shows the potential energy of isinglass to be greater than that of ham, yet its nutritive power is far inferior. Such tables of energy are valuable as affording 208 FOOD IN HEALTH. [Part T. broad indications, and as representing in a general way the value of a diet ; but they must not be taken as throwing light on the obscurities of the nutritive processes. Energy developed by 1 oz. of the following foods when oxidised in the body : Food Stuff. With usual percentage of water. One ounce water-free. Beef (best quality) uncooked... Meat (served to soldiers) Beef, fattened ,, Meat, cooked Cornod Beef (Chicago) Salt Beef Foot-tons. 49 58 96 106 93 52 Foot-tons. 191 232 260 231 194 102 Pork 71 127 Fat 202 331 Dried Bacon ... Smoked Ham Horseflesh ... 292 179 48 344 248 187 White Fish 42 191 Poultry 50 192 Bread ... ... ... ... 88 147 Wheat Flour 124 133 146 144 Rice ... ... ... 127 141 Oatmeal ... 130 153 Maize ... ... 131 162 Macaroni 124 142 Millet 126 144 116 136 119 140 33 127 16 107 Cabbage ... . . . . . 13 144 Butter ... 339 367 Eire's 68 257 Cheese ... 150 237 Milk (Cow's), new Cream ... ... ... 27 109 205 321 Skimmed Milk Sugar ... ... ... 21 126 175 130 Pemmican ... ... ... 270 293 Ale (Bass's bottled) Stout (Guinness) ... 30 42 260 360 Chap, viri] FORCE VALUE OF FOODS. 209 The advisability, in arranging dietaries, of avoiding monotony and providing variety in food should never be forgotten ; for the digestibility, and therefore the nutritive value, of food depend greatly on its palat- ableness, and the stimulus thereby given to the digestive secretions. 210 CHAPTER IX. CERTAIN DIETARIES PRISON DIETARIES SOLDIKRS* DIETARIES SEAMEN'S DIETARIES. WE may now examine with advantage the construc- tion of certain dietaries, especially those adopted in prisons and in the army and navy. In accordance with the recommendations of a Committee appointed to consider the question of Prison Dietaries, in 1878, the Commissioners of Prisons have adopted the principle that the diet should vary with the length of sentence and the shorter the term of imprisonment, the more strongly should the penal element be manifested in the diet. They consider a spare diet is all that is necessary for a prisoner undergoing a sentence of a few days or weeks. . . that " all prisoners," whatever their length of sentence, should commence with the lowest diet, and "graduate through the dietaries proper to all the sentences shorter than their own, until they reach the dietary proper to their own class." Ac- cording to the length of sentence the following four classes of diets are adopted : Class I. For periods of 7 days and under. Class II. For periods of more than 7 days, and not more than 1 month. Class III. For periods of more than 1 month, and not more than 4 months. Class IV. For periods of more than. 4 months. Class I. This diet consists of one pound of bread daily, together with a hot meal once a day, " in the shape of a nutritive stirabout, composed of equal parts of oatmeal and Indian meal." No distinction is made between the sexes, nor during this very short term between prisoners with and those without hard labour. Chap. IX.] PRISON DIETARIES. 211 Class II. For prisoners undergoing more than seven days, but not more than one month's imprison- ment, the following is the dietary adopted : Men with Men with- out hard hard labour. labour and Women. BREAKFAST Daily ( Bread \Gruel 6 ounces 1 pint 5 ounces 1 pint Isun. & Wed. ( Suet Pudding \ Bread 8 ounces 6 6 ounces 5 DlNNEB. ... < Hon. & FrL ( Bread ( Potatoes ... 6 8 5 8 Tues.,Thurs., ( Bread 6 5 &Sat. ... I Soup \ pint f pint SUPPER ... Daily / Bread \ Gruel 6 ounces 1 pint 5 ounces 1 pint For Class III., i.e. prisoners undergoing one month and not more than four months' imprisonment, the dietary prescribed is the following : BREAKFAST Daily DINNER f Bread ... 8 ounces \ Gruel ... 1 pint (Bread Sun. & Wed. < Potatoes ( Suet Pudding! 8 /Bread ... 18 Mon. & Fri. Potatoea ~ ' Men with hard labour. Men with- ' out hard t lalxmr, and ' Women. V without bone Tues-.Thurs., , cL Potatoes SUPPEK. ( Bread \Gruel 8 4 pint 6 ounces 1 pint 6 ounces 1 pint 4 ounces 6 6 2 6 6 | pint 6 ounces 1 pint o2 212 FOOD IN HEALTH. [Parti For Class IV., i.e. prisoners undergoing more than four months' imprisonment, the dietary adopted is the following : Men with Men with- out hard hard labour. labour, and Women. l Bread 8 ounces 6 ounces BREAKFAST Daily J Porridge ... 1 pint ( Gruel 1 pint / ( Bread 6 ounces 4 ounces Sun. & Wed. < Potatoes ... 8 , 8 ( Suet Pudding 12 10 /Bread ... j 8 6 DINNER ...-< Mon. & Fri. \ Potatoes ... j Cooked Meat 12 10 ' without bone 4 3 Tues.,Thurs., &Sat. ... (Bread ... ' 8 ] Potatoes ... 12 ( Soup ... 1 pin ; 6 10 1 pint / Bread ... 8 ounces 6 ounces SUPPER ... Daily < Porridge ... 1 pint ( Gruel 1 pint Bacon and haricot beans may be substituted for beef in the Monday's dinner; this would be superior in nutritive value and would also effect a considerable saving. The application of the " progressive " principle is "so graduated as to accommodate itself to the circumstances of the various classes of prisoners," as shown in the following diagram a prisoner of the 2nd Class beginning with the diet of the 1st Class, and after seven days passing on to that of his own class, and so on. chap, ix.] PRISON DIETARIES. 213 DIAGRAM TO SHOW APPLICATION OF PROGRESSIVE PRINCIPLE. Term. Class I. Class II. Class III. Class IV. Seven days and under | Whole term. More than seven days \ and not more than > one month ) Seven days. Remain- der of term. More than one month \ and not more than > four months . . . ) One month. Remain- der of term. More than four months J Four months. Remain- der of term. For making the bread, whole meal is employed. Beef is the meat recommended for healthy prisoners at labour, and mutton for the sick in hospital ; and in order that the prisoner may get all the constituents of the meat, it is recommended that the broth in which the meat is boiled should be served with it. The soup is recommended to be made from the neck, clod, cheek, leg, or shin of beef, together with split peas, fresh vegetables, and onions. The propor- tions are : In every pint, 4 oz. of clod (or shoulder), cheek, neck, leg, or shin of beef ; 4 oz. of split peas ; 2 oz. fresh vegetables ; 1-J- oz. onions ; pepper, and salt. "Suet pudding. Each pound contains 1 oz. mutton suet, 8 oz. of flour, and about 6^ oz. of water. " Potatoes. The entire absence of vegetable acids from a prison dietary would result, as is well known, in an outbreak of scurvy, and the potato is chiefly valuable as supplying the anti-scorbutic element in its cheapest form." 214 FOOD IN HEALTH. [Parti. The gruel is made with 2 oz. of coarse Scotch oat- meal to the pint, with salt, and one of its advantages is that it can be served hot. Porridge is ordered to be made with 3 oz. of coarse Scotch oatmeal to the pint, with salt. Stirabout is given to prisoners in Class L, as well as to prisoners who are ill-conducted or idle. It is made thus : 3 oz. of Indian meal, and afterwards 5 oz. of oatmeal, are stirred into 2 pints of boiling water, to which \ oz. of salt has been added ; it is kept constantly stirred, and when it is evaporated to a pint and a half, the meals are sufficiently cooked. Cocoa is introduced into some of the dietaries, on the ground "that the health of prisoners under- going long sentences will be benefited by the intro- duction of some slight change of diet at the expiration of nine months from conviction." Correctional diet. The most common diet in use for correctional purposes consists of a pound of bread and a pint of water per diem ; its employment is limited to a period of three days at a time. " After that, one of the undermentioned stirabout diets, according to labour performed," should be given for three days before the repetition of the bread- and-water diet for three days, "and a second interval on the stirabout diet is to elapse before it is again repeated. The entire period, including intervals, for which any single term of this diet may be ordered is not to exceed fifteen days. No task of labour is to be enforced on any one of the nine days on which the bread and water constitute the sole food supplied to the prisoner." The " Stirabout Diet " referred to is as follows : 1st. For Men and Women performing a Daily Task of any Labour not expressly defined as Hard Labour. BREAKFAST Bread, 8 oz. / 1 pint of Stirabout, containing 2 oz. i of oatmeal and 2 oz. of Indian DlNNEE ... ...j meal> with ^ \ Potatoes, 8 oz. Bread, 8 oz. Chap, ix.j PRISON DIETARIES. 215 "This diet to be limited, in the first place, to twenty-one days ; after that, the diet of the class to which the prisoner belongs for one week before its repetition, when it is to be limited to fourteen days. The entire period, including the interval, for which any single term of this diet may be ordered is not to exceed forty -two days." 2nd. Full Stirabout Diet for Men performing a Daily Task of Hard Labour. BREAKFAST Bread, 8 oz. pint of Stirabout, containing 3 oz. of oatmeal and 3 oz. of DINNER Indian Meal, with Salt. Potatoes, 8 oz. Bread, 8 oz. SUPPER Bread, 8 oz. "This diet to be limited, in the first place, to forty-two days ; after that, the diet of the class to which the prisoner belongs, for fourteen days before its repetition, when it is to be limited to twenty- eight days. The entire period, including the interval, for which any single term of this diet may be ordered is not to exceed eighty-four days." The amount of the proximate aliments (as water- free solids) in each diet, as well as the amount of nitrogen and carbon, is set forth in the following tables, and the approximate value in grammes is added for pui-poses of comparison : CLASS I. Men u~ilh and without Hard Labour, and Women. Nitrogenous Matters (Albuminates) 2-00 oz. (56-7 grammes) Carbo-hydrates 12-02 (340-2 ,, ) Fat 0-67 (19-0 ) Mineral Substances 0'76 (21 '0 ) Nitrogen. Carbon. 0-30 oz. (7'5 grammes). 7'44 oz. (210-9 grammes). 216 FOOD IN HEALTH. CLASS II. (a) Men without Hard Labour, and Women. Albuminates 2-23 oz. (63-2 grammes) Carbo-hydrates 11-87 (336-5 ) Fat ^ ... 067 (19-0 ) Mineral ... ... 1-09 (30-9 ) Nitrogen. Carbon. 0'34 oz. (9-6 grammes). 7*46 oz. (211-5 grammes). (b) Men with Hard Labour. Albuminates 2-50 oz (70-8 grammes) Carbo-hydrates 13-60 (385-5 ) Fats 0-76 (21-0 ) Mineral 1-14 (32'3 ) Nitrogen. Carbon. 0-38 oz. (10-75 grammes). 8-51 oz. (241-25 grammes). CLASS IIL (a) Men without Hard Labour, and Women. Albuminates ... 2-94 oz. (85-0 grammes) Carbo-hydrates 14 32 (406-0 ) Fats 0-87 (24-6 ) Mineral ,. ... 1-24 (35'1 ) Nitrogen. Carbon. 0-44 oz. (12-4 grammes). 9-04 oz. (256-2 grammes). (b} Men with Hard Labour. Albuminates 3-27 oz. (92-7 grammes) Carbo-hydrates 16-65 (472-0 ) Fats 0-98 (27'9 ) Mineral M ... 1-31 (37 1 ) Nitrogen. Carbon. 0-49 oz. (13-7 grammes). 10-40 oz. (295-0 grammes). Chap, ix.j PRISON DIETARIES, 217 CLASS IV. (a) Men without Hard Labour, and Women. Albuminates 3 23 oz. (91-5 grammes) Carbo-hydrates 15-51 (440-0 ) Fat 1-00 (28-35 ) Mineral 1'27 (3600 ) Nitrogen. Carbon. 0'49 oz. (14-0 grammes). 9-84 oz. (279-0 grammes). (4) Men with Hard Labour. Albuminates 4-09 oz. (116-0 grammes) Carbo-hydrates 20-17 (572 ) Fat 1-30 (37 ) Mineral 1-55 (44-0 ) Nitrogen. Carbon. 0-61 oz. (17'0 grammes). 12'78 oz. (362-3 grammes). On examination of these diets, it will be seen that Class I. contains about the same quantities of the several alimentary substances as are contained in Playfair's subsistence diet ; and as it is only applic- able to the short period of seven days, its defects are not likely to be attended by any serious con- sequences unless prisoners are set to " hard labour " when on this diet. For this it is quite inadequate, even for so short a period ; and, as the offences for which such short sentences are considered a sufficient punishment are of the most trivial nature, there seems to be no good reason for insisting on such a highly correctional dietary for these the least criminal of offenders. The diet for Class II. is of more importance, as it applies to sentences of one month ; and a defective diet if it should be defective for that length of time might have an injurious effect on the prisoner's health. And it should be remembered that the loss of health attending such a diet is not so likely to make itself manifest during as immediately after this short term of imprisonment, when the prisoner attempts to resume his daily labour ; so that the 218 FOOD IN HEALTH. [Part I. statistics of the health of the prisoners while in prison would scarcely bear on these cases. Again, we have also to consider that a sentence of a month's imprisonment, without hard labour, is often the punishment of very trivial offences, and certainly not such as would seem to call for a severely correctional diet. This diet is very little in excess of Playfair's mere subsistence diet, and much below Moleschott's esti- mate of what is necessary for a man in ordinary work. The defect is chiefly in albuminates : Class IL Prison Diets. Playfair's Sub- sistence Diet. Moleschott's. Albuminates Carbo-hydrates . Fats Salts oz. grammes. . 2-23 or 63-2 . 11-87 336-5 . 0-67 19-0 . 1-09 30-9 oz. grammes. 2-0 or 57 12-0 340 0-5 14 0-5 14 oz. grammes. 4'59 or 130 14-26 404 2-96 84 1 06 30 The diet for men of this class, with hard labour, though more satisfactory, is, no doubt, defective in albuminates and fats. This will be seen by comparing it with the average of several dietaries calculated for men in ordinary work : Mean of Prison Diet, Class II. several Diets Deficiency. (Parkes). grammes. grammes. grammes. Albuminates ... 70-8 122 51-2 Carbo-hydrates ... ... 385-5 332 (+ 53-5) Fats .., 21-0 100 79-0 Salts ... 32-3 28 (+ 4-3) As has been already pointed out, the effects of such a dietary could only be accurately estimated by statistics of the health of prisoners after their dis- charge from such short terms of imprisonment. Chap, ix.) PRISON DIETARIES. 219 The hard labour diets of Classes III. and IV. appear ample, even when compared with the liberal estimate of Moleschott, except that they are very defective in fats, which defect can scarcely be compensated for by the relative excess of carbo- hydrates. Prison Diet : Class III. and Class IV. Moleschott's. Albuminates grammes. ... 92-7 grammes. 116-0 grammes. 130 Carbo-hydrates ... ... 472-0 572-0 404 Fats ... 27-9 37-0 84 Salts ... 37-1 44-0 30 These diets would certainly be improved by in- creasing the proportion of fats and diminishing the carbo-hydrates to a corresponding amount. In connection with these prison diets, Dr. de Chaumont's remarks on the effect on soldiers of imprisonment in convict prisons are particularly in- teresting. He says, referring to the circumstance that soldiers are sometimes, as a matter of convenience, con- fined in convict prisons : " The ordinary diet which is sufficient for the convict is insufficient for the soldier, and that for several reasons : (1) the convict is on the average a smaller man. (2) The previous life of the convict is an irregular one, in which his food is generally insufficient ; whereas the soldier's life is usually the opposite his food is fairly good and his meals are regular. (3) The crimes for which the convict is imprisoned are crimes against society, and his removal to a prison cannot be considered much of a degradation morally, whereas his physical con- dition is really improved ; on the other hand, the soldier's crime is often one of a military character only; hence his removal to a prison is a moral degradation, especially if it be a convict prison. The result is that, whilst the majority of the civil prisoners retain their 220 FOOD IN HEALTH. [Part I. weight or even gain, the majority of soldier prisoners lose." The soldier's dietary. The soldier's daily rations when on home service which he receives from Government consist of 1 Ib. of bread and \ Ib. of meat ; he also has " an allowance, in the nature of partial board wages, estimated at 5d. a clay, which is supposed to be, and which, according to regulations, may be expended on his diet." Parkes gives the following table as representing the usual articles of food, with nutritive value in ounces avoirdupois, which each soldier consumes daily : Articles of Food. Quan- tity. Water. Albu- min- ates. Fat. Car- bo-hy- drates. Salts Total Water free Meat (| bone) ... oz. 12-00 7-20 1-44 o-si _ 15 2-40 Bread 24-00 9 60 1-92 0-36 11-81 31 14-40 Potatoes... 16-00 11-84 0-32 0-02 3-36 0-2 3-72 Green or other ) Vegetables ... } 8-00 7-28 0-14 0-04 0-46 0-6 0-70 Milk 3-25 2-82 0-13 0-12 0'16 0-2 0'43 Sugar 1-33 0-04 1-29 1-29 Salt 0-25 25 0-25 Coffee 0-33 Tea 0-16 Total quantity . . . 65-32 38-78 3-95 1-35 17-08 81 23-19 Calculating out the nitrogen, carbon, etc., in these substances, we get : Nitrogen 272 grains. Carbon in Albuminates ... 837 ) Fats 454 [ 4,588 Carbo-hydrates 3,297 ) Hydrogen in Albuminates 51) 11R Fats ... 65) Sulphur in Albuminates 32 Chap. IX.] SOLDIERS' DIETARIES. 221 To compare it with Moleschott's standard diet, we must state the quantities in grammes : Moleschott's. English Soldier's Diet. Albuminates Fat grammes. 130 84 grammes. 113 38 Carbo-hydrates ... Salts 404 30 482 23 Parkes observes with regard to this diet that it contains considerably less nitrogen than the standard diet, as is indeed evident by the comparison we have given above ; that it contains about the correct amount of carbon, but it would be better if less of the carbon were obtained from carbo-hydrates and more from fat. He recommends the addition of more meat or of cheese, and the addition also of butter or some other fat or oil. He also suggests the introduction of peas and beans, as in the French army. Professor de Chaumont was also of opinion that the food of the soldier is deficient, especially for the younger men, and he thought it highly desirable that the ration of meat should be increased. From inquiries among soldiers, he found that the recruits and young soldiers could eat much more; though the old soldiers, "many of whom had been long accustomed to take spirits, and who had injured their digestive powers by so doing, took less food." Parkes calculated that " the total energy obtain- able in the body from the soldier's daily diet appears to be equal to lifting 3,542 tons one foot. The amount for the internal and external mechanical work of the body being taken at 600 tons lifted a foot, there remains 2,942 tons for the animal heat and all the other processes." He points also to the deficiency of condiments in the soldier's food, and advocates 222 FOOD IN HEALTH. [Parti. especially the use of vinegar, as a digestive agent, a flavourer, and an anti-scorbutic. The Report of a Committee appointed to inquire into the question of Soldiers' dietary, was presented to both Houses of Parliament in June, 1889, and contains some interesting matters bearing on this subject. It points out that as the soldier receives an allowance for food as well as a ration of % Ib. of meat and 1 Ib. of bread, the question is not whether these are sufficient in themselves, " but whether these sup- plies, supplemented by other articles provided out of the messing stoppage, afford a sufficient diet for the soldier." The evidence of the manager of Pearce's Dining and Refreshment Rooms, an institution supplying about 30,000 meals daily to carmen, bricklayers, etc., in London, showed that the average amount of meat without bone supplied to each man for dinner was 5 oz. uncooked, yielding when cooked about 4 oz. According to Brigade-Surgeon Maunsell, who weighed 1,232 rations, the average amount of cooked meat supplied daily to the soldier was 7 oz. 1 dram, exclusive of bone and dripping. The Report also points out that the British soldier receives a larger meat ration than any Con- tinental soldier, and that with the existing scale of diet recruits almost invariably increase in weight. The most interesting and most practical part of the Report is that which refers to the considerable success which has attended the experiments of Colonel Burnett of the 1st Battalion Royal Irish Rifles at Mullingar, for supplying his men with what Surgeon-Major Notter, Professor of Military Hygiene at Netley, has described as a model diet, with a stoppage of only 3d. instead of 5d. a day. This system, or one somewhat similar, appears also to exist in many other regiments. Complaints as to the quality of the bread supplied to the army, the Report states, were almost universal and well-founded. It was often imperfectly Chap, ix.] SOLDIERS' DIETARIES. 223 baked and became stale and sour within a few hours of its issue. Large quantities of ration bread were thrown away by the troops and other bread was purchased in its place. As the class from which the army is recruited rarely eat dark-coloured bread, and have a great prejudice in favour of white bread, it is recommended by the Committee that the ration bread should be made from the same class of flour as the hospital bread. The Committee strongly advise the observance of more care and skill in cooking, as well as the saving and utilisation of the dripping in improving the diet (in that particular in which it is most defective, viz. in fat), and the bones for making soups. Cooking in some regiments was found to be attended with much greater waste than in others in one, 34 Ib. 8 oz. of mutton lost in cooking 9 Ib. 10^ oz. ; whereas in another, 27 Ib. 12 oz., also of mutton, lost only 4 Ib. 8.1 oz. : so that in one case the soldier received only 6J oz., in the other as much as 7| oz. of cooked meat. It has been recognised that the interval be- tween the light tea meal at 4 p.m. and breakfast next day at 7 or 8 a.m. is too long for the soldier, and especially the young soldier, to be without food. The Committee consider that the chief defects in the soldier's diet are due to insufficient interest being taken in this subject by the officers, and that the soldier's rations, supplemented by even a smaller sum than the authorised messing contribution of 3d. a day, afford, with proper regimental arrangements, a sufficient diet. In an appendix to their Report the Committee publish a Memorandum from Colonel C. J. Burnett setting forth the " innovations and improvements " he has made in the messing and rations of the men under his command. For a full account of Colonel Burnett's system the reader must consult this Report. Surgeon-Major J. L. Notter, Professor of Military 224 FOOD IN HEALTH. [Parti. Hygiene, Army Medical School, reporting on this system, says: " I have at last completed working out the value of your diets, and I must say it has astonished me. You have done wonders in the way of improving the soldier's food." Colonel Burnett has succeeded completely in showing that " with the Government ration, supple- mented by a stoppage of 3d. per day from the soldier, the demands of science in the matter of feeding the Army can be satisfied," and Dr. Notter adds, " The ration Colonel Burnett issues is ample, and he states he can provide this anywhere without extra cost." For campaigning no strict scale of diet is or can be laid down ; it would have to be fixed at the time, and would depend on the character of the campaign. The scale should be very liberal, and besides the usual articles of diet, extras should be supplied for special purposes, such as forced marches, rapid move- ments at a distance from the base of supplies, etc. The usual ration should contain at least 375 to 400 grains of nitrogen. Parkes suggests the following as a liberal and varied war ration : Bread 1 Ib. Fresh Meat, without bone 1 Peas or Beans ... ... 3 oz. Potatoes and Green \ r egetables... ... 1 Ib. Cheese ... ... 2 oz. Sugar 2 Salt % Pepper aV Ground Coii'ee 1 Tea Red Wine 10" Or Beer 20 The nutritive value of this diet is about 380 grains of nitrogen and 5,000 of carbon. As useful extras he mentions salt meat, Australian meat, Chicago meat, dried meat, Liebig's Extract, pea and beef sausages, biscuits, flour, meat biscuits, rice, Chap, ix.] DIETARY FOR INDIA. . 225 lime juice, preserved vegetables, brandy or rum, and vinegar. " Bread (which should be well baked) should be issued as long as possible ; and, if biscuit is issued for more than a week, flour or rice should be added to it. When salt meat is issued for several clays in succes- sion, vinegar should be given with it. If no vegetables can be obtained, lime juice should be early had re- course to." He strongly advises that red wine or beer should be supplied, and not spirits. All the Conti- nental armies issue wine rations in war. The use of concentrated and cooked foods is very important for rapid expeditions. The dietary suitable for India and for service in tropical countries must be proportionate to the amount of mechanical work done, as in temperate climates. In India, as elsewhere, it must balance the expendi- ture of energy. It has been thought that it would be beneficial to derive the food supplies more exten- sively from the vegetable kingdom in India than at home, so as to restrict the amount of animal food taken within comparatively narrow limits. But the testimony of some of the most experienced medical officers is opposed to this. " It has often been said that Europeans in India should imitate the natives in their food, but this opinion is based on a misconcep- tion. The use of ages has accustomed the Hindu to the custom of taking large quantities of rice, with pulses or corn. Put a European on this diet, and he could not at first digest it ; the very bulk would be too much for him. The Hindu, with this diet, is obliged to take large quantities of condiments (pepper, etc.). The European who did the same would produce acute gastric catarrh and hepatic congestion in a very short time." It is certain that in the Indian climate spirits are injurious, and wine and beer should be taken in great moderation. The men should not be allowed more than a quart of beer a day, and they would be healthier with a pint. In the hot stations and seasons entire abstinence from 226 FOOD IN HEALTH. [Part I. alcoholic stimulants should be the rule, and tea and coffee should be chosen as the best beverages. The tendency to scurvy, which is greater in the Tropics than at home, points to the desirability and importance of consuming a due proportion of fruit. Ration of the French soldier. Dujardin- Beaumetz makes the remarkable statement that the ration of the French soldier is superior to that of the soldiers of other armies, an opinion which another French authority, Prof. Germain See, is far from sharing, who points out the superiority of the ration of the British soldier, and expresses great dissatis- faction both as to the quantity and quality of the French soldier's rations. The State provides the meat at thirty-five per cent. under market price ; it also supplies the common bread (pain de munition). The white bread (pain de soupe) has to be bought by the soldier. For this and other articles of diet he has to subscribe forty-three centimes out of his daily pay of forty-eight centimes, leaving him five centimes, i.e. a halfpenny, to receive in cash. His dietary consists of Grammes. Oz. avoir. Munition Bread ... White Bread (for Soup) Meat (uncooked)... Vegetables (green) (dried) Salt 760 260 300 100 30 15 26-4 8-8 10-6 3-5 ri 0-5 Pepper 2 (31 grammes) Total 1457 51 -00 550 grammes of biscuit are sometimes given in place of bread, and 250 grammes of salt beef or 200 of salt pork in the place of fresh meat. The dried vegetables consist chiefly of haricot beans. Chap, ix.] FRENCH SOLDIER'S RATION 227 Parkes calculates that the French soldier gets a total of 51 ounces of solid food against the British soldier's 65 ounces ; but when estimated as " water- free " food he gets 24'7 ounces against the British soldier's 23-2 ounces. This is due to the circumstance that the French soldier gets a much larger ration of bread, viz. 35 ounces against 24, which is the British soldier's ration. On the other hand, the British soldier usually gets 16 ounces of potatoes, which con- tain nearly 75 per cent, of water. The French soldier gets too much bread and too little meat. Owing to the lai-ge quantity of bread in it, his diet calculates out much richer both in albu- minates and carbo-hydrates than that of the British soldier; but it is, on the whole, a less nutritious diet. In Algiers, 16 grammes of rice are added to the French soldier's rations ; and when on the march sugar, coffee, and \ litre of wine are issued. In time of war he gets Meat (without bone) 8-40 oz. Bread (or Biscuit, 26-5 oz.) 35-30 Dried Vegetables 2-12 Salt 0-50 Sugar 0-70 Coffee 0-60 Total 47-62 Nine ounces of wine or 2J ounces of brandy are sometimes served out instead of the sugar and coffee. Germain Se'e calls attention to the excessive quantity of bread in the French soldier's ration, much of which, he says, is not consumed, and, if it were, it could not be digested. He also very properly points out that at the age when men enter the army as recruits it is a serious error to suppose that their growth is complete. Many parts of the body do not reach their complete and permanent state "till five- and-twenty years of age, or even beyond that period, p2 228 FOOD IN HEALTH. [Parti. The young soldier should then, from a nutritive point of view, be regarded as still in the period of growth and development, and his food should, therefore, not only be sufficient to maintain the integrity and activity of his bodily organs, but also contribute to his further growth."* The German soldier receives a small and a large ration ; the latter he gets when on marches or manoeuvres, etc. They consist of the following food substances : Smaller Ration. Larger Ration. oz. av. 26-50 oz. av. 26-50 Meat (uncooked) Rice 6-00 3 20 8-82 4-22 Or Unhusked Barley (Grout*) Or Peas or Beans Or Potatoes ... 4-21 8-22 53-08 5-28 10-60 70-50 Salt 0-87 0-87 Coffee 0-468 0-468 Parkes calculates that, when of best quality, these would furnish Albumin- ates. Fats. Carbo- hydrates. Salts. Total Water- free Food. Smaller Ration oz. av. 4-8 oz. av. 1-1 oz. av. 17-4 oz. av. 1-5 oz. av. 24-8 Larger ,, 5-7 1-4 18-0 1-6 27-3 The German soldier gets a little more bread than the British soldier, but less meat. He also gets a ration of rice, which neither the British nor French soldier gets on home service. * Germain Soldat." " Du Regime Alimentaire. R6gime du .Teune Chap. ix. j AUSTRIAN SOLDIER'S RATION. 229 During the Franco-German War the daily German ration (independent of certain extra issues, when pos- sible, of bacon, preserved and smoked meats, peas, white beans, potatoes, etc., in order to change the diet) was : One of these One of these Bread (or Biscuit, 17 oz.) ... 26^ oz. Fresh or Salt Meat 13 Salted Beef or Mutton ... 9 Bacon of Rice ... 4'4 ( Barley or Groats ... ... 4'4 ] Peas or Beans 8'8 (Flour 8-8 Potatoes 3-3 Ib. Salt 7 oz. | 0'7 ,, (unroasted) ) ; or 1 ,, (roasted) Coffee The Austrian soldier receives in time of peace : bread, 31 oz., and meat (without bone), G'6 oz.; suet, 0-6 oz. ; flour (or vegetables), 2-5 oz. ; salt, 0'6 oz. ; with a little garlic, onions, and vinegar. In war time the diet is variable. On four days fresh pork is issued, 6^ ounces daily ; on one day, salt pork, 6 ounces ; on another day, beef, 6 ounces ; and another, smoked bacon, 6 ounces. There is also an issue of butter or fat in addition. He has also a weekly issue of biscuit (244 ounces), flour (176^ ounces for bread and cook- ing), sauerkraut (5j ounces), potatoes (9 ounces), peas (5} ounces), and barley (5 ounces) ; also wine, brandy, and beer. These diets yield j Albumin- 1 w . ates. FuK Carbo- hydrates. Salts. Wuter-free Food. In time of peace . . . 3-7 1-6 17-0 1-0 23-3 In time of war \ 4-5 3-2 22-8 1-0 31-5 average ... j The peace ration contains too much bread, too little meat, and too little fat. 230 FOOD IN HEALTH. [Parti- The Russian soldier has 196 meat days and 169 fast days in the year. On the meat days he gets meat and schtschi (cabbage soup), and buckwheat gruel ; on fast days the meat is replaced by peas and, occasionally, fish. He has a daily issue of 42 ounces of rye bread. The nutritive value of this diet has been estimated as follows, in ounces avoirdupois : Albuminates. Fat. Carbo-hydrates. Salts. Water-free Food. 5-8 1-0 25-0 2-5 34'3 On the march he gets 24|- ounces biscuit instead of bread. On rare occasions, brandy, 135 fluid ounces per annum in 5 ounce rations, is served out. The following is the fresh meat ration of European armies, calculated in ounces avoirdupois,* extracted from a statement prepared by Professor J. L. Notter, M.D. : England ... 12'0 oz. France 10-58 Germany ( smallor ration 3 ' 80 ^ (larger 881 Austria... ... ... ... ... 9'87 Belgium 8'81 Holland 8-81 Switzerland ... ... ... ... 11 - Italy 634 Denmark ... ... ... ... 8 - 74 Sweden 567 Russia ... , 7'05 Turkey 9-06 It would be extremely valuable, in the case of long sea-voyages, and for armies campaigning, if food could be so concentrated that it might occupy but a small amount of space and yet lose none of its nutritious qualities. It would appear, however, to be impossible to procure the food necessary for * Report of the Committee appointed to inquire into the ques- tion of Soldiers' Dietary. Presented to both Houses of Parliament, June, 1889. chap, ix.) SEAMAN'S RATION. 231 maintaining unimpaired the work and activities of the body in a digestible form in a less bulk than 22 or 23 water-free ounces. Concentration, according to Parkes, cannot be carried beyond this, and practically has not even reached this extent. " Life, however, and vigour may for some days be preserved with a much less amount ; and the total amount of food has been reduced to 11 water- free ounces daily, with full reten- tion of strength for seven days, though the body was constantly losing weight. For expeditions of three or four days, if transport were a matter of great diffi- culty, soldiers might be kept on 10 or 12 ounces of water-free food daily, provided they had been fully fed beforehand, and subsequently had time and food to make up the tissues of their own body, which would be expended in the time, and would not have been replaced by the insufficient food." In the British Navy, when fresh provisions can be procured, a seaman's full daily allowance consists of 1 Ib. of fresh meat, \ Ib. of vegetables, \\ Ib. of biscuit, or li Ib. of soft bread; 2 oz. of sugar, 1 oz. of chocolate, \ oz. of tea, and \ pint of spirit. He also has weekly 3 oz. of oatmeal, \ oz. of mustard, \ oz. of pepper, and \ pint of vinegar. When fresh provisions cannot be procured, he gets daily either 1 Ib. of salt pork or salt beef, or f Ib. of preserved meat ; and in addition on certain days \ Ib. of split peas, with celery seed to flavour the soup made from them. On other days he gets flour 9 oz., raisins \\ oz., suet -| oz., to make into a pudding ; and on other days either 4 oz. of preserved potato, or 4 oz. of rice, or 2 oz. of each. 232 CHAPTER X THE ORDER AND FREQUENCY OP TAKING FOOD. IT has become an almost universal custom in civilised life to appropriate certain fixed times in the day for taking food. Not only does this practice appear to be well suited to our physical organisation, and there- fore most consistent with health, but it is obviously a necessary condition of a life full of physical and intellectual activity and occupation, such as the great majority of civilised human beings lead. Reference has been made by various authors to the habits of feeding of other animals, and attention has been directed to the long periods during which the carnivorous animals are accustomed to go without food as compared with the almost continuous feeding of some of the herbivora. But none of these animals in their natural state lead an existence at all analogous to that of civilised human beings, and when such herbivorous animals as the horse or the ox are applied to the service of man, the same mode of feeding, viz. at regular, fixed intervals, is found to suit them perfectly well. The carnivorous animal usually con- sumes an enormous quantity of food, if he can obtain it, at each meal and then passes into a condition of torpor and lethargy, and the human being who attempts to imitate his habits of feeding will be found to be affected with the same kind of languor and -incapacity for exertion after meals. In fixing the intervals which should occur between "' meals, it is necessary to bear in mind that the rate of digestion varies considerably in different persons and at different ages, and that it is also greatly in- fluenced by habits and occupation. Chap. X.] HOURS OF TAKING FOOD. 233 It has been estimated that it requires from four to five hours to digest an average meal ; but some meals and certain kinds of food require a longer time than this, while for some kinds of food a shorter period is sufficient. In a growing active youth or a healthy child, fed on appropriate and readily digested food, the digestive process is comparatively rapid, and the intervals between meals should therefore be shorter than in the case of adults. So also in adults leading an active out-of-door life, the food taken at each meal will be digested more rapidly and more completely than in the case of persons of middle age following a sedentary occupation. In Great Britain (with the exception of boys and girls at school, who are often required to go too long without food) the tendency no doubt is to eat at too short intervals, and in many cases indigestion arises from the stomach being frequently called upon to commence the digestion of a fresh meal before it has completed that of the preceding one. The first meal of the day is breakfast, and it is a very important one. In the case of active persons leading wholesome, regular lives, it should be taken as soon after rising as possible. Persons who require to take exercise before breakfast are either dyspeptic or overfed ; and, except in such persons, any consider- able exertion, without having first taken food, after so long a fast as usually occurs from the preceding meal, is unduly exhausting and calculated to be injurious. The unfed organism at this period of the day is also very susceptible to morbid influences, and especi- ally prone to take harm from exposure to cold, to infection, or other injurious and depressing agencies. Of course, for those who prefer to take a substan- tial meal at noon, or a little earlier, as is the custom to a great extent on the Continent, a cup of good cafe-au-lait, with a little bread and butter or dry toast, or biscuit, taken immediately on rising, is sufficiently stimulating and supporting to carry one over the 234 FOOD IN HEALTH. [Pan I. interval between rising and the midday breakfast or dejeuner a la fourcliette. But in England a substantial early breakfast is popular, and accords well with the business and other habits of average Englishmen. 8 or 9 a.m. is the usual hour for this meal. The quantity and kind of food proper to be taken at this meal must depend on what may be the custom with regard to the food taken at luncheon, or at an early dinner. Those who take a substantial meal in the middle of the day do not require a large breakfast ; a cup of tea, coflee, or cocoa, with a little bread or toast and butter, a boiled or poached egg and a rasher of bacon, is ample in this case. But when only a very light luncheon is taken between breakfast and late dinner a plan which suits many busy professional and business men exceedingly well then the breakfast should be as substantial as the appetite and digestion are equal t.o. A little well- made oatmeal porridge to begin with, then some fish such as sole, whiting, haddock, a fresh or kippered herring, a poached or lightly-boiled egg, with a little broiled ham or bacon, bread and butter, or dry toast, and marmalade, or some fruit compote ; tea, coffee, or cocoa. With a substantial breakfast such as this, and a good vigorous digestion, the organism is well fur- nished to begin the work of the day, and only a very light luncheon will be required. This should consist of the lean of a small mutton chop, or a little cold chicken, with bread or a potato, or a small basin of good soup with a little toast. Nothing more ! Half- past 1 or 2 o'clock is a good time for such a meal. Those who take a light breakfast, and find it con- venient practically to dine in the middle of the day, must, if they are engaged in active intellectual work in the afternoon, be careful not to make a large meal at this hour, as it is almost certain to make them heavy and dull for an hour or two afterwards. An early dinner of this kind should consist simply of a chop or steak, or a cut or two of some good joint, chap, x.] DIFFERENT SYSTEMS OF DEEDING. 235 hot or cold, with a small quantity of bread and vege- tables, a little bread and cheese, or butter ; or, if preferred, a little light pudding or some cooked fruit. The widely-spread custom of taking a cup of tea about 5 o'clock is consistent with either of the above methods. For those who have lunched lightly, it aflbrds that little necessary stimulus and support to carry them on to the dinner-time ; and for those who have dined early, it favourably influences the process of digestion, and rouses the mental and physical energies for the completion of the day's work. A substantial dinner at 7 or half-past (it should not be later) is appropriate for those who lunch lightly. It should consist of soup or fish, or both, an entre'e, or some joint, poultry or game, according to choice; some cooked fruit or light pudding, biscuit and cheese, and fresh vegetables and salads of the season. Those who take an early dinner should take a light supper about half-past 8 or 9 : a little white fish, or chicken and ham, or other cold meat and salad, with a little bread and cheese or butter. Considerable variations in the manner, frequency, and time of taking meals appear to be not incon- sistent with health and convenience. There are, as Sir Henry Thompson has pointed out, certainly three different systems extensively practised. First, there is the Continental system of two meals a day. The dejeuner d, la fourc/iette which corre- sponds with our lunch or early dinner is usually taken between 11 a.m. and noon. This is a sub- stantial but not a heavy meal, and frequently consists of some white fish, or cutlets, or a made dish of some kind, then an omelette and some fruit or cheese. Wine and water is usually drunk with this meal. The only food taken before this meal is a cup of cqfe-au- lait or chocolate, with a little bread and butter or a rusk, which is served in one's bedroom on first getting up. This accords perfectly with the earlier hours of the professional classes on the Continent. Their work begins often at 8 or 8.30 a.m., and they are not 236 FOOD IN I/EAITH. Parti. delayed by a formal meal, but go directly from their bedrooms to their work. By 11.30 they have done three hours' work, and then their first formal meal or dejeuner comes as an agreeable break or rest in the day's labours. They usually take plenty of time over this meal ; and a cup of coffee leisurely sipped, together with a cigarette, occupies the following half hour. The second meal or dinner is taken when the day's work is over, usually between 6 and 7 p.m. This is a substantial meal of soup, iish, one or two moat dishes, sweets, and dessert ; black coffee follows. .Nothing more in the way of solid food is taken. On the whole, less food appears to be taken in this way than on the English system ; more attention, is, however, paid to the cooking, and the food is on that account more stimulating and sup- porting, and less oppressive. What, perhaps, seems most remarkable to an Englishman, in this system, is that it is adopted by all classes of the community in France and elsewhere on the Continent ; whereas, in Great Britain the time of taking food is almost a class distinction. Secondly, there is the system prevalent amongst a large part of the middle classes in England Sir Henry Thompson calls it " the provincial system" of taking four meals a day. It is, no doubt, adapted, to some extent, to their earlier hours and longer day's work. The first meal, or breakfast, is taken about 8 a.m., and usually consists of tea or coffee, bread and butter, some bacon, or salt or smoked fish, or an egg. Dinner is the next meal, usually at 1 or half-past. This commonly consists of a joint and plain vegetables, some pudding, and bread and cheese. Soup or fish may be added to this meal on occasions. Tea follows at 5 or 6. This is not infrequently made a somewhat heavy meal what is called a " heavy tea " and is the great defect in this system. It is much too soon after the substantial midday dinner for another substantial meal, and these ' heavy Chap, x.j ORDER OF MEALS, ETC. 237 teas " are responsible for a great deal of the dyspepsia prevalent amongst this class. There would be no harm in drinking tea at this hour, but the taking of solid food (except with young growing girls and boys) should be postponed to the next meal or supper at 8, if the dinner is at 1 ; at 9 p.m., if the dinner hour is 2 o'clock. This should consist of a moderate meal of nsh or meat, cold or hot, with bread or potatoes. This system of four meals a day is well adapted to young growing people whose digestions are active and vigorous. They require food more frequently, and in larger quantities, than adults. It is similar also to the German system ; but the Germans dine almost universally at 12 30, not later, and their supper is regularly served at 7.30 or 8 p.m. Thirdly, there is the system, already described, adopted by the professional and upper classes of breakfast, lunch, and late dinner, with 5 o'clock tea. In this system it is the lunch which is the difficulty and danger ; it should be, as Sir Henry Thompson observes, sufficient to support activity, not so consider- able as to impair it. Again let it be said, that solid food should not be taken with the 5 o'clock tea, and it is better not to take either sugar or cream with the tea at this hour. A thin slice of lemon added to the cup of tea, which should be made of China tea of good quality, is best. Children should not be allowed to partake of the late dinner ; the four meals system is, as has been already stated, more suitable to their needs. The order of the courses at dinner, i.e. of soup, fish, entree, roast, and sweets, cannot well be improved upon. Soup at the beginning of dinner has been objected to on the ground that it diminishes digestive power by diluting the gastric juice, and tliis objection is valid if a large quantity of badly-made soup is taken. But it does not apply to a small quantity, 4 to 8 oz., of well-made clear soup. Such a fluid disappears quickly on reaching the stomach, as it is rapidly absorbed by its blood vessels and interferes in 238 FOOD IN HEALTH, [Parti. no way with the gastric juice. Its value at the commencement of a meal depends on the fact of its rapid absorption and entrance into the blood, so that the hungry man is quickly refreshed. " Soup intro- duces at once into the system a small instalment of ready-digested food and saves the period of trial, which, in the absence of soup, must be spent by the stomach in deriving some portion of nutriment from solid ali- ment, and thus the organ of digestion itself is indirectly strengthened for its forthcoming duties ; " by filling the vessels of the stomach itself it really assists in the secretion of the gastric juice. A certain interval should be allowed to elapse between the last meal of the day, whether it be called dinner or supper, and the time of going to bed. The functions of the body pass into a state of inactivity during sleep, and all the organs of the body should " rest from their labours." If the chief work of the stomach is not completed or nearly com- pleted on retiring to rest, that rest is likely to be imperfect or disturbed. An hour and a half or two hours is sufficient to allow between a light supper and bed time, but at least two and a half or three hours should elapse between a heavy dinner and retiring to bed. It would be an error, however, to suppose that a perfectly empty stomach contributes to repose ; on the contrary, it frequently is the cause of wakefulness. A certain sense of repletion, a sense of all the wants of the body being completely satisfied, conduces greatly to repose ; this is strikingly manifested in the tendency shown by nearly all animals to fall asleep after a full meal. Many persons who of necessity retire to bed late, and who do not dine very late or eat very largely at dinner, find that they sleep much better if they take a breakfastcupful of clear soup with a little toast or the same quantity of arrowroot before going to bed. It is scarcely necessary to say that the habit of taking food between meals or other than at the stated meal times is most injudicious and hurtful. A meal should not be commenced immediately after active or violent exercise. The half-hour devoted chap, x.] ORDER OF MEALS, ETC. 239 to leisurely dressing for dinner and after violent exercise half an hour's perfect rest before this is the best preparation for the principal meal of the day. The stomach requires to have at its disposal the best and freshest energies of the body for its im- portant work the work, it must not be forgotten, upon which every other energy and function of the body is absolutely and entirely dependent. For the same reason violent exercise after a meal is to be carefully avoided. The taking of strong tea and strong black coffee after dinner should be avoided by those whose digestions are not vigorous ; they act as retarding agencies and tend to prolong the period of digestion, not hasten it ; it is possible, however, as Sir W. Roberts has suggested, that the slightly retarding effect they exercise on digestion may not be altogether a disadvantage in the strong and vigorous. A cup of hot water sipped slowly an hour or two after dinner, instead of coffee or tea, or a hot and very weak infusion of the latter, will sometimes be found a material aid to feeble digestion. 240 CHAPTER XL POOD IN RELATION TO AGE AND CONDITION FOOD IN INFANCY AND CHILDHOOD FOOD AT SCHOOL FOOD IN ADULT LIFE FOOD IN ADVANCED AGE. IN considering the proper relations that should exist between the nature and amount of the food taken, and the age of the individual and the particular conditions under which he is living, we shall have to bear in mind that, as to age, there are three great and principal divisions in human life. First, the age of growth and development, which extends from birth to about eighteen years of age, and this we shall consider as consisting of two parts (a) the period of infancy and childhood, terminating at the tenth year of life ; and (6) the period of scliool life or adolescence. It is especially characteristic of this division of human life that, while it lasts, the individual is to a great extent dependent on others for his food supply and its selection more so, at any rate, than at any subsequent period of his existence. Secondly, there is the period of adult life, the age of completed growth and perfect development; the age of the full and varied employment of all the functions, physical and intellectual, of the organism. It will be convenient to consider under this division the influence, in relation to his food, of the different conditions or circumstances of life to which the individual may be subject. Thirdly, there is the period of advanced age ; the period of declining powers and progressively weaken- ing functions. According to the investigations of what is called " The Munich School," the following table gives the Chap. XI.] FOOD IN INFANCY. 241 minimum amount of food necessary for different ages, stated in grammes : Age. Nitrogen ous. Fat Carbo- hydrates. C'hild under 18 months . grammes. 20 to 36 grammes. 30 to 45 grammes. 60 to 90 ,, from 6 to 15 years. Men (moderate work) Women 70 ,. 80 118 92 37 50 56 44 250 ,,400 500 400 Old Men 100 68 350 ,, Women 80 50 260 It will be necessary in the first place to consider, and to consider at some length, on account of its initial and intrinsic importance, the subject of Food in infancy and childhood. The feeding of infancy may be dealt with under three heads 1st. When the babe is suckled by a healthy mother with a sufficient milk-supply. 2nd. When it is entrusted to a wet-nurse. 3rd. When it is " brought up by hand " and has to be fed by means of what are termed " substitutes for mother's milk." 1st. When an infant is suckled by a healthy mother, its food for the first seven or eight months of its life should be entirely restricted to the mother's milk. This is the only food that is perfectly adapted, by its characters and composition, to the digestive capacities of the young infant. For some time after birth the salivary glands are not developed and the pancreatic secretion, for the first three months, has no power of digesting starch, so that the young infant is not provided with any means of digesting farinaceous food, even in small quantities, and none should there- fore be given. At birth the digestive organs are in a comparatively immature state, the alimentary canal is short and the caecum very small. 242 FOOD IN HEALTH, iPaui. It usually happens that the secretion of milk in the breasts of the mother is not fully established until the third day after the birth of the child ; but if the babe is perseveiingly applied to the breast every two hours, while the mother is awake, there need be no fear of starvation. During the first six weeks the child should be put to the breast every second hour from 5 a.m. to 11 p.m. It should be removed from the breast as soon as it shows an inclination to discontinue sucking; and it should be remembered that at birth the child's stomach is of very small capacity, and the breast should never be forced upon it, so long as it sleeps well, and thrives well, and is content. Feeding every three hours will be often enough, with many children, after the third week, and up to the end of the second month. It must be remembered that these, as well as the periods to be subsequently stated, are only average intervals, useful for general guidance, but which may need modification according to individual peculiarities, some infants feeding much more eagerly than others, and taking more at a time. From the second to the seventh or eighth month the infant should be suckled every three or four hours. The composition of human milk varies somewhat, according to the period of lactation and other circum- stances. After delivery, for the first few days, it is of greater consistence and of a yellow colour, and is known as colostrum. It contains large cells filled with fat granules termed colostrum corpuscles. The regular secretion of milk begins after three or four days. The casein and fat increase in quantity up to the end of the second month, the salts up to the fifth month, and the sugar from the eighth to the tenth month. The greater the quantity secreted, the more casein and sugar and the less fat it contains. The milk of a primipara is richest in solids. The diet of the mother, no doubt, influences chap, xi.] FEEDING IN INFANCY. 243 somewhat the composition of the milk, especially as to the amount of fat it may contain. It should be simple, nutritious, ample, and regular. Rich and stimulating foods should be avoided. She may be permitted, for the purpose of increasing the flow of milk, the free use of animal broths, chocolate, milk, gruel, and sometimes a moderate quantity of porter or stout. Oatmeal porridge at breakfast is excellent, and tends to obviate the constipation that often attends this period of relative physical inactivity. " F.ortunate," says an American writer,* " is the babe that, in our day of advanced civilisation and city-living, can draw from the breast of a robust mother an abundant supply of pure, health-giving, tissue-building food." In such a case the child should be nursed solely by the mother up to eight months, and after that partially to the end of the first year, if possible. The date of weaning must depend, to some extent, on the health of the mother and the development of the child. If both are doing well, between the tenth and the twelfth month, the breast should be gradually withdrawn. After the seventh or eighth month, when the teeth begin to appear and the salivary glands to be developed, some other food may be introduced, once or twice a day, instead of the breast-milk. The following have all been highly recommended : Chapman's Entire-Wheat Flour. This contains some "cerealin," which has the property of converting starcli into dextrin and maltose ; it is rich also in albuminates, fats, and the necessary mineral sub- stances, as in its preparation the pollard or outer parts of the grain are retained. Liebig's Food, Mellin's Food, Allen and Hanburys' Food, Benger's Food, Savory and Moore's Food, and Nestle's Food are all appropriate, as they contain starchy matter in a readily assimilable form, with * Dr. Louis Starr, of Philadelphia. Q2 244 FOOD IN HEALTH. [Pan i. some preparation of malt. A small tablespoonful of any of these malted foods may be given for the midday meal. Mutton broth or jelly made from the shank of mutton is also admissible. But after weaning, and up to a year and a half, milk should still be the chief article of diet. Cow's milk, with about one-fourth water, or the following mixture, is good : Cream, % oz. ; milk (cow's), 4 oz. ; sugar of milk, a dram ; and water, 1^ oz. This should be warmed in a water bath.* A little custard pudding may also be given daily, made by mixing one egg with half a pint of milk, and adding a little sugar. The egg usefully supplies a certain amount of albuminates and fats. After eighteen months the following articles of diet may be gradually and occasionally introduced : A little finely pounded chicken, mutton, or beef, and especially mutton fat, which may be pounded and mixed with a little mealy potato, and a little red meat gravy added to it. Mashed potato and cauliflower carefully passed through a sieve may also be used, as well as stale bread-crumb, soaked in milk or broth. As soon as the teeth are fully developed some food requiring mastication should be given. The foregoing dietary applies to a healthy child brought up by a healthy mother on breast-milk. But it often happens that the mother's milk is defective both in quality and quantity, and in that case it is necessary to change it ; or it may be defective only in quantity, and then it must be supplemented. 2nd. The best substitute for the mother's milk is that of a young and healthy wet-nurse, when she can be obtained. As to the qualities of a wet-nurse : she should be robust and strong, and rather spare than fat ; free * Whenever the milk supply is not wholly beyond the possi- bility of contamination, the milk should be sterilised by boiling or in the manner to be subsequently described. chap, xi.] QUALITIES OF A WET-NURSE. 245 from all inherited tendency to mental or physical disease, and presenting no trace of syphilis, tuber- culosis, or scrofula. She should be cheerful, good- natured, active, and temperate ; she should be between twenty and thirty years of age, and her infant should be of nearly the same age as that of the one to be suckled. She should have an abundance of good milk, the best test of which will be the aspect of her own child. It is better, if possible, that she should be a multipara, as she is, in that case, more likely to understand her business ; but there is no objection to a primipara, if otherwise eligible. It has been said that it is wise to select as wet- nurse a woman whose infant is three months old, as her milk is then of uniform quality, and there is then time to see if there is any syphilis in the infant or mother. If the milk of the wet-nurse is found to disagree with the infant, it may be necessary to change the nurse ; the diet of the wet-nurse should, however, be first carefully investigated. Milk of good quality is secured by proper food, but wet-nurses are usually and unwisely overfed with butcher's meat, and ale and porter, and are in the habit of taking far too little exercise. Their health is liable to suffer from a rich and an over-albuminous diet, especially as they have probably been underfed in their immediately antecedent life. A diet should be given them more in accordance with that to which they have become habituated. Dr. W. J. Thayer, of Brooklyn, New York, offers a valuable suggestion as to the food most appropriate to the expectant mother. " Early in gestation she should begin to eat, at least three times a day, some form of coarse cereal foods, such as oatmeal, Graham, rye, or Indian breads. These articles, being made from the unbolted products of the grains used, contain a much larger proportion of lime salts than the prepara- tions of the tine bolted flour of ordinary employment. 246 FOOD IN HEALTH. [Parti. The result is that the mother supplies her offspring, first through the umbilical cord, and afterwards through the mammary glands, with a pabulum con- taining essential elements for the nutrition of a very important set of organs, namely, the teeth." This should be supplied from the commencement of the development of the teeth, i.e. about the sixth week of intra-uterine life. 3rd. Other " substitutes " for mother's milk and bringing up " by hand " must next be considered. On this the American author already quoted* observes : " There can be no doubt, though the statement is a bold one, and seemingly contrary to nature, that, taking the average, infants properly brought up by hand are better developed and enjoy more perfect health than those completely breast-fed. Of coui-se, there is no artificial food equal to the natural the sound breast-milk of a robust woman and a child fed upon this must thrive, if other circumstances are favourable. Unfortunately the woman who has suffi- cient health and strength to furnish an abundant supply of good milk during the ten or twelve months of normal lactation is unique in our day " (he is speak- ing of American women), "and the great bulk of those who do nurse children, grow pale, thin, and feeble, and give milk which, though sufficient in quantity to fill the suckling's stomach and satisfy the craving of hunger, does not contain enough pabulum to meet the demands of nutrition. Such mothers always complain that their children are puny, peevish, and always ailing, and wonder why their neighbour's babies fed upon the bottle are so round, jolly, and healthy. The explanation lies in the simple fact that good cow's milk is better than bad breast milk ! " Besides cow's milk, ass's milk and goat's milk have been proposed as substitutes for mother's milk. Ass's milk is a good substitute ; it has a very fine curd, and is easy of digestion, but it is costly, and, compared with human milk, is defective in albuminates * Dr Louis Starr. Chap, xi.] SUBSTITUTES FOR MOTHER'S MILK. 247 and fats, as will be seen in the table on page 248, and it would require nearly twice the quantity of ass's milk to supply the nutriment contained in human milk. It has also laxative properties. Goat's milk is richer in albuminates and fats than human milk, and even than cow's milk, and it has also a strong and peculiar odour, but infants do not seem to object to this. One of the advantages of goat's milk is that the animal yielding the milk can be kept on the premises, and its health and feeding carefully superintended, and it can be trained so that the infant can suck the milk directly from the udder. Either of these milks may be boiled, and this process removes the strong odour of goat's milk and the laxative property of ass's milk. The reason why the milk of the ass and even that of the goat will agree with the human infant when cow's milk disagrees, would appear to be owing to their different manner of clotting when they come into contact with the gastric juice. Cow's milk has a tendency to coagulate in the infant's stomach into large, firm, cheese-like masses, which are apt to cause much gastro-intestinal irri- tation, whereas ass's and goat's* milk form a loose flocculent curd like human milk. But in the vast majority of instances it is upon cow's milk we must rely as a substitute for mother's milk ; it has the enormous advantage of being plentiful and cheap, and its defects can, with a certain amount of care, be easily remedied. Moreover, if the cow's milk is boiled as soon as received this not only sterilises it but renders it more easy of digestion,! as the curd coagulates in somewhat smaller masses, and it is less liable to ferment. A comparative study, therefore, of human and cow's milk is an important duty in connection with infant feeding. It must be borne in mind, aa * This is denied by Cheadlo, so far as goat's milk is concerned. ("Feeding of Infants," 3rd edit., p. 6.) t This is doubted by some authorities. 248 FOOD IN HEALTH. [Part I. has already been pointed out, .that mother's milk varies in composition at different periods of lacta- tion, and in different individuals, so that consider- able discrepancies may be discovered in the pub- lished analyses. The nitrogenous constituents are the most changeable, and may vary in different specimens from 4'86 to - 85 per cent., next the fats, and next the salts, the maximum being about three times the minimum. The sugar is the least variable consti- tuent, and contains a nearly uniform standard of 7 per cent. The following table gives the normal composition of human,* cow's, and ass's milk. The third column gives Luff's recent analysis of human milk, which differs considerably from some others. Doubtless the composition of different specimens varies greatly (see p. 54). , Human Milk. (Average.) Cow's Milk. (Average.) Human Milk. (Luffs Analysis.) Ass's Milk. per cent. per cent. per c-eut. per cent. Water 86-766 87-7 88-51 90-5 Total Solids 13-234 12-3 ,, (not fat) ... 9-221 8-48 Fat 4-013 3-75 2-41 1-4 Lactose 6-997 4-42 6-39 6-4 Albuminoids ... 2-058 3-42 2-35 1-7 Ash 0-21 0-64 0-34 i The specific gravity of human milk is about 1031, and its reaction is persistently alkaline ; that of cow's milk is on an average 1029, and it has a highly acid reaction if not quite fresh from pasture-fed cows. It is richer-looking, whiter, and more opaque than human milk. A further very important difference is that its Cheadle's " Feeding of Infants, ' 3rd edit., p. 19. Chap, xi.j SUBSTITUTES FOR HUMAN MILK. 249 nitrogenous constituents are differently affected by coagulating agents. According to Konig, the total amount of albuminoids in cow's milk which is coagu- lated by acids is far greater perhaps four times greater than the non-coagulable portion. In human milk the reverse is the case, and the non-coagulable poi-tion much exceeds, is perhaps twice as great as, the coagulable part. Again, with rennet cow's milk coagulates into large firm masses ; with human milk it forms a light loose curd. The acid gastric juice in the stomach has the same effect, producing in the case of cow's milk a coagulum most difficult to digest, and in the case of human milk one which is readily attacked and broken down by the gastro-intestinal solvents. All artificial food should conform as closely as possible to human milk, and should, like it, clot in fine flakes. If cow's milk is used, its chemical compo- sition and physical properties must be modified in order to make it a fit substitute for mother's milk. The albuminates and fats are largely in excess in the infant's diet as compared with the diet of adults, and this is necessary in order to minister to the very rapid growth which takes place in infancy and childhood, and food has also, on this account, to be taken more frequently. The brain is said nearly to double its weight in seven years. The liver is notably larger in childhood, on account of the greater activity of its metabolic functions. Much difference of opinion exists as to the suit- ability of " condensed " milk as a substitute for human milk. It certainly has the advantage of keeping better than ordinary cow's milk, and it is said by some to be more readily digested by young infants, and that they thrive on it. Others assert that this is a delusion, founded on the circumstance that condensed milk is largely diluted with water, and cow's milk not suffi- ciently ; that the infant appears to thrive because con- densed milk contains a large proportion of added sugar s which forms fat and makes large babies, and 250 FOOD IN HEALTH. [Part I. also counteracts the tendency to constipation, but that it does not contain enough nutrient constituents to supply the wants of a growing infant. In the following table A. Y. Meigs has compared the composition of condensed milk diluted in the pro- portion usual for the first week or so of infant life, with some average specimens of human and cow's milk : Human Milk. Cow's Milk. Condensed Milk (Eagle Brand). Mixture of 1 Part of Con- densed Milk with 24 of Water. Water . . Fat 87-163 4-283 87-012 4-209 27-942 10-335 92-673 1 -095 Casein . . 1-046 3-222 9-522 868 Sugar . . Ash 7-407 101 5-000 527 50-861 1-340 5-206 158 It will be seen that the amount of fat and of casein are much less than in either human or cow's milk, and that of sugar less than in human milk. " The addition of a larger proportion of condensed milk would remove these faults, but at the same time would increase the quantity of sugar to a point incom- patible with perfect digestion. Again, more than one- half of the saccharine ingredient of this preparation is cane-sugar, added for the purpose of preservation, and this material is very liable, when in excess, to ferment in the alimentary canal, giving rise to irritant products that impede digestion. . . . Infants fed upon condensed milk, though fat, are pale, lethargic, and flabby ; although large are far from strong ; have little power to resist disease ; cut their teeth late ; and are very likely to drift into rickets before the end of the first year." This is the opinion of Dr. Louis Starr, of Philadelphia, who concludes that it is never safe to bring up a child solely on this food, but that it may chap, xi.] CONDENSED MILK. 251 be used occasionally as a convenience, such as in travelling, etc. This view of the value of condensed milk appears to be shared by such authorities as Dr. Eustace Smith and Dr. Angel Money. Ashby and Wright, however, in their work on the " Diseases of Children," express a doubt as to the value of the evidence brought against the use of condensed milk ; they have seen many unquestionably healthy children brought up on it from birth. Cheadle also asserts that " if properly diluted it is more digestible than fresh unboiled cow's milk " ; it is undoubtedly con- venient ; it does not readily turn sour, and it may often be substituted with good effect for fresh cow's milk when the latter disagrees and causes vomiting, or at those times when cows are being fed on turnip.s or other watery food, or during hot weather, when milk is apt to turn sour. The deficiency in casein may be compensated for by the addition of a little white of egg, or, better, of raw mea.t juice, half a teaspoonful of either to every other meal, and the addition of a little cream will supply the deficiency in fat. We have received strong testimony in support of this favourable view of the use of condensed milk as a substitute for breast-milk, especially when the "unsweetened" kinds are used, such as Loeflund's. Cheadle thinks there may be a deficiency of anti-scorbutic elements in condensed milk ; but this would be supplied by the addition of raw meat juice. Farinaceous foods are never admissible before the fourth month, and rarely advisable until after the seventh. It must not be forgotten that they differ widely in composition from human milk. In arrow- root, which is one of the most digestible, the pro- portion of albuminates to carbo-hydrates is as 1 . 1 to 20 : whereas in human milk it is as 1 to 5. Moreover, the starch has to be converted into sugar before it can be absorbed, and the digestive secretions which effect 252 FOOD IN HEALTH. [Parti. this conversion are not fully established until the fourth month. The so-called "infants' foods"* usually contain some malted farinaceous substance, and they are of value as additions to, not as substitutes for, milk. Their nutrient value has not been perfectly deter- mined ; but they are especially useful as " mechanical attenuants," and as such tend to prevent the coagu- lation of cow's milk into firm, indigestible curd. They have also a food value of their own, rendering them more serviceable than the starches, as they not only contain a pre-digested carbo-hydrate (dextrin, maltose, and grape sugar), but also some vegetable proteid. Another important point is the quantity of food that should be given to an infant brought up by hand. It must of course vary with the age and appetite of the child, and it must be remembered that too fre- quent feeding is liable to set up gastro-intestinal catarrh. A good practical rule is to let the infant take as much or as little as it likes, provided it thrives ! Infants, as a rule, are overfed in quantity. Rotch has ascertained by actual measurement that the stomach of an infant five days old contains only 6 fluid drams. At the end of the fourth week it is one and a half times or twice as large. By the end of the eighth week it is 3j r times as large. This rapid increase in size corresponds with the rapid growth of the first two months. At the end of the twelfth week it is 3 times as large, at the end of the sixteenth week 3i, and at the end of the twentieth week 3^ ; so that during the third, fourth, and fifth months the in- crease is slight. The quantity of food should be rapidly * " Liebig's food for infants is composed of equal parts of wheaten flour and malt flour mixed with a little potassium car- bonate, and cooked with ten parts of milk. The wheat and malt flour are usually cooked and sold in powder ready to be boiled with the milk." (Parkes.) The exposure of this mixture to a certain heat is attended with the conversion of the starch into, first, dextrin, then maltose, and finally grape sugar. Chap, xi.] RULES FOR INFANT FEEDING. 253 augmented during the first six or eight weeks, and then kept at about the same quantity up to the fifth or sixth month. There is another considerable increase between the sixth and tenth months. "The greater the infant's weight the larger the gastric capacity."* Assuming the average initial weight to be from 6 to Sib. , it is estimated that during the first five or six months the infant will gain from 3i to 4 oz. weekly (Louis Starr says 1 oz. per diem), and at the end of the sixth month will weigh about IGlb., or double his initial weight. The next three months he will gain on an average from 3 to 3J oz. weekly, and by the end of the ninth month should weigh about 20 Ib. During the re- mainder of the first year he will gain from \\ to 2 oz. a week, and at the end of the year usually weighs over 22 Ib. The following is considered an excellent rule for the earlier weeks of infant feeil ing, viz. one hundredth of the initial body-weight should be taken as the starting quantity of food for each meal, and to this should be added 1 gramme (fifteen minims) for each day of life. For instance, if the initial weight is 300 grammes (6 Ib.), then 30 grammes (about 1 oz.) should be given at a meal ; at fifteen days it would have increased to 30 + 15 grammes or 45 grammes (about li oz.), and at eighty days to 30 -f 30 or 60 grammes (about 2 oz.). Ashby and "Wright estimate 5 oz. of good cow's milk (of course, properly diluted and prepared) to be sufficient daily for the first two or three weeks. Starr calculates for the first four weeks an allowance of 121 to 16 oz. of food daily ; 24 oz. for the second and third month ; 2 to 2^ or 3 pints from the third to the twelfth month. Cheaclle's estimate is rather greater. Ashby and Wright consider ! to 2 pints daily sufficient between six and twelve months. After this period it is advisable rather to increase the strength of the food than the quantity. Sonitkin, of St. Petersburg. 254 FOOD IN HEALTH. [Part 1. Dr. Louis Starr gives the following table as a guide : GENERAL RULES FOB, FEEDING. Age. Intervals of Feeding. Average Amount at each Feeding. Average Amount in 24 Hours. 1st week ... ... .,. 2 hours 1 oz. 10 oz. 1st to 6th weeks 2J I*to2 12 to 16 6th to 12th weeks, and ) possibly to 5th or 6th > months... ... ... ) 3 3 to 4 18 to 24 At 6 months 3 6 36 At 10 months 3 8 40 The next point to be considered is the method of preparing the food, the object being to make cow's milk resemble human milk as closely as possible in chemical composition and physical properties. In order to effect this we must reduce the proportion of casein, and increase the proportions of fat and sugar ; we must also remove the tendency of the casein to coagulate in the stomach into large, firm, indigestible masses. By dilution with water the casein may be brought to the proper level, and by the addition of cream and sugar of milk in proper amounts we can restore the level of these constituents. Sugar of milk has the advantage of not having the same tendency as cane- sugar, to acetous fermentation, and it also contains some of the salts of milk. Ashby and Wright have, Chap, xi.] ARTIFICIAL HUMAN MILK. 255 however, failed to satisfy themselves that milk-sugar is in any way superior to cane-sugar, while they com- plain that it is expensive, and tends to pass into lactic acid.* Frankland has suggested the preparation of arti- ficial human milk from cow's milk by the following method : Allow \ of a pint of new milk to stand twelve hours, remove the cream, and mix it with f of a pint of perfectly fresh cow's milk. Take the milk from which the cream was removed, and put a piece of rennet about an inch square (fluid rennet may be employed) into it. Keep the vessel containing it in a warm place, until the milk is fully curdled, an operation requiring five to fifteen minutes, according to the activity of the rennet, which should be removed as soon as the curdling commences, and put into an egg- cup for use on subsequent occasions, as it may be employed daily for a month or two. Break up the curd repeatedly, and carefully separate the whole of the whey, which should then be rapidly heated to boiling in a small tin pan placed over a spirit- or gas- lamp. During the heating a further quantity of casein, technically called " Meetings," separates, and must be removed by straining through clean muslin. Now dissolve 110 grains of powdered sugar of milk in the hot whey, and mix it with the 3 of a pint of new milk to which the cream from the other fluid has been added as already described. The artificial milk should be used within twelve hours of its preparation.! In order to prevent the firm clotting to which cow's milk is prone, some alkaline solution may be added, or some prefer to use a small quantity of a mucilaginous or other thickening substance, such as barley-water, a solution of gelatin, or one of the pre- pared foods, which acts mechanically in obviating the formation of firm clots. * " Diseases of Children." t Cheadle considers that a mixture of 2 parts cow's milk with 1 of water and 3J per cent, of added sugar, "satisfies all the essential conditions. ' ("Feeding of Infants," p. 54.) 256 FOOD IN HEALTH. [Parti. When lime-water* is used for this purpose, it acts by partly neutralising the acid of the gastric juice, so that the casein is coagulated gradually in small masses, or passes on into the small intestine where the secre- tions are alkaline. It must be in the proportion of 1 to 2 of the milk mixture. Or a solution of bicarbonate of soda may be used, about 6 grains to an ounce of water, or an equivalent quantity of the saccharated solution of lime. Thickening substances or attenuants act purely mechanically by, as it were, getting between the particles of casein during coagulation, and so preventing their running together and forming large compact masses. The best for this purpose is barley-water or " barley-jelly." It may be used in the same propor- tions as water. Or a solution of isinglass or gelatin may be used. To make this, put about an inch square of plate gelatin into half a tumblerful of cold water, and let it stand for three hours ; turn the whole into a tea- cup, and put this into a saucepan half full of water, and boil until the gelatin is dissolved. When cold this forms a jelly, of which one or two teaspoonfuls may be added to each bottle of food. Or Mellin's Food may be used ; in this the starch has been con- verted into dextrin and maltose ; a teaspoon ful dis- solved in a tablespoonful of hot water when added to each portion of food makes a very easily digested mixture. Dr. Stowell's recent experimentsf showed that simple dilution had a marked effect " in lessening the size of the clots of cow's milk formed in the stomach;" but the addition of foreign material did * Lime-water is easily made at home for nursery use by taking a piece of unslaked lime the size of a walnut, and putting it into two quarts of filtered water in an earthen vessel, and stirring it up thoroughly ; allow it to settle, and pour off the clear solution as required tor use, replacing with water and stirring up as sonsumed. t Australian Medical Journal, August 15, 1893. Chap, xi.] SCHEDULE OF INFANT-FEEDING. 257 not attenuate the size of the clot to the extent generally supposed. A schedule has been drawn up by Dr. Louis Starr of the diet of an infant from birth upwards. It may serve as a useful guide : DIET DURING FIRST WEEK. For each Feeding. Cream 2 fluid drama. Whey 3 Water (Hot) 3 Milk-sugar ... 10 grains. To be given every 2 hours from b a.m. to 11 p.m., and once or twice during the night if necessary. This will give 12 oz. of food per diem. To make the whey, take half a pint of fresh milk heated to about 140 or 150 F., and IA teaspoonful of wine of pepsin, or one teaspoonful of Fairchild's essence of pepsin, and stir just enough to mix. Let the mixture stand in a warm place until firm coagu- lation has taken place. Next beat up the curd until it is finely divided and strain. Whey contains. in solution the sxigar and the salts of the milk, and holds also in suspension a considerable portion of casein and fat, which passes through the strainer. During the same period Dr. Angel Money* re- commends an oz. of thin barley-water with | an oz. of cow's milk and 15 grains of milk-sugar, to be given every two hours, night and day. DIET FROM THE SECOND TO THE SIXTH WEEK. For each Feeding, Milk (Cow's) i fluid oz. Cream ... t ,, Milk-sugar ... ... 16 grains. Water 1 fluid oz. To he given every 2 hours from 5 a.m. to 11 p.m. = 17 o*. per diem. * " Treatment of JMseases of Children." 258 FOOD IN HEALTH. [Parti. DIET FROM THE SIXTH WEEK TO THE END OP THE SECOND MONTH. for each feeding. Milk (Cow's) 1 fluid oz. Cream ... ... ... ... ^ ,, Sugar of Milk 30 grains. Water lj fluid oz. To be given every 2 hours = 30 oz. per diem. Dr. Angel Money's diet is cow's milk, 9 drams ; barley-water, f oz. ; cream, 2 drams ; milk-sugar, 30 grains ; and water, 3 drams; every 2| hours. DIET FROM THK BEGINNING OF THE THIKD MONTH TO THE SIXTH MONTH. for each Feeding. Milk (Cow's) 2Joz. Cream f ,, Sugar of Milk ... ... ... ... 60 grains. Water 1 oz. To be given every 2J hours = 32 oz. per diem. DIET DURING SIXTH MONTH. Six meals daily, from 6 or 7 a.m. to 9 or 10 p.m. Morning and midday bottles, each. Milk (Cow's) 4Joz. Cream i Mellin's Food 60 grains. Hot Water 1 oz. Dissolve the Mellin's Food in the hot water and add, with stirring, to the previously mixed milk and cream. The other bottles, each. Milk 4|oz. Cream Sugar of Milk ... ... ... ... 60 grains. Water ... ... ... 1 oz. Making a total of 36 oz. of food per diem. For this month Dr. Angel Money's diet consists of cow's milk, 2J oz. ; barley water, | oz. ; cream, 5 drams ; milk-sugar, 60 grains ; and water, 1 oz. every 3 hours. chap, xi.] SCHEDULE OF INFANT-FEEDING. 259 In the seventh month the .Mellin's Food may be increased to two teaspoonfuls, and given three times a day. Throughout the eighth and ninth months five meals a day will suffice. 1st meal, 7 a.m. Milk 6| oz. Cream ... ... ... - ,, Sugar of Milk ... ... 60 grains. Water ... ... ... 1 oz. 2nd ,, 10.30 a.m. Add to the foregoing 1 tablespoonful of Mollin's Food. 3rd meal at 2 p.m., and 4th meal at 6 p.m., same as 2nd. 6th meal at 10 p.m., same as 1st. Equivalent to 40 oz. of food per diem. Barley jelly may be substituted for Mellin's Food.* It is made by putting two tablespoonfuls of washed pearl barley into a pint and a half of water, and slowly boiling down to a pint ; strain, and let the liquid settle into a jelly. Two teaspoonfuls of this, dissolved in 8 oz. of warmed and sweetened milk, are enough for a single feeding, and such a meal may be allowed twice a day. DIET FOR THE TENTH AND ELEVENTH MONTHS. 1st meal, 7 a.m. Milk ... ... 8i fluid oz. Cream ... \ Mellin's Food or Barley \ , Jelly ) * Water (only when Mel- i . lin's Food is used) } " 2nd 10.30 a.m. 8 oz. of warm rnilk. 3rd ,, 2 p.m. Tho yolk of an egg, lightly boiled, with stale bread crumbs. 4th 6 p.m. --Same as 1st. oth ,, 10 p.m. Same as 2nd. On alternate days the third meal may consist of 6 oz. of beef-tea, with a few stale bread-crumbs. Mutton, chicken, or veal broth may be occasionally used instead of beef-tea. Infant's beef tea is not * Eustace Smith R 2 260 FOOD IN HEALTH. [Pani. made so strong as that for adults. (| Ib. of beef to a pint.) To remedy a tendency to vomit the milk in firm clots, each bottle at the age of six weeks may consist of either Milk ... ... . , IJoz. Cream ... Sugar of Milk .., 30 grains. Lime Water \\ oz. or Milk l|oz. Cream \ ,, Sugar of Milk 30 grains. Barley Water ... ... ... ... 1| oz. Boiling sometimes makes the milk more digestible, and tends to arrest diarrhoea if it exists. If it should be necessary to have recourse to ass's milk, it should be used fresh from the udder. One ass is capable of nourishing three children for the first three months of life, two children for the fourth and fifth months, and one child after this period to the ninth month. If all these foods disagree, pre-digested milk must be used. Cheadle considers it is best for a young infant to begin with peptonised milk and water as a substitute for human milk. In this most of the casein is converted into soluble peptone. But although of great value as a temporary food, he is much opposed to its adoption as a permanent diet for a healthy infant, chiefly because it " weakens the digestive powers of the stomach ;" and he states he has "more than once seen scurvy arise upon peptonised milk." Complete peptonisation has the disadvantage of giving a bitter taste to the milk, and children will refuse to take it ; very young infants are said not to notice it. Par- tial peptonisation is better. The process should be stopped the instant the slightest bitter taste appears. " Peptogenic Milk Powder," made by Fairchild, can be conveniently used for this purpose. It contains Chap, xi.j SUBSTITUTES FOR MILK. 261 pancreatin, bicarbonate of soda, and milk-sugar. It can be used as follows : Take of Milk 2 oz. Water 2 Cream \ A measure of peptogenic milk powder. Heat this over a brisk flame to about 140 to 150 i.e. pleasantly warm when sipped. Keep at this temperature for six minutes. When properly pre- pared this contains the albuminoids in a minutely coagulated and digestible form, has an alkaline re- action, contains the proper proportion of salts, milk- sugar, and fat, and has the appearance of human milk. By shortening the time of heating, the degree of pre-digestion can be diminished. "When peptonised milk is given, the peptonising process should be gradually reduced. . . This change should not be abrupt ; a child's stomach resents sudden changes." (Cheadle.) When milk in any form, and however prepared, still disagrees, it is best to omit it entirely, and try some other food for a time, such as Mellin's Food ... 60 grains. Hot Water 3 oz. for each feeding given every 2 hours at the age of six weeks ; or Veal or Chicken Broth (|lb. of meat to pint) 1 oz. Barley Water or Jelly .. l| or . Whey 1 oz. Barley Water 1 Sugar of Milk \ A teaspooiiful of raw beef-juice every two hours will often be retained when all other food is rejected. As soon as milk food can be resumed, it of course should be resumed. 262 FOOD IN HEALTH. [Parti. Ashby and Wright recommend a trial of Biedert's cream mixture for the first few weeks when the child cannot digest cow's milk. It is made by mixing 4 oz. of cream with 12 oz. of warm water, and adding \ oz. of milk-sugar. It contains 1 per cent, of casein, 2 '5 per cent, of fat, and 3 '8 per cent, of sugar. As the child grows older, milk is added till it reaches equal parts. Most infants digest cream exceedingly well. Meigs' modification of this is as follows : Make a solution of milk-sugar (2J oz.) in water (1 pint) ; put it in a cool place. For each feeding mix 1 oz. of cream, \ oz. of cow's milk, 1 oz. of lime- water, and li oz. of the solution of milk-sugar. The same authors strongly commend Savory and Moore's peptonised milk as very palatable and easily pre- pared by mixing with warm water. Much of the casein in it has been converted into peptone. It keeps well for a few days, being preserved by the addition of cane-sugar, and is concentrated to i or \ of its bulk of milk. We can also testify to the value of this preparation. Whey is a very useful food, when milk disagrees, and is not so much used as it merits to be ; shaken up with a little white of egg and cream, it forms a highly nutritious mixture. Oatmeal water made by boiling two tablespoonfuls of oatmeal with a quart of water for four hours or longer, and straining through muslin, is useful alone, or mixed with peptonised milk or cream. If the food calculated for the various periods of infant life should appear to be in excess of the child's wants, the quantity can be reduced to that proper for the period next below it. Food containing barley jelly, or made with oat- meal, arrowroot, baked Hour, etc., either with or without milk, can be readily predigested, or partially so, as follows : Barley Jelly J oz. Sugar of Milk 60 grains. Warm Milk 8 oz. Chap, xi.] SUBSTITUTES FOR MILK. 263 Add 3 grains of Fairchild's Extractum Pancreatis and 5 grains of bicarbonate of sodium, and keep warm for half an hour before feeding. Peptonised beef-tea may be given when the child is of an age to take meat-broth. Cheadle recom- mends a mixture of bread jelly, raw-meat juice, cream and sugar as a very nutritious and valuable infant's food. The bread jelly and the meat juice are prepared in the following manner. To make the bread jelly : Take 4 oz. of crumb of bread made of seconds flour two or three days old, soak in cold water for six or eight hours ; then squeeze all the water out of it (lactic acid and other peccant matters are thus removed). Place the pulp in a pint of fresh water, and boil gently for an hour and a half, so as to break up the granules of starch and promote its conversion into dextrin and glucose. Rub this semi-fluid gruel through a fine hair-sieve ; when cold, it forms a smooth jelly. For children who can digest no milk, this jelly may be simply mixed with enough warm water (one tablespooriful to 8 oz. of water) so as to have the consistence of thin cream, and a little refined sugar added. To make it, however, a suitable food for more than merely temporary purposes, it would need the addition of some albu- minate and some fat. Its percentage composition, mixed in the proportions stated, is proteids, 0'74 ; fat, (H3; carbo- hydrates, 4' 15. If the addition of milk can be tolerated, then a mixture of 3 oz. of bread jelly to 4 oz. of milk (or peptonised milk) and 4 oz. of water will make a fairly good food ; or the necessary amount of proteids and fat may be obtained by the addition of raw-meat juice and cream. The raw-meat juice is directed to be thus pre- pared : Mince fine the best rump steak, then add cold water in the proportion of one part of water to 4 of meat. Stir this well together and allow it to soak for half an hour. Express the juice by forcibly twisting this through muslin. This juice contains 5'1 per cent, of proteids, 2'1 of extraction, and 0'7 of salts. 264 FOOD IN HEALTH. [Parti. The following is the mixture : Four parts of the above bread jelly mixture (with water only), three parts of raw-meat juice, half a part of cream, and one-fifth part of sugar. The bread jelly and the raw-meat juice must be quite fresh, and made twice a day. Raw-meat juice Cheadle considers the " best material for supplying proteids to the food of children who cannot digest a sufficient amount of the milk proteid-casein," and from its richness in salts he regards it as an excellent anti-scorbutic. After the first year far less change is needed in the food from month to month. DIET PROM TWELFTH TO EIGHTEENTH MONTH. Five meals a day. 1st meal, 7 a.m. A slice of stale bread, broken and soaked in 8 oz. new milk. 2nd 10 a.m. 6 oz. of milk with a soda biscuit, or thin slice of buttered bread. 3rd ,, 2 p.m. 6 oz. of beaf-tea, with a slice of bread. One good tablespoonful of milk and rice pudding. 4th ,, 6 p.m. --Same as 1st. 6th 10 p.m. One tablespoonful of Mellin's Food, with a breakfastcupful of milk. These quantities may prove too much, except for very robust children, and it must be noted whether they cause any indigestion, and if so they must be diminished. As AN ALTERNATIVE DIET. 1st meal, 7 a.m. The yolk of an egg lightly boiled, with bread-crumbs. A teacupful of new milk. 2nd 10 a.m. A teacupful of milk, with a thin slice of buttered bread. 3rd 2 p.m. A mashed boiled potato, moistened with 4 tablespoonfuls of beef-tea. Two good tablespoonfuls of junket. 4th 6 p.m. A breakfastcupful of new milk, with a slice of bread broken up and soaked in it. 6th 10 p.m. Same as 2nd. chap, xi.] DIETARY FOR YOUNG CHILDREN. 265 The fifth meal is not always necessary, and sleep should not be disturbed for it. A cup of warm milk should, however, be available during the night if required. DIET FROM EIGHTEEN MONTHS TO Two AND A HALF YEARS. 1st meal, 7 a.m. A breakfastcupful of new milk, the yolk of an egg lightly boiled, 2 fun slices of bread and butter. 2nd 11 a.m. A teacupful of milk with a soda biscuit. 3rd ,, 2 p.m. A breakfastcupful of beef -tea, nritton or chicken broth ; a thin slice of stale bread ; a saucer of rice and milk pudding. 4th ,, 6.30 p.m. A breakfastcupful of milk with bread and butter. As AN ALTERNATIVE DIET. 1st meal, 7 a.m. Two tablespoonfuls of thoroughly-cooked oatmeal or wheaten grits, with sugar and cream ; a teacupful of new milk. 2nd 11 a.m. A teacupful of milk, with a slice of bread and butter. 3rd 2 p.m. One tablespoonful of underdone mutton, pounded to a paste ; bread and butter, or mashed baked potato, moistened with good plain dish gravy ; a saucer of j unket. 4th 6.30p.m. A breakfastcupful of milk, a slice of soft milk-toast, or a slice or two of bread and butter. If these diets at any time disagree, return to a plain milk diet, or milk with Mellin's Food. The preceding tables must only be taken as indicating averages. Many children thrive best on a purely milk diet up to the age of two or two and a half years. When a child is thriving and content on milk diet, be in no haste to alter it. It should not be forgotten, as is sometimes the case, that a child, however young, occasionally re- quires, and is better for, a drink of water. Pure water, not too cold. The most scrupulous cleanliness must be observed with regard to all the vessels containing the infant's 266 FOOD IN HEALTH. [Pani. food. Each meal must also be prepared at the time it is wanted, and not taken from a stock ori hand. The temperature of the food of young infants should be about 95 F. It is also most important, unless the source of the milk supply is absolutely above suspicion, that all milk used for feeding infants should be boiled or sterilised. A description of methods of sterilising milk will be found in the Appendix. Children who have cut their milk-teeth may be fed for a twelvemonth i.e. up to the age of three and a half years as follows : 1st meal, 7 a.m. One or two tumblerfuls of milk, a saucer of thoroughly cooked oatmeal or wheaten grits, and a slice of bread and butter. 2nd 11 a.m. (If hungry.) A tumblerful of milk, or a teacupful of beef-tea, with a biscuit. 3rd 2 p.m. A slice of underdone roast beef or mutton, or a bit of roast chicken or turkey, minced as finely as possible ; a baked potato, thoroughly mashed with a fork, and moistened with gravy ; a slice of bread and butter ; a saucer of junket, or rice and milk pudding. 4th 7 p.m. A tumblerful of milk, and one or two slices of well-moistened milk-toast^ For the rest of childhood, a chief point is to see that the child does not eat hastily, but masticates his food leisurely. The diet should be plain, but varied, and the following lists of suitable dishes from which to select may serve as a convenient guide : BREAKFAST. Daily. Milk. Porridge and Cream. Bread and butter. One dish only each day. Fresh fish. Eggs, lightly cooked. Chicken hash. Grilled fat bacon. Thoroughly ripe sound fruit may be allowed with this meal in small or moderate quantity. Chap, xi.] DIETARY FOR YOUNG CHILDREN. 267 DINNER. Daily. Clear Soup. Meat, roasted or broiled, and cut into small pieces. Bread and butter. Two dishes each day. Potatoes, baked and Spinach. [mashed. Stewed celery. Cauliflowers. Hominy. Macaroni, plain. Peas. French beans. Junket, rice and milk, or other light pudding. SUPPEK. Daily. Milk. Milk-toast, or bread and butter. Stewed fruit. As to quantity, if a child eats slowly and masti- cates thoroughly, he may generally be trusted to satisfy his appetite at each meal. Fried food and highly- seasoned dishes should be avoided. Salt, but no other condiment, should be allowed, and pure water should be the only drink. Some feeble and thin children may, however, be allowed, from time to time, a little sound beer or porter. Recently, in America especially, Kefir, the product of fermentation of cow's or goat's milk, has been highly extolled as a substitute for mother's milk. It is manufactured like koumiss, and has been used for ages in the Caucasus. Kelir is a partially-digested milk, and is believed by some to fulfil an important indication in infant feeding namely, the breaking up of the curd of cow's milk without introducing indigestible matter into the infant's stomach. As the casein of cow's milk is exactly the same as that of human milk, the difference in the curding must be due to something which is found in the one and not in the other. Schmidt has shown that this is due to the presence in human milk of hemi-albumen in proportionately larger quantities than in cow's milk. 268 FOOD IN HEALTH. [Parti. In kefir we have the soluble forms of albumen due to the action of the ferment, and consequently the light, flocculent coagulation. Food at school. Assuming that the period of school-life extends, on an average, from ten to eighteen years of age, it is scarcely necessary to say that this is one of the most critical and most important epochs in the life of the individual as regards sufficient and adequate nutrition. It is a time of active growth and. development both physical and intellectual, and it is a time when any serious check to the perfect and complete evolution of the organs and functions of the body may lead to ineradicable mischief, and severely handicap the individual in the subsequent " struggle for existence." Those who are entrusted with the care of the young of both sexes during this period are, perhaps, sometimes apt to regard with too little attention and interest the physical development of those under their charge, and this from a too great eagerness to promote their intellectual culture. It should be remembered that the education of the mind is, and should be, a lifelong process there is no need of hurry, but that the development of the body is strictly limited to a certain period of existence, and becomes finally and irrevocably arrested at a given date. It should, then, be ever present in the minds of those who undertake the education of youth that they are in a special and peculiar way responsible for their physical growth and development, and that these cannot proceed satisfactorily without a careful and intelligent arrangement and supervision of their food. And not only is this period of life one of continuous growth and development ; .it is also one of remarkable physical activity. So that there is a constant and twofold demand for appropriate food the demand of the growing organs, and the demand connected with muscular activity and mental training. At no period of life is it so necessary to be provided with a complete and liberal dietary. Chap, xi.] 'FOOD AT SCHOOL. 269 Another point which is very constantly overlooked is the rapidity and activity of the digestive and assimilative functions in many growing young folk; and provision should always be made for some plain and wholesome food, such as bread and butter, or bread and cheese, to be accessible to the hungry boy or girl at other than the ordinary meal-times. The rate of growth in any individual cannot be con- trolled or regulated by general rules, and when this is taking place with exceptional rapidity exceptional quantities of food are needed. The diet at school must not only be abundant in quantity ; it must also be suitable in quality. It must contain a proper proportion of albuminates, to minister to the growth of the muscular and other tissues ; it must contain fats and starches, for the development of heat and muscular energy, and the former is an important agent in tissue-growth; and it must contain the necessary proportions of mineral substances to furnish the materials necessary for the growth and consolidation of the hard tissues, as the bones and teeth, especially phosphates of lime. In the remarks which follow we have to acknow- ledge our indebtedness to the valuable experience of Dr. Clement Dukes, the Medical Officer of Rugby School, as set forth in his excellent work on " Health at School," with whose views we are, with one or two exceptions, in entire accord. In considering the details of a school dietary he calls attention to the need of more variety, both in the kinds of food provided and the manner in which they are cooked and served. The likes and dislikes of young children should, he considers, be more consulted, as affording trustworthy indications of what suits their constitu- tions. Some cannot digest fats or starches even the sight of fat will prevent their eating. This is, no doubt, greatly to be regretted, as both fats and starches are very important alimentary substances ; still, they may nearly always be given in certain com- binations, and many children who would not touch 270 FOOD IN HEALTH. [Parti. the fat of roast or boiled mutton will eagerly devour suet pudding with sugar or jam. The objections to certain important food substances which children some- times manifest should, if possible, be corrected, or the attempt be made to correct them, in early childhood (it is often too late to do so at school) ; for the acquirement of certain strong distastes to particular articles of food often proves exceedingly embarrassing in after-life. What can be more troublesome to the physician in dealing with the food of invalids to find, as he sometimes does, a rooted distaste and objection to milk ? It is difficult to believe that such- a distaste is not often a fault of education. We are disposed to urge, as a qualification of Dr. C. Dukes's recommenda- tion, that the likes and dislikes of school-children should be considered, that they should only be so after repeated judicious attempts have been made to overcome them. Another suggestion that Dr. Dukes makes is that the craving of school-children for sweets should be gratified, that their clandestine visits to the con- fectioner's are the result of a natural craving which should be gratified in a regular and legitimate fashion. The cooking, also, he urges, should be more carefully looked after, as roast joints are often so imperfectly cooked and underdone as to be unwholesome, as well as unpleasant to look at ; while the distaste often manifested for green vegetables too frequently origin- ates in the careless manner in which they are cleaned and the peculiarly unattractive fashion in which they are seryjgd. In large establishments it would involve veTynttle extra trouble to serve the green vegetables in the form of purges, nicely flavoured ; and as a laxative food this would prove most useful in neces- sitating daily attention to the bowels, which boys and girls at school often neglect. The personal super- vision of the master or his wife is invoked in these matters as well as in more attractive carving. Another highly important matter in the arrange- ment of meals at school is that the pupils should be Chap. XI.J FOOD AT SCHOOL, 271 allowed ample and sufficient time to eat them, and the master should see that the food is properly masticated, or, at any rate, that sufficient time is allowed for this process, as imperfect mastication is a common cause of indigestion, and may become an injurious habit, which, like other bad habits, should be corrected at school. It seems that in certain schools, or with certain masters, boys are sometimes detained in school as a punishment during a portion of the dinner or breakfast time, so that the time available for feed- ing is seriously encroached upon. Such a system shows a lamentable absence, in the authorities, of the most elementary understanding of the conditions of health. The number of meals, and the hours fixed for taking them, are also serious matters, aad especially .with growing girls. It is undesirable, especially with the younger and less robust pupils, that they should be given any task before breakfast. The practice of preparing a lesson at 7 a.m., on an empty stomach, and after a long fast, especially in winter, is indefensible. The pupils should be allowed hot milk, or hot coffee and milk, or cocoa, with a piece of bread, before going into school at all. This is most essential for the delicate or average boy or girL At 6.45 to 7.15 a.m. there should be, then, a provision of hot coffee, or cocoa, with plenty of milk a beverage both nutritious and stimulating. At 8.30 a.m. Breakfast, after the first lesson ; this should be a good meal, with some animal food ham, bacon, cold beef, fish, or eggs. Some porridge. Bread and butter, or jam or marmalade. Hot milk and water, or coffee. (Everything should be provided for the boys, and they should not be required to buy anything for themselves.) At 1.30 p.m. Dinner, which should be a good meal of meat, pudding, potatoes or green vegetables, or haricot beans, pease-pudding, etc. (School should cease at least 15 minutes before the meal, to give the boy time to wash and prepare himself for dinner.) 272 FOOD IN HEALTH. [Parti. 6 to 6 p.m. Tea, with bread and butter, an egg, marmalade, jam, or potted meat. Water-cress, lettuce, celery, or other fresh salads might be served at this meal or at supper. As to supper, Dr. Dukes thinks boys should either not have any supper, so that they may go to bed without food in their stomachs, or that merely bread and butter, or bread and milk, or a glass of milk or water should be provided. He strongly objects to cheese, meat, beer, or pastry at supper ; he considers a meat supper with beer as most objectionable in growing boys, as tending to excite their passions and calculated to lead to immorality. We cannot altogether accept these unqualified objections to supper. Our own view is that, instead of a meal at 5 or 6 p.m., only a few hours after a heavy dinner, it would be better to serve simply coffee, cocoa or tea, or hot milk and water at that hour, and provide a fairly nutritious, but unstimulating, supper at 8 p.m. Porridge made with milk would be excellent ; or tapioca, or rice pudding, with mar- malade, or bread and butter with some salad or fruit, or, in winter, some good soup with bread or other fari- naceous substance, or any other light, but nutritious, food. The need for this seems to us obvious. We are dealing with a period of rapid growth when digestion and assimilation are active ; and it is, surely, undesirable that a fast extending from a light meal at 5 or 6 p.m., to 7 a.m., and sometimes 8 a.m., the following day a fast of thirteen or fourteen hours should be inflicted on a rapidly-growing boy or girl. This prolonged fast has appeared to us to be attended with, and often to be the cause of, serious loss of health, especially in girls' schools. For it must be remembered that girls between twelve and sixteen years of age often develop with amazing rapidity, and require ample and frequent supplies of food. We are fully convinced that the an?emia and constipation Chap, xi.] FOOD AT SCHOOL. 273 so commonly observed among young girls at the approach of puberty are frequently due to insufficient supplies of food, or to food of unsuitable quality. The constipation is probably due to a deficiency in fresh vegetables, and the want of a sufficiently bulky and stimulating diet ; while the ansemia is, in many instances, the direct result of an imperfect supply of animal flesh that is, of food which contains the maximum of iron and the material necessary for red corp uscle-niaking. As to different articles of diet, we can coincide with most of Dr. Dukes's recommendations. The bread should be wholemeal bread. This is no doubt the best bread for growing children and young people. There is little risk of their not being able to digest it, and it is certainly richer in the mineral substances they especially require than fine white bread. But what is of far more importance is that the bread should be well made that it should be good and palatable, not sour, sticky, or musty. The al- lowance of bread should not be limited, and butter should be given with it, as wheaten bread is deficient in fats. Farinaceous and saccharine foods should be freely supplied as heat- and force-developing foods, and as more digestible than fats. Mj]jc should be abundantly provided for all adolescents as an essential part of their regular diet. It contains all the necessary elements of food in a readily assimilable form, and is particularly fitted for nourishment during rapid growth. When there is ally possibility of its serving as the medium of the / conveyance of disease it should be boiled before I consumption. Meat should be provided twice a day at breakfast and dinner during the time of active growth. This may be in the form of ordinary butcher's meat, or fish bacon, sausages, eggs, etc. Dr. Dukes estimates that 1 lb. of uncooked meat should be the average ration, including fat : this a 274 FOOD IN HEALTH. [Parti. would yield about 9| ounces of cooked meat, allowing a loss of 40 per cent, for bone and cooking. All boys do not require so much as this, only the biggest and strongest. Monotony should be avoided, and more effort should be made to give variety to the food provided at different meals. Fish should be more largely utilised, and a fish day once or twice a week, in places where a good supply of fresh fish is available, should be instituted. Attempts should be made, as has already been said, to overcome the distaste that exists for green vegetables. They should be cooked and served in a more attractive form ; or soup with plenty of vegetables should be given once or twice a week in winter ; or beetroot, pickles, and salad should be more freely provided. This is of much importance, as eczema is prone to appear amongst boys at school who are kept on a too exclusively animal diet. Puddings or pastry should be provided frequently at dinner, and visits to the pastrycook's before dinner should be strictly prohibited. " Hampers " are objec- tionable and a frequent cause of illness. Beer is only needed by the more delicate boys, but we have seen thin, delicate boys with small appetites greatly benefited by a glass of light, sound beer with dinner. The greater relative defects in the diet of girls' schools were animadverted upon some years ago by the late Dr. Combe. He pointed out then that the system of diet " in female boai'ding-schools is often insufficient for due sustenance and growth, and, consequently, the natural expression of impaired health, if not actual disease, is a marked feature in the aspect of most of the pupils. So defective indeed is the common school management in this and other respects that we have the best authority for considering it as a rare excep- tion for a girl to return home in full health after spending two or three years at an English boarding- school. Germain S^e also insists upon the urgent Chap. XL] FOOD AT SCHOOL. 275 necessity of paying more attention to the feeding of young girls at school. We should understand, he says, " the absolute necessity of animal food, of abundance of meat plainly cooked, which contains all the principles of the blood, fibrin, hiemoglobin, and iron itself, in sufficient am&unt to enable us to dispense with ferruginous drugs. Such an albuminous diet, together with nitrogenous farinaceous foods and fish, and an abundant supply of oxygen and an open- air life, supplies all that is required." In a model French lycee at Paris he found the following arrangements as to food : For the first breakfast : Chocolate, milk, soup, or cafe-au-lait. As to meat, this is calculated as cooked meat from, which fat and bones have been removed. The oldest pupils get 100 grammes at each meal, i.e. 200 grammes (about 7 oz.) daily. The older pupils of the second and third classes, 85 grammes each meal, i.e. 170 grammes (about 6 oz.) daily. The series of average pupils, 70 grammes, i.e. 140 grammes (about 5 oz.) daily. And the smaller boys, 50 grammes, i.e. 100 grammes (3^ oz.) daily. Three times a week, on Sundays, Tuesdays, and Thursdays, at the midday meal they get two courses of meat = 134 grammes (nearly 5 oz.) for the oldest, 112 (4 oz.) for the next, 94 (about 3| oz.) for the next, and. the small boys 84 (3 oz.). It will be seen that during three days in the week the eldest pupils get at the midday and evening 'meals together 234 grammes of cooked meat (8 oz.) This is about the quantity necessary ; but the other quantities are much too small, and the great reductions made for the younger boys are quite unjustifiable. On ordinary days the eldest boys get only 7 oz. (200 grammes) of meat, which is not enough, and the youngest only 3-| oz. (100 grammes), which is a serious B2 276 FOOD IN HEALTH. [Parti. deficiency. This allowance of meat is what is given in one of the model lycees. Professor G. See states that in many others the feeding is far more defective. Food in adult life. The considerations which should guide us in determining the food appropriate to adult life have already been incidentally dwelt upon. In the first place we have to consider the circumstance that growth and development are for the most part over ; but it must also be remembered that although, in young adults, the framework or skeleton of the body has ceased to grow, it is by no means certain that other organs of the body have, in all cases, reached their full development ; and it is a very well-known fact that the body, especially in the male, commonly continues to increase in weight for some years after adult life has been attained. It is prudent, in many instances, to regard the young man as not having quite completed his physical develop- ment until he has reached his twenty-third or twenty- fifth year. Complete organic development is much earlier arrived at in the human female. When, however, growth and development are completely over, it is clear there cannot be precisely the same food requirements as exist when growth and development are in active progress. But throughout healthy and active adult life, although food is no longer needed for the purposes of growth, it is needed in due and sufficient amount to meet all the require- ments attending the daily work of the organism, to supply the force developed in the various forms of energy which the human body normally displays, and to keep in sound repair all the various organs employed. The food appropriate to adult life must thus de pend very greatly on the conditions and circumstances which affect each individual on sex, on physical development, on occupation, on climate, on habits, and other personal peculiarities. The general principles which should govern us. in chap, xi.] OVER-FEEDING IN ADULT LIFE. 277 dealing with individual cases, may be gathered from what has been said in preceding chapters. A few points only in the application of these will here be dwelt upon. Much has recently been written on the tendency to over-feeding in adults, and there can be no doubt that too much food is habitually consumed by great numbers of the rich and leisured classes ; but we must be extremely careful not to apply this conclu- sion too generally, or to persons whose diets are fixed for them, and who have no choice in the matter. Too little food is probably more injurious than too much, and it is quite possible, as has been authorita- tively asserted, that " the effects of casual repletion are less prejudicial and more easily corrected than those of inanition." It is not, however, casual, but habitual, repletion that has been protested against. A young man in sound health, and taking very active exercise,, may exceed occasionally, without any great harm, but r frequent or habitual excess will leave a "surplus fund of nutrient material unused, to be stored up in some form. When a certain amount has been thus disposed of, the capacity for storage varying greatly in different persons, an undesirable balance remains against the feeder." What is termed a " bilious attack " may rectify this, and each recurring attack may " clear the system, and so on during several years of life. If the individual takes abundant exercise and expends much energy in the business of life, a large quantity of food can be properly disposed of. On the other hand, if he is inactive, takes little exercise, spends most of his time in close air and in a warm temperature, the balance of unexpended nutri- ment soon tells more or less heavily against him, and must be thrown off in some form or other, more or less disagreeable."* " After the first half or so of life has passed away, instead of such periodical attacks of sickness, the unemployed material may be relegated in the form of * Sir H. Thompson's "Diet in Relation to Age and Activity." 278 FOOD IN HEALTH. [Parti. fat to be stored on the external surface of the body, or be packed among the internal organs, and thus he or she may become corpulent and heavy, if a facility for converting appropriate material into fat is con- sistent with the constitution of the individual ; for some constitutions appear to be without the power of storing fat, however rich the diet or inactive their habits may be. When, therefore, this process cannot take place, and in many instances, also, when it is in action, the over-supply of nutritious elements ingested must go somewhere, more or less directly, to produce disease in some other form, probably at first interfer- ing with the action of the liver, and next appearing as gout or rheumatism, or as the causes of fluxes and obstructions of various kinds. Thus recurring attacks of gont perform the same duty, or nearly so, at this period of life that the bilious attacks accomplish in youth, only the former process is far more damaging to the constitution, and materially injures it." Thus it is that excess of food in adult age ministers to the development of disease in more advanced life. It is, however, true that in youth, when the whole system abounds in vigour and strength, much super- fluous food may be disposed of first, by the greater activity of the functions of digestion and absorption ; and secondly, by the capacity youth possesses for excessive muscular exertion, by which it can use up and eliminate such excess, almost at will. "But the neglect to adjust a due relation between the ' income ' and the ' output ' cannot go op for an indefinite period without signs of mischief appearing in some quarter." Many methods of eliminating this excess of food are practised. The various forms of muscular ac- tivity involved in out-of-door games and exercises, so long as they can be adopted with safety, are as valuable as they are popular ; but their pursuit is often unwisely protracted to a period of life when they are no longer safe or useful, and it is then that Chap, xi.j DIET iff TRAINING. 279 the eliminative effects of the Turkish bath or of an occasional course of purgative waters find their appro- priate application. Of late years a habit of drinking milk as a bever- age at meals has been largely adopted, without, apparently, reflecting that milk is a highly nutritious fluid food which has the property of becoming solid when it meets the acid gastric juice; and a large excess of solid food may thus inadvertently be taken. " There are even some persons who must wash down their ample slices of roast beef with draughts of new milk ! an unwisely-devised combination even for those of active habit, but for men and women whose lives are little occupied by exercise it is one of the greatest dietary blunders which can be perpetrated. It is altogether superfluous and mostly mischievous as a drink for those who have reached adult age and can digest solid food."* The quantity of food, then, required in adult life will be conditional, to a great extent, on the habits of the individual with regard to physical activity. And this brings us to the subject of " training " for athletic exercises, a process which has for its object the development of the highest degree of strength and activity attainable by the human body, so as to enable it to perform, without injury to itself, feats involving great or protracted exertion. In this process some loss of weight, some loss of stored-up redundant material, almost invariably takes place. If this* is carried too far, the subject is weakened instead of sti'engthened, and he is said to be "over- trained." If it is not carried far enough, and the subject remains encumbered and embarrassed with useless fat or other unnecessary material, he is said to be "under-trained." The competent and experi- enced trainer endeavours to hit oil the happy mediuni 4 " the exact and precise balance between the two conditions." * Sir H. Thompson : " Diet in Relation to Age and Activity." 280 FOOD IN HEALTH. (Pan i. Training usually involves a combination of diet and exercise, and a period of six weeks is usually devoted to the process. When properly carried out, it is attended with a loss of fat and water and an increase both in bulk and firmness of the muscles ; and this is accompanied by a feeling of lightness and freedom, and " fitness " for exertion. The skin especially improves in appearance) and should become "clear, smooth, fresh-coloured and elastic.'' It used formerly to be the custom, now abandoned as injurious, to begin a course of training by an emetic and repeated saline purges. The transition from the usual diet should not be too sudden, but duly graduated, and the food selected should be palatable and digestible. Lean meat always enters largely into the diet of training, for it has been established that a meat diet leads to the removal of superfluous water and fat, lessens weight, and imparts firmness and endurance to the muscles. Beef and mutton, roast or grilled and " underdone," are usually preferred. Toast or stale bread, and a moderate quantity of potatoes and green vegetables, especially watercresses, are allowed. All entries, all puddings and pastry, are strictly for- bidden, as are all sauces, pickles, and condiments ; the object being to preserve or develop a simple, natural appetite, and not provide food which may provoke to excess. To meet the loss of water from the body involved in active exertions a certain amount of fluid must be taken; but it is usual to limit this with some care, and only sufficient to allay thirst should be taken, and this should be slowly sipped, any excess of drink being injurious. Bai'ley- water, toast-and-water, tea, coffee, and cocoa are permitted, as well as a little beer or light wine. No spirits. Only three meals a day should be taken : one at 8.30 or 9 a.m. ; the second, about 1 or 2 p.m. ; and a supper between 8 and 9 p.m. After the period of training is over the transition to the ordinary habits of feeding should again be easy and gradual. Chap. XL] DIET IN TRAINING. 281 Maclaren gives the following schemes of training as carried out at Oxford and Cambridge : A DAY'S TRAINING FOR THE SUMMER RACES. Oxford. 7 a.m. Rise. A short walk or run. 8.30 a.m. Breakfast of un- derdone meat, crust of bread, or dry toast, tea (as little as possible). 2 p.m. Dinner, meat (as at breakfast), bread, no veget- ables (not stiictly adhered to), 1 pint of beer. 5 or 5.30 p.m. Rowing exer- cise. 8.30 or 9 p.m. Supper, cold meat or bread, sometimes jelly or watercresses, 1 pint of beer. 10 p.m. Retire to bed. Cambridge. A run of 100 or 200 yards as fast as possible. Underdone meat, dry toast, tea, 2 cups (later only 1), watercress (occasionally) Meat (as at breakfast), bread, potatoes, and greens, 1 pint of beer. Dessert oranges, or biscuits or figs, 2 glasses of wine. Rowing exercise. Cold meat, bread, lettuce, or watorcresses, 1 pint of beer. A DAY'S TRAINING FOR THE WINTER RACES. Oxford. 7.30 a.m. Rise. A short walk or run. 9 a.m. Breakfast, as in sum- mer. 1 p.m. Luncheon, bread or a sandwich, and ^ pint of beer. 2 p.m. Rowing exercise. 5 p.m. Dinner, meat as in summer, bread, same rule as in summer as to vegetables, rice pudding or jelly, and \ pint of beer. 10 p.m. Retire to bed. Water strictly forbidden. As little liquid to be drunk as possible. Cambridge. 7 a.m. Exercise as for sum- mer races. 8.30 a.m. Breakfast as in summer. A little cold meat, bread, and pint of beer, or biscuit and glass of sherry (some- times yolk of egg in the sherry). Rowing exercise. 5 to 6 p.m. Dinner, as in summer. 282 FOOD IN HEALTH. [Parti. Adults whose lives are necessarily and chiefly devoted to intellectual or other sedentary occupations should not attempt to consume the same amount of food as those whose duties or pursuits involve much physical activity in the open air. The kinds of food they take may also frequently be modified with ad- vantage. The substitution of fish, to some extent, for butcher's meat has much to recommend it in these individuals. It is not so rich in nitrogenous substances as butcher's meat, and does not throw so much work on the eliminating functions ; and the lighter kinds are much easier of digestion. There is, however, no foundation for the popular view that fish contains elements which adapt it in a special manner to be a " brain-food " or to sustain and promote intellectual labour. Brain-w_oiiers_slLOuld live much on light food not demanding much effort of the stomach to digest, and they should remember that the digestion of heavy meals involves also a greater expenditure of nerve- force. Besides fish, eggs, milk, light porous well- made bread, fresh vegetables and fruit should form their chief sustenance. They should take only a small amount of butcher's meat, and that especially on those occasions when they are able to take more physical exercise. Some animal fat is, however, useful, such as fresh butter or cream, or a rasher or two of fat bacon at breakfast. It is a remarkable fact that whereas the muscles contain only three per cent, of fat, the brain contains 8 per cent., and the nerves twenty-two per cent. ; and this " high percentage of fatty matters contained in nervous substances indi- cates the necessity of fat for the proper performance of the functions of the nerves." Climate and temperature, as well as physical activity, influence also the quantity and quality of the food required. It is well known that in tropical countries, as well as in countries where they have prolonged hot seasons, as in the south of Europe, the natives live Chap, xi.] CLIMATE AND JJIET. 283 much on vegetable foods and fruit, when these can be obtained, and consume much less animal food and fatty substances than the natives of northern Europe ; whereas in Arctic regions, where, it is true, no vegetables can be obtained, the inhabitants consume enormous quantities of animal flesh and fat. The necessity of supplying the body with a large propor- tion of combustible food, such as hydro-carbons, when the external temperature is very low, is obvious ; and it is equally clear that very little food of this kind is needed when the external temperature is high. In Britain during the heat of summer some modification of the habitual diet should be made ; less animal food and fats should be consumed, and more vegetable substances and fruit should be taken in their place. Many idiosyncrasies with regard to particular articles of food have to be considered, not only in adult life, when, however, they become more marked, but at all ages. Some persons cannot digest milk, others cannot take eggs in any form : some can eat no fat ; some are made ill by certain kinds of fish, etc. All these peculiarities have to be reckoned with. These are sometimes due to inherited tendencies ; sometimes they are the growth of habit. Some persons do best with long intervals between their meals ; their digestions are slow. Others with quick digestions require food more frequently. Long fasts are, as a rule, ill borne by feeble persons who cannot eat largely at their meals, and such persons are often better for taking a small quantity of food between their late dinner and breakfast, which usually involves a fast of twelve or more hours. A little light food on going to bed, or, if they wake, as they are prone to do, in the night, is advisable. This may be simply a cup of clear soup, or beef-tea, or gruel, milk, or arrowroot. It is to be noted also that women require less food than men, as their bodies are usually smaller, and they more commonly lead inactive, sedentary lives. 284 FOOD IN HEALTH. They, however, pass through critical periods, which may require special care ; e.e allowed."* It has been found (Von Noorden) that if equal weights of different kinds of carbohydrates are given in succession, the diet in other respects being the same, that grape-sugar (dextrose, glucose) raises the percentage of sugar in the urine to the highest point most quickly. Starch and other carbohydrates (such as maltose and dextrin) approach grape-sugar very closely in this respect. Fruit-sugar (levulose) in- creases the glycosuria to only half the extent, or even less than grape-sugar does. Milk-sugar and cane- sugar occupy a middle place in their glvcosuric action between grape-sugar and levulose. There are, as might be imagined, great practical difficulties in constructing a satisfactory dietary for diabetics exclusively of albuminates and fat; indeed, the quantity of fat necessary to supply the requisite amount of carbon needed in the system is with diffi- culty appropriated by the organs of digestion ; and to attempt to meet the demand for carbon by albumin- ates alone would necessitate a quantity of such foods altogether unmanageable. We are, then, in the end, driven to adopt a mixed diet, the different articles of which have to be selected with especial regard to the amount of sugar-forming material they contain, choosing, of course, those which contain the minimum, and always looking to the albuminates and fats as the chief nutritive elements of the dietary. And, first, with regard to bread. This forms so important an article in the habitual daily dietary of the healthy, and the ordinary kinds of bread are so rich in carbohydrates, that the ingenuity of physicians * "A Practical Treatise on Urinary and Renal Diseases." (Fourth edition. ) chap, in.] BREAD FOR DIABETICS. 381 has been greatly taxed to produce a bread for the diabetic which shall prove a satisfactory substitute for ordinary bread. Bouchardat suggested gluten bread as a suitable food for the diabetic ; this is a bread made of wheat flour, deprived by repeated washings of as much of its starch as possible. But gluten lu-ead is never entirely free from starch, and, unless it is prepared with great care and by known manufacturers, may even contain a con- siderable quantity. It is also by no means agreeable to the palate ; yet, when well and carefully prepared, it undoubtedly supplies a need. Sir William Roberts speaks highly of a gluten bread made in the form of small, palatable buns by Bonthron, 106, Regent Street, London. They keep about a fortnight, and he found them nearly free from starch. Gluten meal may be used for thickening broths and for making puddings. Bran bread, introduced by Prout, made from bran washed as free from starch as possible, has also been largely used for diabetics ; but, unless very carefully prepared, it contains a considerable amount of starchy material and also a large proportion of indigestible cellulose, which with some persons sets up a great deal of gastrointestinal irritation. Dr. Camplin's formula for bran cakes is one of the ; it is as follows : " Take a sufficient quantity (say, a quart) of wheat- bran ; boil it in two successive waters for a quarter of an hour, each time straining it through a sieve ; then wash it well with cold water (on the sieve) until the water runs off perfectly clear ; squeeze the bran in a cloth as dry as you can, then spread it thinly on a dish and place it in a slow oven ; if put in at night, let it remain until the morning, when, if perfectly dry and crisp, it will be fit for grinding. The bran thus p:epared must be ground in a fine mill, and sil'ted through a wire sieve of such fineness as to require the 382 FOOD IN DISEASE, [Partii. use of a brush to pass it through ; that which remains in the sieve must be ground again until it becomes quite soft and tine. Take of this bran powder 3 oz. (some patients use 4 oz.), the other ingredients as follows : 3 new-laid eggs, 1 oz. (or 2 oz., if desired) of butter, and about | pint of milk ; mix the eggs with a little of the milk, and warm the butter with the other portion ; then stir the whole well together, adding a little nutmeg or ginger, or any other agreeable spice. Bake in small tins (patty-pans), which must be well buttered, in a rather quick oven for about half an hour. The cakes, when baked, should be a little thicker than a captain's biscuit ; they may be eaten with meat or cheese at breakfast, dinner, or supper ; at tea they require rather a free allowance of butter, or may be eaten with curd or any of the soft cheeses. " It is important that the above directions as to washing and drying the bran should be exactly fol- lowed, in order that it may be freed from starch, and rendered more friable. The bran in its common state is soft, and not easily reducible to fine powder. In some seasons of the year, or if the cake has not been well prepai-ed, it changes more rapidly than is con- venient. This may be prevented by placing the cake before the fire for five or ten minutes every day." These cakes are made by Blatchley, 167, Oxford Street, London. Sir William Roberts suggests the use of seven eggs, instead of three, as an improvement; also the addition of a teaspoonful of sodium bicarbonate. " Torrified " bread, made by toasting thin slices of ordinary bread before the fire until they are deeply and thoroughly browned almost blackened so that the starch and gluten are in great part destroyed by the heat, is a highly acceptable form of food to some diabetics. Pavy introduced almond cakes as a substitute for ordinary bread, and it is undoubtedly a valuable one. By washing the meal of sweet almonds with acidulated water, the greater pert of the sugar is removed, and Chap, in.] BREAD FOR DIABETICS. 383 the meal so treated may by careful preparation be made into a palatable cake or biscuit. Seegen also advocates the use of almond cakes, and gives the following recipe for making them : Take of blanched sweet almonds \ lb., beat them as fine as possible in a stone mortar; remove the sugar contained in this meal by putting it into a linen bag and steeping it for a quarter of an hour in boiling water acidulated with vinegar ; mix this paste thoroughly with 3 oz. of butter and two eggs. Next add the yolks of three eggs and a little salt, and stir well for some time. Whip up the whites of these eggs and stir in. Put the dough thus obtained into greased moulds, and dry by a slow fire. Almond cakes are not popular with the French authorities. G. See prefers a small quantity of ordinary bread 5 oz. daily or the same quantity of potato-meal. Dujardin-Beaumetz also objects both to gluten bread and to almond cakes ; the former he maintains is often found to contain a considerable percentage of starch ; and he warmly advocates the use of potatoes instead, for those diabetics who cannot do without some food of this kind. Potatoes cooked in the oven contain, he asserts, only 8 '3 per cent, of sugar-forming material, while gluten bread contains 27 per cent. These figures, of course, apply only to the gluten bread prepared in Paris. We must also remember that potatoes have no claim to be considered as at all approaching gluten bread in nourishing properties, as they only contain 2 '8 per cent, of albuminates. Dujardin-Beaumetz advocated the use of "soya" bread for diabetics, of which he gives the following as the composition : SOYA BREAD. Water 45'000 Proteids 20-168 Fats 9-350 Starch and Sugar 2'794 Phosphoric Acid 0-863 384 FOOD IN DISEASE. [Panii. This bread, he states, keeps well, and has an agreeable taste, and contains much less sugar-forming material than gluten bread, the best kind of which, he asserts, contains at least 16 per cent, of starch and saccharine substances. Lecerf * was one of the first to call attention to the value of the meal of the Soya hispida in dietetics. It has a leguminous fruit, like the haricot, and is a native of China and Japan, but is now cultivated in Austria. The Chinese extract from soya a fatty sub- stance which they use as milk, and even make cheese with it. The meal is very rich in nitrogenous sub- stances, more so than animal flesh, and the amount of starchy and saccharine substance is very small. Professor Attfield gives the following analysis of the Soya bean flour ; Proteids 41-24 Fats 13-70 Carbohydrates 30-35 Phosphates 4'81 Other Salts 0-52 Moisture 9-38 100-00 Van Abbott prepares both bread and biscuits of this flour. Some patients greatly object to the taste. All kinds of animal flesh and fats are permitted to the diabetic (except liver), and all kinds of fresh and preserved meat, provided that sugar has not been used in their preservation ham, bacon, sausages, fowl, game, fish, fresh and smoked, Crustacea (crabs, lobsters, etc.), oysters. Eggs, cheese, butter, cream, and all animal fats and oils, cod-liver oil, olive oil, may also be partaken by them. " Fat is an invaluable nutrient mate-rial to the diabetic ; it is his sheet-anchor. This is owing, in the first place, to its high nutritive value, and, secondly, * Journal de Medccine Pratique, 10 Juin, 1888, p. 923. Chap, in.] DIET OF DIABETICS. 385 to the fact that its ingestion never increases the glycosuria." (Von Noorden.) In cooking any of the above, as e.g. fish, it must be remembered that no flour or other starchy material may be used, or in the preparation of sauces ; and when " melted butter " is used as a sauce it must not be thickened with flour. As one great object in the diet of the diabetic is to supply the deficiency of carbon owing to the exclusion of the ordinary carbo-hydrates by an in- creased consumption of fats, we may make free use of such articles of diet as pdte de-foie-gras, sardines in oil, thon in oil, filets d'hareng saure a la Norvegienne ; and Dujardin : Beaumetz extolled the use of caviare, because it excited appetite, and he stated he had patients in the last stage of diabetes who owed their resurrection to the use of caviare. Green and fresh vegetables are freely allowed, and should enter as much as possible into the dietary of the diabetic cabbage, spinach, sorrel, lettuce, dande- lion, cucumber, watercresses, and those other vegetables commonly used for salads ; and some physicians allow a small quantity of such vegetables as green French beans, asparagus, celery, onions, leeks, and even carrots and truffles. Carrots, turnips, beans, peas, and beet-root are, however, most commonly prohibited. Fruits are altogether prohibited by some, and not so entirely by others. All agree in forbidding the sweeter kinds of fruits, and all candied and preserved fruits. But many authorities consider a moderate amount of fresh acidulous fruits permissible goose- berries, apples, currants, cherries, etc. ; they contain more levulose than grape-sugar. All vegetables and fruits containing large amounts of starch and sugar must be strictly forbidden. The question of beverage is a very serious one to the diabetic, for his thirst is, as 'a rule, urgent and constant, and his temptation, therefore, to drink when and what he ought not to, is very great. 386 FOOD IN DISEASE. [Partii. All strong alcoholic drinks must be forbidden, except in very small quantities, and largely diluted with water or an alkaline mineral water. A small quantity of the lighter acid wines, such as claret, hock, and still Moselle, may be allowed, mixed with water. Unsweetened spirits brandy, gin, and whisky, mixed with water may occasionally be sub- stituted for wine. Weak infusions of tea and coffee or cocoa, also made without sugar, are admissible ; these may be sweetened, if required, with minute quantities of saccharin (not more than \ grain of this substance should be taken daily, as gastric pains and disorders have been provoked by its constant use in larger closes). As to wines, it is desirable to notice which kinds (of those generally permitted) are best borne by different diabetics. All saccharine wines (ports, champagnes, Sau- ternes, etc.), liqueurs, and beer must be strictly avoided. To resume : the following may be taken as the main indications to be satisfied in fixing a regime for the diabetic : 1. Reduce to a minimum or abolish altogether all sugar-forming foods, i.e.. all substances containing starch or sugar. 2. Raise to the physiological maximum all flesh foods, i.e. give as much animal food meat of all kinds as can be well digested and assimilated. 3. Find suitable substances to replace the neces- sarily discarded carbo-hydrates and these are to be found amongst the various animal and vegetable fats. Their richness in carbon renders them fitter for this purpose than albuminates. 4. Promote muscular activity in order to consume the excess of sugar in the blood. This last indication must be applied with dis- crimination ; and it must be remembered that in the graver forms of diabetes the thin wasted diabetics much muscular exercise is ill borne; on the other Chap, in.] ALKALINE WATERS IN DIABETES. 387 hand, the stout, gouty, glycosuric patients are doubt- less benefited by exercise. I have already alluded to the value of alkaline waters in diabetes. They often prove of so much use that they may be regarded as forming a fit part of the diabetic regime. Their use is frequently attended by a diminution of the excessive thirst, a disappearance of the dis- tressing dryness of the mouth, by a less frequent need to pass water, and by a removal of cutaneous irritations and eruptions. The mode of action of these alkaline waters re- mains obscure ; but their good effects are undoubted. It is scarcely necessary to say that we must not expect to observe these good results of the use of alkaline waters as frequently in the graver as in the slighter, and especially in the gouty, forms of diabetes. If we employ the stronger alkaline waters, like those of Vichy and Vals, we may direct the patient to drink from 3 ox. to 6 oz. half an hour before each meal ; the weaker waters, like those of Neuenahr, Ems, Apollinaris, etc., may be taken in larger quantity, and may be used to mix with wine. In diabetes, as in nearly every form of disease which we are called upon to treat, our guiding rule should be "discrimination!" We must adapt our regime to individual cases, and we must observe carefully whether the measures we adopt are well or ill tolerated by different patients. We should, therefore, frequently examine our patients' urine, and notice what influence is exercised on the amount of sugar excreted by different articles of food. We should also weigh our patients frequently to ascertain the effect of the dietary adopted on the nutrition of the body. If we follow this plan we shall discover that some diabetics may be permitted a much more liberal and more varied dietary than others, and that measures which on theoretical grounds might appear necessary, often prove practically undesirable. z2 388 FOOD IN DISEASE. [Pan 11. Von Noorden, in his already quoted work on Diabetes,* makes some very judicious observations, from the above point of view, on the diet suitable to the several groups of diabetics, and especially as to the extent to which carbo-hydrates may be utilised the object to be kept in view in all those diet schemes being to maintain and, if possible, increase the strength of the patient, to keep stationary or even increase the store of albumin in the body. "Any diet," he says, "which is not adapted to assure the maintenance of the diabetic's store of albumin is, in my opinion, unsuitable for long-continued use ; it may be employed temporarily, but as a permanent thing it is objec- tionable and dangerous." He points out that "the difficulty of affording nourishment to the sufferer from diabetes is increased in inverse proportion to the tolerance of carbo-hydrates. While in the case of one diabetic we are able to give such an amount of carbo- hydrates that, although a small proportion is lost in the urine, the large remainder suffices to cover a quantitatively important part of the daily tissue change, in another no advantage worth mentioning accrues from the ingestion of carbo-hydrates, give them in what quantities we will." But we are not compelled to banish the carbo-hydrates entirely in those cases in which a certain degree of tolerance for them exists. " When, for example, a patient excretes no sugar while taking 50 grammes of bread, and perhaps 1 grammes of sugar while taking 100 grammes of bread daily, we can then permit him, with a good conscience, to eat from 50 to 100 grammes of bread. . . . We need have no apprehension even if we exceed a little the limits of tolerance in these cases." He further very wisely remarks, " the reduction of carbo- hydrates signifies much more than a mere game of hide-and- seek with the glycosuria. Through blind indulgence very material injury may be caused, but through a limitation of the ingestion of carbo-hydrates, regulated according to the neces- sities of the individual case, a very positive advantage may be gained." But he further adds, " for every really grave case of diabetic glycosuria the fat and flesh diet, to the exclusion of carbo-hydrates, is to be regarded as the ideal regimen." It is, however, important also to bear in mind, as he observes, that individuals who have been for a certain time several weeks, for instance on a diet containing no saccharine or starchy ingredients, often acquire a tolerance of carbo- hydrates, and excrete much less sugar after the ingestion of a certain quantity of amylaceous food than they did before. " The sugar-consuming function of the body is spared by the temporary withdrawal of carbo-hydrates, and is thus given an opportunity for recovery and restoration of strength." Of all the professed substitutes for bread, Von Noorden * "Twentieth Century Practice," vol. ii., 1895. Chap, in.] VON NOORDEN: DIET FOR DIABETICS. 389 prefers "Aleuronat" bread, because with a comparatively small proportion of carbo-hydrates it preserves the genuine bread- taste, and many diabetics take it readily for months at a time. His observations and experience as to the value of alcohol in diabetes are also interesting. It is very useful, he thinks, in carrying out the " fat and flesh diet," as it facilitates greatly the ingestion of considerable quantities of fat and lessens the risk of disgust for it being produced. The patient should take a small quantity of alcohol with or after fatty food. Cognac, whisky, or Kirsch, or good Burgundy may be taken with or without soda-water. Alcohol also " introduces a not insignificant amount of fuel into the body," and it saves the consumption of some other non- nitrogenous substance, especially fat. " Since we often have to give the diabetic very large quantities of fat, it is a matter of great importance that we perceive in alcohol a means whereby a certain reduction in the allowance of fat can be effected." But we must not use it in larj;e quantities or we may produce its poisonous effect on the protoplasm of the cells. The &\ orige limit to the daily con- sumption of alcohol should be about 60 grammes (2 ozs.), or from 3 to 4 ozs. of brandy or whisky. It is especially in the cases in which a long indulgence in alcohol has been common that it is necessary as a nervine and cardiac tonic. In the aged and obese with arterio-sclerosis only the lightest wines should be used. In order to apply these principles to the practical feeding of diabetics, he finds it convenient to divide them into the following groups : (1) Cases of mild glycosuria in elderly persons. (2) Mild glycosuria in young persons. (3) Moderately severe forms of glycosuria. (4) Severe forms of glycosuria. (1) This form of glycosuria is, we have already seen, benign. The amount of sugar excreted is reduced to a mere trace by a considerable abstraction of carbo-hydrates from the food. It is better in these cases to put up with such a slight glycosuria than to get rid of it by a rigid exclusion of carbo- hydrates. Forbid certain articles which consist entirely or chiefly of carbo-hydrates e.g., sugar, pastry, sweet wines, and dishes made with flour, rice or sugar. Allow, but in reduced amount, beer (1 to 2 glasses daily), or a little light wine. The patient may be allowed also to eat a limited amount of bread, potatoes, and other vegetables at his meals. In the obese a rapid and great loss of weight must be guarded against by an increase in the carbo-hydrates. " Dia- betics feel better and are better protected against danger when their store of fat is above that desirable for the healthy." We 39 FOOD IN DISEASE, [Partii. should urge such patients to the free use of butter with bread and potatoes to eat bacon and other fat meat and the richer kinds of chee?e. (2) This form in young persons is often dependent upon some nervous disturbance. We must be much more cautious about allowing carbo-hydrates to these patients than to the elderly, because there is much more danger of the glycosuria assuming a progressive character. " In view of the varying intensity of the glycosuria in young persons, it is advisable that an exact determination of the limits of tolerance, accord- ing to the formula already given (page 376), should be made at least twice a year." It is undesirable to reduce the amount of carbo-h)'drates in the diet below what is absolutely necessary in order to keep the glycosuria in check, and it is hurtful to exceed the tolerance to any appreciable extent. Milk containing the easily decomposable milk-sugar he commends in these cases. " The best means of determining the amount of carbo- hydrates that can be allowed is by the addition of milk to the daily bill of fare. The standard diet (page 376) is first increased by the addition of one litre of milk a day, and then it is ascer- tained how much starch (in the form of bread) can be added to the food without giving rise to glycosuria." This ought to be from 60 to 100 grammes. The carbo-hydrates should be restricted to bread and potatoes, and moderate quantities of fresh vegetables and fresh fruits, but the bread should be limited to 100 and the potatoes to 150 grammes. It is most important with this class of patients, whose metabolic changes are much more active than in the elderly, that a certain fixed or adequate quantity of fatty food be included in the daily dietary. The drinking of 2 pints of milk daily, one in the morning, early, the other in the evening,, at bed-time, is of great value. The milk should be sipped slowly, "at least twenty minutes being taken in its consumption." The daily amount of fat taken should vary between 80 and 100 grammes; also 30 grammes of alcohol in some form, in order to economise in fat. The following represents the definite quantity of fat-con- taining foods which must absolutely be taken in the twenty- four hours : Butter, 60 grammes (with bread, bread and cheese, and potatoes). Olive Oil, 10 grammes (with salad). Rich Cheese, 30 grammes. Egsrs, 2. Milk, 1 litre. With these alcohol, 50 grammes (in some dilute form). The patient .to consult his own taste with the rest (nitrogenous part) of the diet. Chap. III.] VON NOORDEN: DlET FOR DIABETICS. 39! Such patients, Von Noorden thinks, often do well at a milk cure in the mountains, where, in addition to the other suitable articles of diet, 3 litres of milk may be taken daily. (3) The moderately severe forms comprise those cases in which the excretion of sugar is arrested or reduced to small amounts (10 to 20 grammes) only by total abstinence from carbo-hydrates. This form occurs mostly in the young and middle-aged, and is attended by emaciation rather than obesity. Having determined the limits of tolerance, such patients " should be subjected to a 3-weeks' course of complete abstin- ence from carbo-hydrates at least twice and if possible three times in the year, while in the intervals a certain amount of carbo-hydrates may be allowed." These periods can be employed to determine the oscillations of tolerance. In the period of strict abstinence the diet of such a patient must be made as varied as possible, and should be divided into five meals. "The dietetic treatment of such an individual demands the sacrifice of time, patience and thought." The "sample bill of fare" suggested for this period will be found, with others, at page 392 et seqq. In the intervals, the tolerance is tested directly after the " strict diet " by increasing additions of bread, and, if it is found to be raised, more carbo-hydrates may be added, and a diet similar to that for No. 2 group established. But this is rarely practicable. In most cases 4 ozs. of good wheat bread is the average amount permissible. As much fat as possible must be introduced into the diet, in one way or another butter, cream, bacon, olive oil, yolks of egg, marrow, etc. about 150 to 180 grammes of fat daily. He should take also about 40 grammes of alcohol per diem in the form of a pint of wine and one glass of cognac or old whisky. The daily consumption of fats may consist of Butter, 3 ozs. Olive Oil, 1 to 2 tablespooiifuls. Bacon, 20 grms. Five medium-sized hen's eggs. These fats must be used in the preparation or dressing of other foods, and as much ingenuity as possible should be applied in their preparation. Tables are added (I., II., III., and IV.) of the different foods (I.) allowable unconditionally ; (II.) allowable in moderate quantity; (III.) conditionally allowable; and (IV.) especially valuable. If the patient is content to take " Aleuronat " bread, 100 grammes of which are equivalent to 50 grammes of ordinary bread, he is then allowed 2 pints of milk. Von Noorden con- eiders " milk cures " useful in some of these cases. All the carbo-hydrates may be given in the form of milk 3 litres of milk instead of 150 grammes of bread. These are "especially 392 FOOD IN DISEASE. [Partii. recommended in greatly-weakened individuals and those suffer- ing from grave complications. They should not be continued in general longer than three or four weeks at a time, and are hest instituted during- the patient's stay in the country or in the mountains." These cases are also benefited by a moderate Carlsbad course. (4) Severe forms of glycosuria are those in which, in spite of a continued diet as free as possible from carbo-hydrates, sugar is constantly excreted in the urine. In these cases, even although the carbo-hydrates aggravate the dubetic disturbance, Von Noorden maintains they "cannot be permanently dispensed with. They are always to be regarded as incidental articles of diet, or, as it were, luxuries," and he would divide the regime of such patients into (a) & period of strict diet, and (b) diet in the intervals. The former should resemble that sketched for Group 3, but it must be much stricter, and should last four weeks instead of three, and take place almost every quarter. The choice should be made from the lists of " unconditionally alloivable foods " (Table I.) and "especially valuable foods'" (Table IV.). (b) In the intervals, carbo-hydrates in restricted quantities are to be allowed. "We must, despite all theoretical opposi- tion, permit the use of carbo-hydrates to almost as great extent as in the case of the patients in the preceding category, who are suffering from the moderately-severe forms of glycosuria." Of the " unconditionally allowable foods " he may take any he wishes, and always in large amount ; of three or four articles of "foods permissible in moderate quantities' 1 and of "conditionally allowable foo/ts," he should take amounts equivalent in value to from 80 to 120 grammes of white bread. It is especially necessary in these cases to ensure the con- sumption of an adequate quantity of fat, " for fat is for these patients the only thing upon which they can rely to maintain their strength and prolong their lives." Alcohol they also require in larger amounts than the milder forms as much as 80 grammes a day " such a close being justified by the greater ingestion of fat, the tendency to heart failure, and the general nervous exhaustion." He distributes the alcohol about the day thus : A pint of still Moselle at lunch, a pint of good old Burgundy at dinner, and a liqueur-glass of brandy or whisky three or four times a day. VON NOORDEN'S SAMPLE BILL OF FARE for moderately-severe cases during the periods of strict abstinence from carbo-hydrates. 8 a.m. (1st Breakfast.) Ham, 100 grms. ; a cup of tea; a glass of cognac. Chap, in.] VON NOORDEN: DIET FOR DIABETICS* 393 10.30 a.m. (2nd Breakfast.) 2 eggs fried in 10 grms. of butter. 12.30 p.m. (Luncheon.) Cold roast meat, 150 grms. ; mayon- naise, made with the yolk of one egg and one spoonful of o,il ; raw cucumber, with 5 grms. of vinegar, one spoonful of oil, salt and pepper ; Gorgonzolt cheese, 15 grms.; half-bottle of Moselle; a cup of coffee with a tablespoonful of cream. 5 p.m. (Tea.) A cup of tea, a boiled egg, and a glass of cognac. 7.30 p.m. (Dinner.) A cup of bouillon, with 15 grms. of marrow ; boiled salmon, 80 grms. ; asparayus, % to ^ lb., with butter, 20 grms. ; smoked ox ton ff tie, 30 grins. ; capon, 100 grms.; salad, with 5 grins, of vinegar and a spoonful of oil ; half- bottle of Burgundy. 10 p.m. A glass of cognac with seltzer- water. VON NOORDEN'S DIET TABLES. TABLE I. Unconditionally Allowable Foods. Fresh meat and fowl ( wild or domestic), tongue, heart, brain, sweetbreads, kidneys, marrow-bones. Preserved meats. Dried and smoked, or salted. Fresh fish, cooked without any farinaceous sauce or addition of any kind, and eaten with butter (plain or melted). Preserved fish . Dried, salted or smoked, or preserved in oil (sardines, anchovies, etc.). Caviare, cod-liver oil. Shellfish. Oysters, mussels, and other bivalves, lobster, cray-fish, crabs, shrimps, turtle. Meat extracts and peptones. JBffffs, raw or cooked. Fats, animal and vegetable. Fresh vegetables. Lettuce, endive, cress, spinach, cucumbers, onions, leeks, asparagus, cauliflowers, red and white cabbage, sorrel, French beans. These maybe taken boiled in broth and dressed with butter, lard, or any other fat. Preserved vegetables. Pickles. Spices. Salt, pepper, cayenne, curry, cinnamon, cloves, nut- meg, mustard, saffron, anise-seed, carraway-seed, parsley, dill, borage, laurel, capers, olives, garlic, etc. Soups. Clear soups and broths, with or without eggs, marrow, fresh or dried vegetables (Julienne), clear turtle, etc. Cheese, especially the fatty or cream cheeses. 394 FOOD IN DISEASE. iPartii. Beverages. Effervescing natural or artificial waters, to which may be added lemon- juice, saccharin, glycerin, and the various spirits brandy, rum, etc.; light Moselle or Khine wines, claret, or Burgundy ; coffee, black or with cream, sweetened with saccharin ; tea in the same way, or with rum. TABLE II. Articles Permissible in Moderate Quantities (containing an unimportant amount of carbo-hydrates). These dishes if two to four are selected daily offer a great variety in patients' dietary. Calves' liver, giblets (up to 100 grms.), liver sausages, meat sausages, German and Frankfort sausages, sausage- meat balls, brawn. 60 to 100 grms. Pate-de-foie-gras, potted beef, ham, tongue, salmon, lobster, anchovies. -| to 1 tablespoonf ul. English Sauces. Worcester, Harvey, anchovy, Indian soy, etc. 1 tablespoonful. Cream. 4 to 6 tablespoonfuls a day. Cocoa. Prepared, without sugar. 25 grms. Cheese of all kinds. 25 to 60 grms. Vegetables. Salsify, turnip-root, celery, turnip greens, pumpkin. 2 tablespoonfuls. Green peas, beans, carrots, Brussels sprouts. 1 table- spoonful. li artichoke, 1 truffle. Edible mushrooms. 1 tablespoonful. Raiv ditto. 8 radishes, 2. sticks of celery, 2 medium-sized tomatoes. Nuts. 2 walnuts, 6 hazel nuts, 3 almonds, a thin slice of cocoanut, 8 Brazil nuts. Fresh Fruits. 1 thin slice of melon, 1 small apple, 1 or \\ peach, 1 spoonful of raspberries or strawberries, 4 spoonfuls of currants, 6 greengages, 12 cherries, \ a medium-sized pear, etc. TABLE III. Conditionally Allowable Foods. These are in the place of an equivalent quantity of bread, which must be deducted from the diet. The quantities = 50 grammes of white bread. Milk, 1 litre (or 1J litre of Russian koumiss). Kephir, 1 to 1^ litre (prepared without sugar). Cream, 1 litre. Chap. III.] VON NoOKDEJf's DlET TABLES. 395 Rye bread, Graham bread, or pumpernickel, 60 to 65 grms. Aleuronat bread (Ebstein's formula), 100 grms. Zweibach (made without sugar), and other cakes, 35 grms. Cocoa and chocolate, 30 to 40 grms. Chestnuts (unshelled), 60 grms. Cane sugar, 35 grms. ; fruit or milk sugar, 40 grms. Sweet compotes, 35 grms. Fruit jam, 50 grms. Honey, 40 grms. Flour. Wheat, rye, barley, oat, 40 grms. ; bean, pea, lentil, 45 grms. Rice, and other starch preparations macaroni, oatmeal 35 grms. Lentils, peas, beans (weighed dry), 50 grms. Green peas, 100 grms. Potatoes, new, 180 grms. ; winter, 140 grms. Apples, pears, plums, apricots, cherries, grapes, etc., 120 grms. Strawberries, raspberries, mulberries, currants, blackberries, etc., 200 grms. Peaches, 3. Raisins or dried dates, 40 grms. Figs, 50 grms. Bananas, 3. Walnuts, hazel nuts, almonds, or Brazil nuts, a handful. Beer, litre. Sweet wine, $ litre. TABLE FV. Especially Valuable Foods on account of their richness in albumen and fat. 100 grammes of each. Oil (vegetable). Putter. Bacon and ham. Devonshire and other cream. Cream, Cheddar, Brie, and other cheeses. German sausage (Cervelat wurst). Fat pork, beef, mutton, goose. Smoked ox tongue. Yolk of egg. Eels. Smoked mackerel. Caviare. Fat siilmon, fresh or smoked. 396 FOOD IN DISEASE. [Part II. DIABETIC DIETARIES. I.PAVY'S. Sanctioned : Butcher's meat of all kinds, except liver. Ham, bacon, and other pre- served meats. Poultry and game. Fish of all kinds, fresh and cured, including the crus- tacea. Animal soups, beef-tea, and broth (not thickened). Eggs, cheese, cream cheese, cream, butter. Almond, Iran, or gluten substi- tutes for ordinary bread. Greens, spinach. Turnip-tops, watercress. Mushroom, mustard-and-cress. Cucumber, lettuce, endive. Radishes, celery. And the following only in mode- rate quantity, after boiling in much water : Turnips, French beana. Brussels sprouts, cabbage. Cauliflower, broccoli, sea-kale. Asparagus, vegetable-marrow. Pickles, olives, vinegar, oil. Jelly, flavoured, but not sweet- Savoury jelly. . [ened. Blanc-mange,made with cream and not milk. Custard, made without sugar. Nuts of all kinds, except chestnuts. Forbidden : Sugar in an}- form. Wheaten bread and ordinary biscuits of all kinds. Rice, arrowroot. Sago, tapioca. Macaroni, vermicelli. Potatoes, carrots. Parsnips. Beet-root. Peas. Spanish onions. Pastry and puddings of all kinds. Fruits of all kinds, fresh and preserved. Beverages. Tea, coffee, cocoa from nibs. Dry sherry, claret, hock. Dry Sauterne, Chablis, Bur- gundy. Brandy and spirits, un- sweetened. Soda-water. Burton bitter ale in moderate quantity. * "Food and Dietetics." 2nd edition, 1876. Milk, except sparingly. Sweet ales, mild and old por- ter and stout, cider. All sweet and sparkling wines. Port wine, unless sparingly. Liqueurs. Chap. III.]' DIABETIC DIETARIES. 397 2. SEEGEN'S.* Sanctioned : In any quantity : Flesh of all kinds : preseryed (smoked) meats, ham. Tongue, bacon. Fish of all kinds. Oysters and shell-fish. Crabs, lobsters. Animal jellies. Aspic. Eggs, caviare, cream, butter, cheese. Spinach, cooked salads, endive. Cucumber, green asparagus. Watercress, sorrel. Artichokes, mushrooms. Nuts. In small quantity : Cauliflower, carrots. Turnip, -white cabbage. Green beans. Berries, such as strawberries, raspberries, currants; also oranges and almonds. Forbidden : Farinaceous foods of all kinds. (Bread only in very small quan- tity according to the discretion of the physician.) Sugar. Potatoes, rice, tapioca. Arrowroot, sago, groats. Peas, beans. Sweet fruits, as grapes, cher- ries, peaches,apricots,plums, and all kinds of dried fruits. Beverages. In any quantity : Water, soda-water. Tea, coffee. Bordeaux and Rhine and Mo- selle wines. Austrian and Hungarian table wines. In short, all wines that are not sweet, and that contain only a moderate amount of alcohol. In very small quantities : Milk, unsweetened. Almond emulsion. Brandy, bitter beer. Lemonade, unsweetened. Champagne and sweet wines and beers, must, fruit wines and fruit juices and syrups. Sweet lemonade. Liqueurs. Ice and sorbets. Cocoa and chocolate. " Der Diabetis Mellitus." Berlin, 1876. FOOD IN DISEASE. [Part 11. 3. SIR WILLIAM ROBERTS'S. Sanctioned : Butcher's meat. Poultry and game. Fish. Cheese. Eggs. Butter, fat, and oil. Broths, soups, and jellies, made without meal or sugar. Cabbage, endive, spinach. Broccoli, Brussels sprouts. Lettuce, spring onions. Watercress,mustard-and-cress Celery. Substitutes for bread : Bran-cake, gluten bread (and meal), almond meal, rusks and biscuits. " Torrified " or charred bread. Dry sherry, claret, bitter ale. Brandy and whisky (in small quantities). Tea, coffee (no sugar), choco- late (made with gluten meal), soda-water, bi-tar- trate of potash water. Forbidden : All saccharine and farinaceous foods. Bread, potatoes. Rice, tapioca, sago, arrow- root, macaroni, etc. Turnips, carrots, parsnips, beans and peas. Liver (contains much sugar- forming substances), and therefore Oysters ( containing Cockles < enormous Mussels ( livers. The "pudding" of crabs and lobsters. All stveet fruits, as apples, pears, plums, gooseberries, currants,grapes,oranges,etc. Port and all sweet wines. Sweet ales and porter. Rum and sweetened gin. 4. GERMAIN SEE'S.* 1. All kinds of animal flesh, boiled or roasted. Ham, bacon. All kinds of fish, Crustacea, oysters. Eggs, cheese (well-kept). 2. Fats of all kinds, butter, lard, and sauces without flour. 3. Permits 5 ox. of bread or potatoes daily. 4. Also roots and green vegetables. 5. Sacchaiin, to replace sugar. 6. Forbids milk as a general rule. 7. Considers the best beverages to be wines that are not sweet, and tea and coffee, without sugar. 8. Recommends Vichy water before meals, especially in gouty cases. * "Dn Regime Alimentaire." Paris, 1887. Cnap. in.] DIABETIC DIETARIES. 399 6. DUJARDIN-BEAUMETZ'S. He adopts with little modification the dietary of Bonchardat. strongly recommends the substitution of potatoes cooked in tlte oven for bread, even gluten bread ; also the use of soya bread. prescribes soups made with fatty substances, and with poached eggs ; also vegetable soups made with cabbage, onion, Julienne soup, but without turnips and carrots ; and soups made with potato and leek. allows all kinds of animal food, fish, molluscs, and crus- tacea, and cautions against the use of sauces containing flour. ,, recommends all kinds of fats. ,, allows such vegetables as spinach, sorrel, French beans, lettuce, cabbage, asparagus, celery, artichoke, dandelion, and all salads. forbids beet-root, carrots, turnips, and allows only small quantities of onions and leeks. ,, rejects all fruits but gooseberries ! advises for beverages, wine mixed with a natural alkaline water; light infusions of tea and coffee, if required, sweetened with glycerin, but without sugar and milk. Also to relieve the thirst, bitter infusions, as of quassia and cinchona. Milk he forbids entirely. jit specialities he recommends sardines in oil, thon in oil, fo'u- t/ras, caviare, and Filets d'hareng saure a la Norvegienne. 6. BOUCHARDAT'S. Sanctioned : Forbidden : All kinds of meat (150 to 200 All substances rich in carbo- grammes of fat daily), hydrates, cooked in any way, but Milk, without meal or sugar. All kinds of fish. Lobsters, crabs, oysters. Snails. Eggs. Cream. Cabbage, lettuce, spinach, ar- tichokes, asparagus, green beans, etc. Peaches and strawberries. Substitute for bread : gluten bread. Beverages. Claret or ( For men 1 pint to Burgundy \ 1 pint daily. 400 FOOD IN DISEASE [Part n. 7. CANTANI'S. (This is a very exclusive diet.) Sanctioned : Forbidden : Meat and animal fats of all Liver. kinds (at all meals). Suiter, as it contains traces of Fish of all kinds. lactose. Lobsters. Cheese. Olive oil (instead of butter). Milk. Eggs (in milder cases). All farinaceous and saccharine Substitute for bread : Pavy's foods absolutely. almond cakes (only for con- All fruits, valescents who cannot en- All green vegetable and roots, tirely dispense with bread). Beverages. Pure water. Lemonade. Soda-water. Chocolate. Persons habituated to the use Vinegar, of strong wines and spirits Rum, cognac, may add to the water 10 to Tea and coffee (in severe 30 grammes of pure alcohol cases), daily. Red wine. Tea and coffee in small quan- tity in milder cases. Cantani considers much salt injurious, as well as much pickled pork or salt fish. He requires the adoption of this absolute meat and fat diet for three months in very mild cases for two months, in very severe cases for six or nine months. If after two months the urine contains no sugar, he allows green vegetables ; after another month, cheese and old red wine ; and after another fortnight, almonds and nuts. A month or so after this he permits juicy fruits, not too sweet, as straw- berries, raspberries, peaches, apples, and sour oranges ; still later, plums, gooseberries, green beans and peas, tomatoes, melons, cucumbers, and gourds. After another fortnight, milk and fresh milk foods may be used. Finally, if after repeated examination no sugar be found in the urine, small quantities of farinaceous Chap. HI.] DIABETIC DIETARIES. 401 food may be cautiously permitted, but their use must be restricted for life. It is best to avoid altogether cane-sugar and sweets of all kinds. Can tan i urges the consumption of as much fat as possible, and especially of " pancreatic fat," as easy of digestion. It is prepared of pancreas, cut up into small pieces, well mixed with a certain quantity of melted bacon fat or lard, left to undergo an artificial digestion for about three hours, and finally lightly roasted before the fire. In mild cases he prescribes pure sugar-free cod-liver oil, in 20- to 100-gramme 8. EBSTEIN'S. Ebstein maintains that every case should be indivi- dualised. The food he prescribes depends on the age and individuality of the patient. For thin persons he prescribes more fat than for corpulent ones. EAKLY BREAKFAST. One cup of coffee or tea (black), without milk and sugar. White broad toasted, 30 to 50 grammes ; or brown bread, well buttered butter, 20 to 30 grammes. The yolk of an egg, a little fat ham, or some German sausage (if required). If any food be needed bctwetn this meal and dinner, let it be a cup of broth, with the yolk of an egg. DINNER. Broth, with yolk of egg or marrow (the marrow-bone is boiled for half an hour, to solidify the marrow). Some peptone may be added to the broth. Meat (180 grammes, free from bone), roasted, boiled, or stewed beef, mutton, pork, veal, fowl, or venison (fat meat preferred). Gravies, with cream or yolk of egg, not flour. Orjish, with melted butter. Vegetables, prepared with much fat ; purees of leguminous plants. Salads, dressed with vinegar and oil, and some cream. The foud should be well salted and spiced. After dinner, a cup of coifee or tea. A A 402 FOOD IN DISEASE. [PartiL SUPPEE. One cup of tea or broth. Meat roasted, ham or cheese, or an egg, or fish, caviare. Bread 30 to 50 grammes, with butter, 20 to 30 grammes. Apples, pears, and stone fruit are allowed in small quantities. Beverages. He forbids absolutely the use of beer, limits the use of spirits, and allows about half a bottle of wine daily. If the patient digests milk well, he allows it in moderate doses, and cream especially. 9. DURING'S. This dietary differs from most others, and is founded oa the theory that the most important factor in the causation of diabetes is a faulty diet and disturbed digestion. During therefore insists only on a restricted diet and the selection of the most digestible foods. FOR EARLY BREAKFAST. Millr, with a little coffee, but no sugar (some lime-water to prevent milk from becoming sour in stomach). Stale white bread, ad libitum. Or oatmeal, barley, or rice-gruel, made with water, a little salt, but no butter (if bread cannot be borne). FOR 2ND BREAKFAST. White bread, stale and well-baked. An egg lightly boiled. Rice or oatmeal gruel, with or without milk, a breakfast- cupful. Or half a glass of good red wine (with water in certain cases). FOR DINNER (TAKEN BETWEEN 2 AND 3 O'CLOCK). Soup, with rice, barley, or oatmeaL Meat, roast, 250 grammes (game, ham, and smoked meats as free from fat as possible, are permissible), no condi- ments, no fatty sauces. CompSte of dried apples, plums, cherries. Diied peas or white beans, in some cases. Chap, in.] DIABETIC DIETARIES. 403 Green vegetables, asparagus, French beans, carrots, cauli- flowers, cabbages (boiled in water with salt, not with fat or stock). Dessert of a little raw fruit, apples, cherries, and one small glass of red wine, diluted with water. FOR SUPPER (ABOUT 7 P.M.). Gruel of barley, oatmeal, or rice, with salt (but no butter), and strained. In some cases may be made with milk. Ice or iced water, to relieve thirst between meals. He lays great stress on the mode in which these vegetable foods are prepared ; especially the cereals used for making gruel and the legumes are, before being cooked, to be steeped for some time, and boiled long enough to make them more easily digested. The following list of dishes which the diabetic patient may eat, even when on a strict regime, will show that he has still a considerable variety of foods accessible to him ; we divide them into those for breakfast, dinner (early), and supper : BREAKFAST. Eggs, boiled, buttered, poached and served on puree of green vegetable (spinach, lettuce, Brussels sprouts, etc.). Curried eggs. Omelette de jambon. ,, savoury. Ham or bacon, cold (boiled) or grilled. Chicken or game, cold or grilled. Brawn. Spiced beef. Kidneys, grilled with puree of green vegetable. Grilled bones. Finnan haddock, grilled and eaten with fresh butter. Soles, fried in butter, or grilled and ditto. Herrings, fresh, fried or grilled, and with butter, or with mustard sauce. kippered. Salmon, smoked. Cod's roe smoked and grilled, eaten with fresh butter. Mushrooms, stewed. Beverages. Tea, coffee, cocoa, with or without saccharin and cream, or cream and Apollinaiis water, or hock or claret and seltzer-water. A A 2 404 FOOD IN DISEASE, DINNER. (Better if taken early.) Soups. Purees of green vegetables (as spinach, sorrei, lettuce), celery, Julienne, tomato, game soup, hare soup, bisque soup, clear turtle, clear soups with savoury herbs, or with grated Parmesan cheese, or with poached eggs, creme de Volaille. (Care must be taken not to use any thickening" of starch, or any sugar or sweet wine.) Fish. Oysters (variously cooked or raw) ; soles, boiled, grilled, fried, or cold fillets with aspic jelly; salmon, grilled in slices with boiled cucumber and savoury sauce, or boiled or water-douched ; turbot, cod, mullet, etc. etc. etc. Crab and lobster, with greon salad. (Green salads with cream and oil dressing may be server with any of these.) Beef, mutton, pork, veal, goose, turkey, chicken, ducks, game, wild-fowl, hare, rabbit, sweetbreads. These may be cooked in a variety of ways e.g., mutton cutlets or pork chops with puree of tqniatoes, spinach, or lettuce ; pheasant boiled with celery sauce ; chicken, game, and other meats may be served cold with aspic jolly and pickles or cucumber, or made into rissoles with parsley and other savoury herbs. Vegetables, green, in purees with meat-gravy or cream : Lettuce, spinach, sorrel, sprouts, turnip greens, Scotch kale ; asparagus, green, with plain melted butter, and tarragon flavouring ; French beans, tomatoes, stewed celery, vegetable-marrow, cucumber, boiled and served with meat-gravy ; and mushrooms, grilled. Gooseberry or green-currant fool, custard pudding, almond pudding, junket. SUPPER. Any of the meats or fish, cold or grilled, already mentioned, with salad, cream or other rich cheese ; lobster mayon- naise; omelettes, savoury, an jambon ; cauliflower au gratin ; foie-gras, chicken, devilled ham, turkey and French beans ; custard pudding ; sardines, caviare, or Finnan haddock on gluten-bread toast. Much ingenuity may be usefully applied to varying the mode of cooking and serving these various articles of food. The several diabetic substitutes for bread may be utilised in their preparation. CHAPTER IV. DIET IN ALBUMINURIA. THE presence of albumen in the urine occurs under a variety of circumstances differing greatly in their significance and seriousness. Some of the abnormal conditions which give rise to the presence of albumen in the urine are temporary and comparatively unim- portant ; others are more or less permanent and of extreme seriousness. It is to the latter that the term "chronic Bright's disease " is usually applied, and the morbid condition then associated with the albuminuria is the existence of organic structural changes in the kidneys them- selves. These are cases of "chronic renal" disease. The presence of albumen in the urine occurs also temporarily in the course of many acute febrile dis- orders, as, for instance, in the exanthemata, especially in scarlet fever, in diphtheria, and indeed in nearly all severe forms of acute febrile diseases in some part of their course. Some of the instances of chronic Bright's disease no doubt originate in acute inflammatory affections of the renal organs, "acute Bright's disease," and these may occur without the coexistence of any other febrile malady. Albumen may occasionally and temporarily be present in the urine in connection with dyspepsia, and from improper feeding, or from over-exertion, too rapid growth, and other debilitating influences. Albuminuria from passive hypersemia of the renal vessels, as a part of that general venous obstruction dependent on chronic heart and lung disease, forms a part of the clinical history of those affections, the dietetic management of which will be subsequently considered. 406 FOOD IN DISEASE. [Pan n. We are now chiefly concerned with those instances of albuminuria in which appropriate dietetic treatment is called for, and of these the cases of so-called chronic Bright's disease are by far the most important. The question whether a diet rich in albumen, or an excess of albuminous ingesta, can give rise to albuminuria has been investigated experimentally by many observers with somewhat conflicting results. It is generally admitted that when albuminuria exists certain kinds of food will often cause a great increase in the quantity of albumen excreted in the urine ; but it is by no means so generally allowed that a temporary albuminuria can be produced by excess of certain kinds of food in the same way as temporary glycosuria can be brought about. Certain instances have undoubtedly been observed of persons who, when apparently in good health, pass albuminous urine after a large meal, or after prolonged muscular effort, but who do not do so when fasting or after repose. It is, however, doubtful if it is strictly correct to call this " physiological albuminuria," and the ex- planation put forward by Leube of this circumstance is probably the true one viz. that it only occurs in persons who inherit, or are born with, an abnormality of the renal structure in the form of a diminished resistance in the renal filter to the passage of albumen. Prof. Sir T. Grainger Stewart has instanced " cheese, pastry, and eggs," as forms of food which he has observed to be capable of inducing albuminuria in certain persons,* and he mentions the case of a medical colleague who whenever he indulged in pastry or cheese was pretty sure to suffer from albuminuria, with puffiness of the eyelids. It has also been shown by several observers that egg-albumen injected into the veins of animals (Stockvis), or under the skin (Semmola), or into the rectum, is followed by albuminuria. There is nothing * ' ' Lectures on Important Symptoms : Albuminuria," p. 145. chap, iv.] ALBUMINURIA FROM FOOD. .407 to be wondered at in this, seeing that the albumen injected in these expei'iments has not undergone any digestive changes, has not been peptonised, is, therefore, in an unassirailable condition, and is consequently excreted from the blood by the kidneys ; whereas when serum-albumen i.e. albumen which has undergone the digestive process and become assimilable is similarly injected no albumen appears in the urine. But it has been also asserted that egg-albumen taken into the stomach in large quantity will cause albuminuria. Setting aside individual peculiarities (a few indi- viduals can never take eggs in any form without suf- fering disturbances of health), great discrepancies occur in the observations made as to this point by different experimenters. Stockvis and some others have stated that in animals and in themselves they have found that when egg-albumen (uncooked) was taken into the stomach in large quantity a portion of it was excreted in the urine. Stockvis suggested as an explanation of this fact that a portion of the uncoagulated albumen entered the blood unaltered, and was, therefore, eliminated as unassimilable. Nussbaum, Coats, and D'Arcy Power claim to have seen albu- minuria produced in the same way. Lauder Brunton, however, failed to produce albnminuria by swallowing six raw eggs in succession ; and Dr. Maguire swal- lowed the whites of twelve raw eggs without pro- ducing albuminuria. Another observer* ate nineteen raw eggs in thirty-six hours without producing albuminuria. The probable explanation of these discrepancies in the results which have been obtained from eating raw eggs is simple enough. We are familiar with the great variation in the rapidity of digestion and the capacity of digesting different articles of food in different individuals. In those in whom the digestion of albuminous food is slow and limited, if fed on raw * Dr. Dobradin, quoted by Sir T. Grainger Stewart. 408 FOOD IN DISEASE. [Pan n. eggs, some of the egg-albumen escapes digestion, and passes into the blood unaltered, just as it might do if injected into the rectum ; while in others, whose capacity for the rapid digestion of albumen is great, a far greater amount of egg-albumen can be digested and assimilated in a short time. It has also been stated that albuminuria can like- wise be produced by eating an excessive quantity of cooked eggs, and the authority of Claude Bernard is quoted in support of this statement. The results of some experiments instituted by Prof. Sir T. Grainger Stewart* led him to the con- clusion " that the introduction of raw egg-albumen into the stomach induces albuminuria ; that the albumen is always in small quantity ; that it dis- appears when ordinary diet is resumed ; and that it is not egg-albumen but serum-albumen which is dis- charged." If we examine Prof. Sir T. Grainger Stewart's cases, we find one, a case of " locomotor ataxia," took ten raw eggs daily, in addition to his ordinary diet, for a period of nine days. Albumen appeared in the urine after two days. One, a case of " mitral incompetence," took nine eggs daily for seven days. Albumen appeared in the urine on the first day. One, a case "free from organic lesion," took ten eggs daily for three days, in addition to the ordinary diet, and albumen appeared in the urine from the first day. And in the fourth, a case of chorea, " the eggs were not well borne by the stomach," and the albu- men in the urine may, therefore, have been the result of dyspepsia. We should be disposed to take exception to all but one of these cases. The well-known digestive abnormalities of the ataxic should have rendered such a patient unsuitable for a test experiment ; and the presence of " mitral * Op. cit. Chap, iv.] ALBUMINURIA FROM FOOD. 409 incompetence " would give so great a tendency to venous hypersemia, that the occurrence of slight tem- porary albuminuria might be readily provoked. The occurrence of temporary albuminuria under circumstances like these has been explained by the suggestion that the blood, becoming surcharged with albumen, some of the excess escapes by the kidneys ; but may not the true explanation be that the inges- tion of so large an excess of albuminous material throws upon the kidney such an excess of nitrogenous waste (to be excreted), that a temporary functional hypersemia of the kidneys is excited, and that this leads to a slight escape of albumen from the blood ? It appears to us that this is a sound physiological explanation of what is observed to occur, and ac- counts for its occurring in feeble or disordered con- stitutions, and not in the perfectly sound and vigorous. Sir T. Grainger Stewart also tested the effects of some other articles of food, as cheese and walnuts, and came to the conclusion that, although "particular articles of diet induce alburainuria in some people, yet the quantity of albumen is usually minute, and it has little tendency to persist after the resumption of ordinary food." Pettenkofer's and Voit's observations * convinced these physiologists that albuminuria was never caused solely by excess of nitrogenous food. Voit gave a dog weighing 35 kilogrammes 2,600 grammes of meat in twenty-four hours, and found not the least trace of albumen in the urine; yet the animal had absorbed nearly six times the amount of dry albumen con- tained in the fluids of its body. Professor Oertel also experimented on the effects of the ingestion of egg-albumen. He gave to his dog, weighing only 7| kilogrammes, the whites of 20 eggs in 24 hours by the stomach, and after various trials he never found albumen in the urine. He also gave to one of his patients affected with heart disease, besides 150 grammes (about 12 oz.) of meat, 190 * Quoted by G. S6e, " Du Regime Alimentaire," p. 705. 4io FOOD IN DISEASE, [Partii. grammes (about 7 oz.) of bread, and 200 grammes (rather more than 7 oz.) of vegetables, six raw eggs daily for 12 days i.e. 72 eggs altogether containing 4GO grammes of" dry albumen, without finding a trace of albumen in his urine. He obtained, moreover, the same negative result with a patient who ate, on an average, six boiled eggs daily. It is, then, safe to conclude that the occasionally observed occurrence of albuminuria as a result of the ingestion of albuminous food in excess is an accidental peculiarity or idiosyncrasy, and not an ordinary physiological phenomenon. With regard, however, to diet in albuminuria when connected with existing renal disease, there is, as has already been said, an almost general consent that richly-nitrogenised food is distinctly prejudicial, and more especially so if it consists of brown meats, of eggs, or of highly-spiced food. Sir T. Grainger Stewart has, nevertheless, expressed his belief that in the cirrhotic form of Bright's disease diet is a less important element in treatment than in cases of tubular inflammation ; and he gives the par- ticulars of cases in which he oixlered eight raw eggs daily in addition to the usual "low diet," without causing any material change in the secretion.* But, as Dujardin-Beaumetz has well pointed out, in dealing with cases of advanced Bright's disease, it is not so much the quantity of albumen that appears in the urine that should be our chief concern, but rather the extent of the renal changes, and the con- sequent retention of products of nitrogenous waste in the system ; and it is to avoid or diminish the risks of this intoxication with urinary excreta that our dietetic rules should be directed.! The clear indication, then, is to administer food which is found to be readily assimilable, and which will least tax the digestive functions, and at the same time furnish the smallest amount of nitrogenous waste calling for elimination by the damaged kidneys. * Op. cit., p. 206. t " L'Hygiene Alimentaire," p. 188. Chap, iv.] MILK DIET IN- ALBUMINURIA. 411 To fulfil this indication it has been proposed to restrict the food of those suffering from both acute and chronic Bright's disease exclusively or almost exclusively to milk ; and it is certain that some of the most remarkable and best results in the treat- ment of these cases have been obtained from a strict adherence to milk diet the regime lacte of French authors. In cases in which this plan of feeding has been well borne, it has been observed that the flow of urine has increased, the excretion of albumen diminished, the amount of urea and extractives has been augmented, and the anasarca has disappeared. But great practical difficulties are often en- countered in procuring the adoption of this method by the patients themselves, and in not a few cases a diet consisting exclusively, or even largely, of milk is not well tolerated. It is, however, quite established that an ex- clusively milk diet can completely supply all that is needed to repair the nutritive wants of the organism. As a food for adults milk is defective in the amount of carbo-hydrates which it contains, and which is required in the adult body for the develop- ment of animal heat and muscular energy. According to Pettenkofer's and Voit's calculation, the daily ration for an adult should contain 137 grammes of dry albumen ; 117 of fat; and 352 of carbo-hydrates. The invalid who takes little exercise and expends little in muscular exertion would require somewhat less, and it is reckoned that from 5 to 7 pints (i.e. 100 to 140 oz.) of milk daily will be sufficient for all the requirements of an adult. Seven pints of milk are estimated to contain 216 grammes (about 74 oz.) of albumen and casein; 172 ( 6" ) of butter; nnd 161 ( o ) of lactose. 412 FOOD IN DISEASE. [Partii. If this quantity falls short in the relative propor- tion of carbo-hydrates, it makes up for this by the increased proportion of fat and albuminates contained in it. Milk is also rich in chlorides and phosphates, salts essential to the due nutrition of the tissues. It has been suggested that the other saline ingredients con- tained in milk may exercise a diuretic action, but it seems more probable that the increase in the flow of urine observed to accompany an exclusively milk diet is due to the quantity of water ingested. It has been maintained by G. See and Dujardin-Beaumetz that lactose is an active diuretic. The mode of applying this exclusively milk diet is as follows : If the patient's stomach will bear the sudden suppression of all other kinds of food, the full quantity of milk may be at once taken daily ; but if the stomach shows less tolerance of the change, it should be made more gradually, and half a glass or a glass of milk should be taken at suitable intervals, and other kinds of food slowly and by degrees replaced by it. The milk should be as fresh from the cow as it is possible to obtain it, and drunk at the ordinary temperature, not boiled, and with no flavouring or addition whatever. It is better to take it in small or moderate quantities at short intervals a glass (6 oz.) every hour during the day, and two glasses on getting up and on going to bed; or when it is inconvenient to take it so often, two glasses may be taken every two hours. When the patient is restricted entirely to milk, it must be remembered that he will require to take from 18 to 24 glasses of 6 oz. each in the twenty- four hours. It is very important that at the commencement of this diet the doses should be small ; dislike of the remedy and digestive troubles are much more likely to occur and interfere with the success of the treat- ment if the patient is allowed to begin by taking large quantities at a time. Chap, iv.] MILK DIET IN ALBUMINURIA. 413 If diarrhoea should occur, it is a sign that the milk is not digested, and the diet must be altered or modified ; a reduction in the quantity may be all that is needed. As soon as the tolerance of this milk diet is established, and the patient is able to take from five to seven pints a day, tin inconvenience arises in the form of obstinate constipation ; and, at the same time, the patient often complains of an unpleasant taste in the mouth and a dirty tongue. The state of the mouth may be improved by sip- ping a little soda- or seltzer-water after each glass of milk ; and the constipation must be encountered by some suitable aperient a little Gregory's powder or compound liquorice powder, or citrate of magnesia or a capsule of castor-oil, or a teaspoonful of Carlsbad salts, or an aperient enema ; either of these may be taken, according to the discretion of the medical attendant or the inclination of the patient. In very troublesome cases of constipation, an addition to the daily diet of a few stewed prunes or the pulp of one or two baked apples may be per- mitted. The body- weight usually diminishes somewhat during this treatment ; the urinary secretion is often increased to a remarkable extent, and this diuresis is generally accompanied by a disappearance of dropsy, if it exists. The abundant urine is pale, clear, with a peculiar greenish-yellow reflection, said to be characteristic of the milk diet ; usually of low specific gravity, on account of the quantity excreted, and of diminished acidity ; the amount of albumen excreted will usually be observed to diminish gradually from day to day, while the proportion of urea arid salts is progressively increased. It has been noticed that during the night, when the ingestion of milk is necessarily interrupted, the urine is passed in less quantity and is more 414 FOOD IN DISEASE. [Partii. albuminous. Jaccoud, therefore, recommends that the patient should take advantage of any chance wakings during the night to drink a few doses of milk, so as to keep the urinary secretion constantly under its influence. The period during which the treatment should be maintained cannot be fixed with any strictness. It must depend upon the nature of the case and the progress of the patient. If we are treating a case of acute nephritis, and have adopted the exclusively milk diet from the com- mencement, three or four weeks may suffice to get rid of the albuminuria, and we may slowly and gradually return to the ordinary diet. In chronic parenchymatous nephritis (inflamma- tion of the tubules), the result of treatment will depend upon the age of the patient and the duration and extent of the kidney lesions. In advanced cases, where cure is not possible, considerable amelioration in the general condition of the patient may constantly be observed, together with an increased flow of urine, disappearance of dropsy, a steady diminution, little by little, of the amount of albumen, which, although it may not entirely dis- appear, at the end of six or eight weeks will be reduced to a minimum. The kidney lesions are irreparable, but the milk diet has lessened, in a great measure, the excretion of albumen, and has restored a due elimination of the nitrogenous and other urinary excreta. In cases of cirrhotic or interstitial nephritis (gouty contracted kidney), an exclusively milk diet is less urgently indicated. When, however, the cardiac compensation begins to fail, and symptoms of uraemia are threatening, then great advantage may follow the adoption of this mode of treatment. We are in ignorance at present as to the precise manner in which the milk acts on the organism or on the diseased kidneys so as to produce the beneficial results observed. Chap, iv.] DIET IN ALBUMINURIA. 415 In those cases in which an exclusively milk diet is badly borne or absolutely rejected by the patient, we must fall back on some other method of feeding. We should, in the first place, endeavour to induce the patient to accept a modified milk diet, and supply him with dishes largely composed of milk, but which have the advantage of agreeable flavouring, without which food of all kinds is so repugnant to many. Milk may be made the basis of soups, to which various vegetable flavouring substances may be added, as onions, celery, and the usual aromatic herbs commonly employed for such purposes, together with a little salt and pepper ; fragments of toasted bread may be served with these milk soups. Arrow- root, tapioca, rice, and vermicelli may be used to thicken milk, and a little grated lemon-peel or cloves or nutmeg may be used to flavour foods thus made ; or a small quantity of fruit jelly, such as red-currant jelly, may be eaten therewith. On leaving off the exclusively milk diet the patient should be permitted, by slow degrees only, to return to the ordinary diet. At first a little arrowroot, tapioca, or rice should be substituted for a portion of the milk ; then a little fish, chicken, or other white meat, and a little green vegetable, cooked fruit, and a small quantity of good sound Bordeaux wine, mixed with seltzer-water, may be taken with the midday meal. Should the attempt to return to a mixed diet be attended with an increase in the quantity of albumen excreted, the exclusively milk diet must again be resorted to. It must, of course, be borne in mind that an irre- parably damaged kidney cannot be made structurally sound by milk diet or by any other remedy ; and in such cases, after the albumen has been reduced to a minimum by the milk diet, a return to a carefully- arranged mixed diet may not only be justi6able, but advantageous. Oertel, Grainger Stewart, and others have shown 416 FOOD IN DISEASE. [Partii. that in many cases such a diet rich in albumen is well tolerated, and not attended with any notable increase in the amount of albumen excreted in the urine. It is in acute cases, and especially in those cases which seem to be passing from acute to chronic, and before the structure of the kidneys has been hope- lessly damaged by inflammatory and degenerative changes it is in such cases as these that the exclu- sively milk diet is attended with such brilliant results. When the milk diet is inadmissible, we have then to consider what is the best alternative. It has already been pointed out that the subjects of albuminuria must carefully avoid any excess of nitrogenous food. Senator recommends that animal flesh should be altogether avoided, or limited to, at most, a little white meat, while all kinds of veget- ables and fats are permissible. Dujardin-Beaumetz also testifies that he has obtained excellent results by restricting patients with albuminuria to vegetable food. Farinaceous food, fresh vegetables, and fruit, together with milk, butter, cream, and other fats, afford all that can be needed for the nutrition of the body. Dujardiu-Beaumetz commends the onion, espe- cially, as an addition to soups ; and he states that when he has found his albuminuria patients unwilling to relinquish meat, pork has appeared to him to in- crease the amount of albumen excreted less than other meats, and he is, therefore, in the habit of recommending them either ham or cold roast pork, and the fat in particular. He differs from Senator in not thinking well of fish in these cases ; he believes it increases notably the amount of albumen in the urine. As cheese is a highly albuminous food it should be avoided altogether, or taken only in very small quantity. As a beverage, he prefers milk, so long as the patient can tolerate it ; all spirits and undiluted .nap. iv.) DIET IN ALBUMINURIA. 417 wines, and all kinds of beer lie forbids entirely ; he allows, in certain cases, a small quantity of wine, especially tannin wine (St. Raphael), mixed with the alkaline waters of Vals or Vichy. Animal broths, beef-tea, and meat extractives are rarely desirable in the diet of nephritic patients. Their mode of preparation leads to the extraction of all the possible toxins there may be in the meat, and these may irritate the kidneys. They may also favour the occurrence of unemia. Seminola of Naples has advocated the habitual use of the following drink for patients with Bright's disease : Sodium iodide ... ... ... ... 15 grains. phosphate 30 chloride 90 Drinking water 36 oz. He recommends that this should be drunk daily, either alone or mixed with milk, and states that he has obtained the best effects from its use. There has recently been manifested something of the nature of a revolt against the excessive advocacy of a milk diet in chronic Bright's disease. It has been said that such cases do better on a " full " diet. This we think is leaning too much to the other extreme. Inferences from observation of hospital patients alone must be received with much caution, for this class detest a milk diet. Their only idea of a sufficient diet is an abundance of animal flesh, and it is quite possible that milk diet fails to produce good results on them because of their intense and un- reasoning distaste for it ; but there can be no doubt whatever that remarkably good results have been obtained, in properly selected cases in private practice, by the adoption of a milk diet. Few physicians can have had a larger experience in these cases than Sir Geo. Johnson, and he testifies that " in some cases, under the influence of an exclusive milk diet, albuminuria, even of long duration, speedily B B 4i 8 FOOD IN DISEASE. [Panii. passes away." He mentions the case of a lady who had had post scarlatinal albuminuria for fifteen months, who completely and rapidly recovered on an exclusively milk diet. He refers also to the case of a patient, 55 years of age, with " chronic gouty albu- minuria," whom he advised to try an exclusive milk diet. " This he continued for more than five years, taking about a gallon of skimmed milk daily. On this simple diet his health greatly improved, and he frequently reported himself as feeling quite well, though a trace of albumen still remained. After five years on milk diet he gradually went back to solid food, without alcoholic stimulants, and I have heard of him quite recently as remaining in good health."* The observations on this subject put forward by Professor Andrew H. Smith, M.D., of New York, are so much to the point that we venture to quote them here t : " The only true standard (of a suitable diet) is to be found in the general condition of the patient. If on changing from a non-nitrogenous diet to a nitro- genous one we find a general improvement in the patient's condition, it is an evidence that the change was beneficial, no matter if the albumen fills a larger portion of the test tube. On the other hand, if we cut off a large proportion of animal food from the diet, and our patient grows more dyspeptic, weaker, more amemic, more dropsical, it is nothing to the point that only one-half or one-third of the former quantity of albumen is found in the urine ; the change has done harm, and the sooner we change back again the better. "We should, above all things, seek that diet for the patient which he can best digest and assimilate, for we may rest assured that the products of faulty digestion and assimilation will irritate the kidneys * " Medical Lectures and Essays," p. 764. t "Hare's System of Practical Therapeutics," vol. iiL, p. 49. 1892. Chap. iv. DIET IN ALBUMINURIA. 419 more than any amount of normal material they may be called upon to eliminate, while, at the same time, the general system will suffer from lack of support." In conclusion, we would call attention to the following interesting observations and conclusions as to the influence of different kinds of diet in chronic Bright's disease made by Dr. Nikolas S. Zasiadko, of St. Petersburg,* who has carried out a series of comparative clinical experiments on ten patients suffering from chronic nephritis, his object being to elucidate the influence of a vegetable, animal, and mixed dietary on the course of the disease. In each instance the experiment lasted thirty days, during the first ten of which the patient was kept on a vegetable diet, during the second ten on an animal one (with the addition of some bread), and during the third period on a mixed diet. It was found that (1) under the influence of vegetable food the daily amount of albumen in the urine markedly decreased ; the arterial tension sank, dropsy consider- ably increased ; the pulse became slower, weaker, and more easily compressible ; the appetite was gradually lost ; the general state grew worse, the patient becoming weaker, apathetic, etc. (2) Under the influence of animal food the daily quantity of albu- men in the urine markedly increased ; the arterial tension rose ; cedematous swellings were diminished ; the pulse became more frequent and fuller ; the body weight decreased pari passu with the disappearance of dropsy ; the daily amount of the urine, the propor- tion of its solid constituents, and specific gravity increased ; the general state improved, the patient growing stronger, more cheerful, etc. (3) A mixed diet stood midway in its effects, but came nearer to the animal one in regard to its influence on albu- minuria. (4) The proportion of albumen in the urine per se affords no criterion for determining the gravity of the renal lesion. The patient's dietary should also be always taken into consideration, as the ingestion * Vratch, No. 39, 1890, p. 880. B B 2 420 FOOD IN DISEASE. [Partii. of an abundant proteid food raises the said proportion by causing a " dietetic albuminuria," which quickly disappears on decreasing the quantity of food proteids. (5) In view of the fact that chronic Blight's disease (a) consists in a general affection of the vascular system and not of the kidney alone ; and (6) is accompanied by a profound alteration of the blood, characterised by an increased proportion of water and a decreased proportion of proteids, haemoglobin, and morphological elements, rational treatment should consist in raising the patient's general nutrition by means of a liberal diet abounding in proteids. Such diet does not give rise either to any renal irritation (hsematuria, hsemoglobinuria, exacerbation of the renal process) or to uraemia. (6) The best dietary for chronic Bright's disease is a mixed one. In inter- stitial nephritis, accompanied by general weakness, animal should predominate over vegetable food ; in parenchymatous nephritis with profuse albuminuria, vegetable food with milk should be in relative excess. (7) Boasted or cooked Italian chestnuts markedly diminish the proportion of albumen in the urine, owing to their containing tannic acid. We give these conclusions for what they are worth, and they must not be accepted unconditionally, but rather as suggestive of further observations in the same direction. 421 CHAPTER V. DIET IN GOUT AND CALCULOUS DISORDERS. IF gout is, as we have maintained elsewhere,* mainly due to disturbed retrograde metamorphosis of the nitrogenous constituents of food, it follows that it must be a disease greatly under the control and influence of diet. Closely related to those morbid disturbances in the metabolism of nitrogenous food which give rise to the well-known manifestations of gout are certain states of the blood and other fluids, which, owing to the abnormal amount or insoluble nature of the excreinentitious solids contained in them, or to some other morbid, physical, or chemical change in these fluids, tend to deposit some of their solid constituents within the body. In the more common forms of gout this tendency is shown in the deposition of insoluble urates in and around the joints. In what are termed gravel and calculous disorders we find solid deposits occurring in the urinary passages ; and in this con- nection we may also consider the analogous deposits which occur in the biliary tracts. From a dietetic point of view we shall find it convenient to consider these related conditions to- gether, as they are capable of being influenced and controlled by much the same dietetic rules. Too much stress has been laid on insufficient bodily exercise as a principal cause of the conditions adverted to, when associated with too liberal an animal dietary ; for a careful examination of the habits of life of those who suffer from these affections * "The Therapeutics of the Uric-Acid Diathesis." Britisk Medical Journal, January 7th and 14th, 1888. 422 FOOD IN DISEASE. [Panii. will lead to the discovery that very many are persons of exceedingly active habits, who are at the same time large feeders. Indeed, their habits of muscular exercise, as in hunting, racket-playing, etc., are often attended with profuse perspiration, and the exces- sive loss of fluid from the surface by cutaneous transpiration, together with a large consumption of nitrogenous and other food, and the production of an excess of nitrogenous waste, combines to produce a relative excess of solid matter in the blood and in the urinary and biliary excretions, and this directly favours the deposition of gravel and calculi. So that it is necessary to seek the remedy, in many instances, rather in a reduction or modification of the food than in an increase of bodily activity. And there are instances in which it may even be advisable to restrain, rather than promote, the latter, especially when we desire to lessen the amount of nitrogenous waste added to the blood. There are, however, it must be admitted, certain rare forms and instances of these maladies which appear to have their origin in a deeply-rooted, often (but not ahvays) inherited vice of nutrition, or per- verted metamorphosis, in which these morbid dis- turbances in the metabolism of nitrogenous food and waste are almost beyond the reach of remedy either by food or medicine. I refer especially to those, happily somewhat rare, cases of crippling gout in which the digital articulations of both upper and lower extremities become the seat of large and multiple deposits of urate of soda, often producing great chronic deformity and helplessness. Such cases have not, perhaps, been so exhaustively studied as they deserve to be, but, so far as our own observations have extended, they are more commonly found amongst the examples of what has been called " poor man's gout " i.e., cases in which the general nutrition is manifestly defective, and in which there has been no history either of generous living or of deficient exercise. Chap, v.] NATURE OF GOUT. 423 It is also necessary to bear in mind at the outset that gout is a general, constitutional, chronic malady, and that the attacks of acute arthritis, so commonly regarded as the characteristic manifestations of gout, may be entirely absent, and, even when present, may constitute by no means the most serious part of the morbid phenomena with which the gouty person is afflicted. We must also, and more especially, look to disturb- ances in the assimilative functions, to disorders of digestion, stomachic and intestinal, to functional de- rangements of the circulatory and nervous systems, to changes in the coats of the superficial arteries, and particularly to the physical and chemical characters of the urine, as presenting important indications of the existence of the gouty state i.e., of the presence of uricsenria, or other allied morbid states of the blood, calling for dietetic treatment. If we accustom oursel ves to look at gout with this wider and more general conception of its nature in our minds, we shall not fail to recognise its influential presence in connection with many vague morbid states often greatly misunderstood. You will find in young children,* in the nursery even, but more commonly at school, who happen to be the offspring of intensely gouty parents, severe headaches, troublesome neuralgias, chronic skin affec- tions, attacks of asthma, and various other disturb- ances of health connected with the inheritance of the gouty constitution, and dependent on morbid states of the blood which are capable of being modified and ameliorated by diet. In women, and not only those who have passed the climacteric, but also in young women although, no doubt, the eliminative character of the menstrual functions saves them from much of the goutiness of the male sex it will be found that many of tho * G. See has stated that out of 200 gouty patients he found 30 per cent, under 20 years of age. "Du Regime Alimentaire," p. 429. 424 FOOD IN DISEASE. [Partii. vague affections of the nervous system, which are commonly associated with those ill-comprehended pathological states denominated " Hysteria " many of these troublesome, although apparently trivial, disturbances of health are really of gouty origin. Three facts have certainly been established (mainly by the labours of Garrod) in connection with gout : 1st, that in the gouty there is an excess of uric acid in the blood ; 2nd, that during an attack of gout there is a diminution of uric acid in the urine often by one half; and 3rd, that at the end of an attack there is an. excess of uric acid in the urine. And these facts are interpreted as meaning that before and especially during an attack the blood is surcharged with uric acid, and that at the end of the paroxysm this excess is discharged in the urine, and the patient is, for a time at any rate, set free from his uricsemia. But although it is generally admitted that in gout there is an excess of uric acid in the blood, it is not certain whether this is due to an abnormally large production of uric acid in the body, or simply to an abnormal retention of it there. The deposition of uric acid in the bodies of the gouty may be simply dependent on a diminished faculty on the part of their fluids to hold the salts of uric acid in solution ; and this inability to hold the uric acid salts in solution may depend on an abnorm- ally acid state, or, what is the same thing, a diminished alKilinity of those fluids. It was held, and is still held by many, that uric acid represents a low grade of oxidation of the nitro- genous waste necessarily produced in the metabolism of albuminous foods, and that when such foods are taken in great excess they cannot be completely oxidised into urea, which is very soluble and readily eliminated ; consequently, an abnormally large pro- portion is converted into uric acid, representing a lower grade of oxidation, and the salts of this acid, being very insoluble, are less readily eliminated, and Chap, v.] DIETETIC INDICATIONS IN GOUT. 425 therefore tend to accumulate in the blood and to be deposited within the body. This view, of course, traces gout to an excess of nitrogenous ingesta. But if we refer gout to a deficient alkalinity and diminished solvent power of the fluids, however brought about, we get a wider, and perhaps a truer, grasp of the causation of the disease; for while this view recognises the causative influence of an excess of albuminates in the food, it does not exclude other causes, which we must take into con- sideration in explaining the occurrence of this disease in many persons. It has been noticed (Voit and Hoffmann) that strongly acid urines show a tendency to deposit sedi- ments, and it has been pointed out that in the metabolism of albumen the sulphur and phosphorus contained in it become converted into sulphuric and phosphoric acids, all of which may not be completely neutralised, and may be sufficiently in excess to augment the acidity of the urine ; so that an excess of albuminous food may contribute to the deposition of insoluble salts of uric acid by diminishing the alkalinity of the fluids, which, indeed, it is known to do. In the same way, those dyspeptic conditions, which are so common in some gouty persons who are not large feeders, may tend to an increased formation of the organic acids, and so to a re- duction in the alkalinity of the blood, and thus bring about uriccumia i.e., a retention of uric acid in the blood. Thus we already see that one of the most im- portant dietetic indications in the treatment of the gouty is to maintain the normal alkalinity of the fluids, and to maintain or augment their solvent power. And precisely the same indications with regard to food apply to the tendency to the forma- tion of uric acid gravel and calculi. As we have already pointed out, it is a well- established fact that a highly nitrogenised animal dietary increases the acidity of the fluids of the body, 426 FOOD IN DISEASE. [Pan n. and especially of the urine ; and it is equally well known that a vegetable dietary increases their alkalinity. One of our chief objects, therefore, in construct- ing a dietary for the gouty is to diminish, within suitable limits, the amount of animal food they con- sume, and to replace it with an equivalent quantity of appropriate vegetable substances. The extent to which this can be carried with safety will depend upon the habits of life, the occu- pation, and the digestive peculiarities as they are met with in individual cases. For the indolent and sedentary, animal food should be reduced to a minimum ; to the energetic and active, a more liberal proportion may be allowed. But in all cases we must, above all things, avoid exciting dyspeptic states by an unwise urgency of dietetic rules ill-adapted to the digestive peculiarities which many of these patients present. Great moderation in the consumption of animal food is, then, one of the first rules for most, though not all,* gouty persons. It is also the experience of the majority of authori- ties that in the food of the gouty, fats as well as albuminates should be reduced to the minimum ; fatty, saccharine, and gelatinous foods, by interfering with the complete metabolism of the albuminates, tend to the production of uricsemia. Bauer points out that we ought not only to restrict the amount of fat in the food, but that as corpulent persons perspire freely, and therefore, as a rule, secrete a concentrated urine liable to yield deposits, we should also adopt other means to prevent the accumulation of fat. G. S6e also insists especially on the prejudicial effects upon the gouty of a diet rich in nitrogenous food when combined with sugar, gelatin, and fats. * It seems impossible to avoid admitting, for the evidence is very strong in its favour, that certain gouty persons do better on an almost exclusively animal diet than on any other. "SVe shall return to this point later. (See note appended to chapter vi) Chap, v.) DIETETIC PRINCIPLES IN GOUT. 427 Eb.stein, however, advocates the consumption of a moderate amount of fat, so as to diminish the quantity of carbo-hydrates needed, as he regards these as the most fattening of all foods. He also considers fat useful as quickly satisfying the appetite and diminish- ing the desire for food. We see no reason for withholding a moderate amount of fatty foods from gouty persons who show signs of defective nutrition, provided they digest them without difficulty ; but, on the other hand, we should restrict them as much as possible in the diet of the corpulent and well nourished. It is a grave error to impose on the gouty a too rigorous abstinence. Their diet must contain all that is needed for the due nutrition of the body and for maintaining its functional activity. It must, therefore, be proportioned, in some measure, to the work and activities of individual organisms. But it is a wise precaution at all times to draw the supplies of food, so far as is practicable, and well within the digestive capacities of the patient, from the more readily-digested and more nutritious vegetables. Green vegetables and fresh fruits are especially suitable, as they are known to render the urine more alkaline, while they do not favour the deposit of fat in the body ; but an exclusively vegetable diet is by no means to be commended, save in quite exceptional instances. The feeble digestion of many gouty persons is unequal to appropriating that comparatively large mass of vegetable food which is necessary to supply the wants of the system, and a certain proportion of more concentrated and easily -digested animal food is, therefore, necessary for them. White are generally considered more appropriate than broivn meats ; and, bulk for bulk, this may be true. But there is no proof that small quantities of well-cooked and tender mutton or beef are more pre- judicial to the gouty than larger quantities of chicken 428 FOOD IN DISEASE. [Partii. and rabbit; indeed, the latter, although a white meat, has often appeared to us more difficult of digestion than beef and mutton. There is a general consent that smoked and dried or pickled pork, game, tish, and other meats, should be proscribed, as they all present very condensed forms of nitrogenous food, and excite thirst, which is not always quenched with pure water ! Rich and fat sauces should be altogether avoided, and all entrees and made dishes which are served with sauce. Strong meat-soups and extracts are also particularly undesirable ; and when soups are taken, they should be vegetable soups, only slightly flavoured with animal extract. One teaspoonful of Valentin's Meat- juice added to half-a-pint of a purely vegetable soup imparts quite as much of this flavour as need be desired. Cheese, as one of the most concentrated forms of nitrogenous food, and as often difficult of digestion, should be avoided, except in very small quantity. As the yolk of egg contains a large amount of fat and lecithin, eggs should enter as little as possible into the dietary of the gouty. Fish, oysters, and the Crustacea must be partaken of sparingly, and the rich and firmer fish, such as salmon, mullet, mackerel, and perhaps lobster and crab, had better be altogether avoided. An almost unlimited choice of fresh vegetable food may be permitted potatoes and the ordinary green vegetables and salads. Sorrel, tomatoes, and asparagus have, however, been especially prohibited, on the ground that they contain oxalates, and oxalic acid is a congener of uric acid. But we have been recently assured that it is an error to proscribe toma- toes, as they contain but a very small amount of oxalic acid ; whereas spinach, which has been so universally approved of, is, next to sorrel, the richest in this acid.* To asparagus, if eaten without melted butter, we see no practical objection. Indeed, we are inclined * Dujardin-Beaumetz, "L'Hygiene Alimentaire," p. 169. Chap. V.] FOOD FOR THE GOUTY. 429 to regard the objection to those vegetables as rather theoretical than practical. But we must remember that gouty persons are very prone to idiosyncracies, and we must therefore be cautious how we extend each individual peculiarity into a general rule. Those dry vegetables which are both rich in albuminates as well as in carbo-hydrates, such as haricot and other beans, peas, lentils, should be par- taken of only in small quantity. Mushrooms and truffles are prohibited. Bread, which is also a highly nitrogenous food, should be taken only in moderation, and is, perhaps, least harmful when well toasted. Bouchardat has proposed to substitute potatoes for it. Most fresh, ripe fruits are wholesome, and most cooked fruits, as stewed or roasted apples, etc. ; but the highly-saccharine fruits, whether fresh or dry, are not so suitable, and should be taken in very moderate quantities ; and we must here again bear in mind that there are a few gouty subjects who are unable to eat certain fruits with impunity. It is best to train the gouty patient to observe carefully for himself the influence of particular articles of diet on his health ; for although in the majority of cases certain fruits and vegetables are of undoubted value, in the case of a small number of the gouty they produce digestive disturbances, and must therefore be avoided. Next, as to the best beverages for the gouty ; and first, as to milk. Some differences of opinion exist with regard to milk ; and no doubt there are great individual peculiarities in respect of its digestibility. Some cannot digest it at all, some dislike it exces- sively, and others can digest it in any quantity and are fond of it. For the latter, we consider that it serves as an admirable form of food, especially if skimmed or diluted, presenting, as it does, all the principles necessary for the nutrition of the body in a form readily assimilated by those with whom it agrees, and containing a large quantity of water. It is an 43 FOOD IN DISEASE. [Part n. advantage to render it slightly alkaline, by adding to it some alkaline water, such as Vals, Vichy, or Apollinaris water, when it often acts freely as a diuretic. Indeed, we are in the habit of advising our gouty patients, and those who have shown any tendency to the deposition of uric-acid gravel, to drink, about ten minutes before their first meal, a breakfastcupful of hot milk and water, to which a small level saltspoonful of bicarbonate of potash and the same quantity of table salt should be added. In this form, well diluted and rendered distinctly alka- line, we can see no objection to its use ; but, as we shall find presently, Sir H. Thompson is much opposed to the free use of milk by those with a tendency to uric acid or oxalate of lime deposits. Ebstein has maintained, and Germain Se"e also, that of those who deposit uric acid gravel there are some whose urines do not contain any excess of uric acid ; but that this acid is deposited simply because these urines are not in a condition to hold it in solu- tion : either they do not contain enough water, or they may contain an excess of acid phosphates, which combine with the soda needed to hold the uric acid in solution ; it thus becomes free, insoluble, and deposited in the crystalline form. In such instances the value of an abundance of slightly alkaline watery beverages is very obvious. A large draught of hot water half an hour before a meal and at bedtime, and the use of the alkaline table waters to mix with wine, or what- ever other stimulant is taken, should be recommended. The habit of drinking, in some form or other, a con- siderable quantity of water is an important point in the dietary of the gouty ; and whatever wine or spirit they take should be largely diluted, either with pure water or with an alkaline effervescing table-water. The value of drinking considerable quantities of hot water has been largely insisted on by many physicians, and we have had occasion to form a favourable opinion of the practice if kept within certain limits. chap, v.j BEVERAGES FOR THE GOUTY. 431 Strong beers, porter and stout should be avoided by all gouty persons. We have known a few instances in which stout has been well borne, but a large quan- tity of alkaline salts was at the same time taken habitually. Cider, which contains malic acid in combination with potash, has been said by Meissner and Koch to favour the formation of uric acid, and on that account- has been prohibited to the gouty. Germain See, how- ever, considers cider, especially when sparkling, an excellent diuretic, which favours the expulsion of uric acid gravel ; and his opinion is, as we shall see, shared by Sir H. Thompson, who considers it a useful bever- age in calculous disorders. Of wines, all strong, sweet, or spirituous wines should be carefully avoided, such as sweet or strong champagnes, ports, sherries, Madeira, Burgundy, and the stronger clarets. All wines which contain much sugar, alcohol, tannin, or free acid are unsuited to the gouty. Still Moselle, light hock, some of the best Hungarian wines, light, well-kept, fine-quality Bor- deaux all these are permissible in small quantity, diluted with an alkaline table-water, so as to neutralise any free acid they may contain. The more distinctly diuretic the effect of the wine, the better, as a rule, will it agree with the gouty. For gouty persons with cardiac asthenia, a condition now met with (since the visitation of influenza) much more frequently than used to be the case, we have found 2 or 3 glasses daily of dry port that has matured in the wood well tolerated. With regard to alcoholic beverages in general, it may be said, unhesitatingly, that the gouty persons who can do without them entirely are wise to do so. If they cannot exist comfortably without some small or moderate amount of an alcoholic beverage, then they must exercise great care in its selection. There is all the difference in the world between the effects of a fine, mature, high-quality wine or spirit and the commoner kinds of the very same beverages. They 432 FOOD IN DISEASE. [Panii. should always be well diluted. Of spirits, the best are fine old Scotch whisky, dry Plymouth gin, and the finer kinds of French cognac, when they can be obtained. Tea and coffee, when not strong, are both exceed- ingly useful bevei'ages to the gouty, unless they are found to trouble the digestion, which they will do with some persons. In that case it is necessary to take them without sugar. It is the quantity of sugar so commonly taken with these beverages that helps to make them injurious. The best China tea, and not Indian tea, should be employed for infusion, as the latter contains far too much tannin. Germain Se*e observes : " Warm aromatic drinks like tea produce a kind of washing-out (lavage) of the uriniferous tubes, which are the receptacles of the uric acid ; in my long practice I have been furnished with many proofs of the utility of these beverages to the gouty." Dujardin-Beaumetz states, on the authority of Esbach, that black tea, infused for five minutes, will yield as much as 2 grammes per 1,000 of oxalic acid, and he, on that account, proscribes its use in gouty disorders. We hesitate to accept this statement without further investigation, and we should certainly not forbid gouty patients generally to drink tea. Persons with deposits of oxalates might do well to avoid it, as they are usually dyspeptics. On the authority just quoted, cocoa is also said to be very rich in oxalic acid, containing from 3'5 to 4'5 grammes in 1,000. If this should prove to be correct it would have to be forbidden in cases of oxalate of lime deposits. Phosphatic urinary deposits are usually secondary to some other morbid state, to the removal of which the dietetic or other treatment must be directed. The formation of biliary calculi is also often found to occur in the gouty, and may doubtless depend Chap, v.] DIET IN CALCULOUS DISORDERS. 433 on the same causes as uratic deposits, viz. on too great concentration and defective alkalinity of the fluids. The deposition of biliary concretions may depend either on an excess of cholesterin (the chief constituent of gall-stones) in the bile, or on a de- ficiency in solvent power of the fluid of the bile allowing the cholesterin to be deposited, although it may not be in excess. The formation of an excess of cholesterin appears to be sometimes dependent on an excessive consump- tion of fats, or upon exaggerated activity of the nervous functions, cholesterin being looked upon by some as derived from the products of nervous waste. Its deposition, when the bile is defective in alka- linity, has been demonstrated by Thenard, and this condition of the bile has been traced to a too exclu- sive animal dietary. Sedentary habits, of course, promote such deposits by favouring the stagnation of bile in the gall-bladder. Whatever may be the cause, when biliary concre- tions are known to exist, a most carefully regulated dietary should be insisted upon. Fatty substances should be entirely, or almost entirely, excluded from the food, as well as sugar. The quantity of food taken should be strictly within the limits of what is necessary for the due maintenance of the nutrition of the body, and all excess must be strictly forbidden. Farinaceous substances may be taken in modera- tion. Peas are regarded by some as unsuitable, as they are said to contain a fatty body analogous to cholesterin. So far from carrots being appropriate in these cases, as used to be thought, they are to be avoided, as they contain sugar and " vegetable cholesterin." Animal food should be taken in strict modei'ation, the fat being always avoided. Eggs also sparingly, not more than one daily. Green vegetables and fruits (not the sweeter kinds) are very useful, and so ai - e potatoes \ bi-ead should be taken in moderation. c c 434 FOOD IN DISEASE Partii. For beverage a little wine may be permitted, with some alkaline water, such as Apollinaris, Vals, or Vichy. A breakfastcupful of hot water, slowly drunk or sipped> half an hour before meals, is also most useful. Sir Henry Thompson, whose large experience in the treatment of calculous disorders gives to his testi- mony exceptional value, has stated it to be his belief that " in nineteen cases out of twenty an undue deposit of uric acid will disappear under a proper dietary," and its formation in calculous masses be prevented ; and the same observation he applies to deposits of oxalate of lime. He does not, however, consider that much is gained in such cases by any great diminution of nitrogenous food ; but he insists very strongly on the necessity of eliminating as com- pletely as possible fatty and saccharine substances from the dietary. A certain limited quantity of fatty matters he allows, but forbids saccharine sub- stances entirely. It is also best, he considers, that all alcoholic drinks should be avoided, or, in certain cases, taken only in very small quantities. If a little wine is thought necessary, he prefers, as we do, in such cases that still Moselle or a light Rhine wine should be drunk, to which we always recommend the addition of a little alkaline table-water, to neutralise the free acid all these wiues contain. He approves also of a little very light beer or sound cider, neither sweet nor acid, and he rightly urges the importance of brewing in England some light infusion of malt and hops like the light lager beers of Germany. Champagne, if sweet, he regards as especially harmful ; but we have found a small quantity of dry and sound champagne, mixed with Apollinaris water, as well borne as any other wine in these cases. Bordeaux wines, unless unmistakably pure and sound, as well as of light quality, are to be forbidden, as are all sweet wines, ports, sherries, etc., and all strong beers. Chap, v.] SJJR H. THOMPSON'S DIETARY. 435 The important point is, that all the beverages should be free from saccharine matters. As to the kind of food prescribed : it is, in the first place, necessary to ascertain the patient's habits of life, whether they are active or sedentary. Those who lead active lives must be allowed more hydro- carbons and more meat than the sedentary. In advanced age it is of great importance so to limit the dietary as to avoid overtaxing the eliminative organs. The calculous patient is, in the greater number of cases, too stout, and he should be allowed only a very spare amount of fats. A reduction of weight is a good sign, and it is an undoubted advantage if, by dieting, a loss of four or five pounds in weight in the first month can be effected. When not corpulent, a less rigid abstinence from fats may be permissible. The following fat-containing foods must be es- chewed, or taken only in very small quantities : Milk, cream, butter, cheese, eggs (especially ome- lettes), pastry, fat pork, suet in puddings and pastes, and the fat of roast and boiled meats. Rice or sago puddings, being mixtures of milk, egg, and sugar, Sir Henry Thompson speaks of as "in the last degree objectionable for uric-acid-making, gouty patients,'' although he admits that they are excellent for children and healthy people. Farinaceous puddings may be permitted, if not made sweet, but with light broth instead of milk, a moderate amount of white of egg. and some condiment (a pinch of curry) instead of sugar. All articles of food containing cane-sugar should be expunged from the dietary ; by so doing we lighten the work of the liver, and lessen the manifold vicarious duties performed by the kidneys. He commends the Carlsbad dietary, in which sugar and butter are absolutely forbidden, a method of reducing uric acid deposits more effectual than that of eliminating meat from the dietary. c c 2 436 FOOD IN DISEASE. [Partii. Nitrogenous food in moderation is permitted, but the hydrocarbons are greatly diminished. The following is the dietary which Sir H. Thompson ecomuiends in calculous affections : Fish in all its forms, except those containing much fatty matter i.e. herrings, mackerel, eels, and the thin part of salmon. Game in all forms. Poultry. Lean meat in moderate quantity. Preparations of gelatin. Savoury jelly, or jelly agreeably fla- voured, but unsweetened. Butter in moderation (this is the only direct form of fat ad- mitted fat in some form being necessary). An egg or two, on account of their usefulness in all cooking operations. (The objection to eggs applies only to the yolk, or fatty part.) Milk in strict moderation, and only with tea, coffee, or cocoa. It is very undesirable and noxious in large quantity, as it contains a large proportion of fat and sugar, and its casein is digested with difficulty. It is less objectionable when thoroughly skimmed. Well-made whole meal bread. Oatmeal. Pearl barley. Macaroni, and other Italian pastes. Some coarse meal is needed to act as an aperient and prevent constipation. Whole meal bread is improved in flavour and texture by an admixture of fine (not coarse) Scotch oatmeal, in the proportion of about one-quarter to one-third of the wheat- meal employed. Dry haricots and lentils are most nutritious vegetables, and should be taken made into purees. They are digested with ease, and contain much nutritious matter. Rice, sago, tapioca, and arrowroot, are all useful if treated as savoury dishes, not as sweets. Fresh green vegetables are especially good. Fresh green peas and broad beans, well masticated. Light salads are permissible to persons who digest them easily, but they must not be taken by those who digest them with difficulty. Celery, sea-kale, asparagus, tomatoes, potatoes, and artichokes, are all permitted ; so also are apples, roasted or baked, without added sugar. The following are to be avoided : Rhubarb, gooseberries, currants, strawberries, raspberries, grapes, plums, pears, nnd all sweet fruit, fresh or preserved. Saccharin may bo substituted for sugar. Chap.V.] CANTANfs DlETARY. 437 The following diet, adopted with advantage by a medical man who suffered from gout and gravel, was published in the Practitioner : 7.30 a.m. Ten oz. of very hot water. 8 a.m. Breakfast. Equal parts of weak tea and milk, a small quantity of white sugar, a slice of fat bacon without a strip of lean, bread, and fresh butter. I p.m. Milk pudding, rice, sago, tapioca, macaroni, a blanc- mange, and small biscuits, with butter. Ten oz. of hot water. 4 to 5 p.m. Ten oz. of hot water. 6 p.m. Dinner. White fish or fowl (usually boiled), greens, bread (no potatoes). Claret, 7 oz. 8 to 9 p.m. Ten oz. of hot water. II p.m. Ten oz. of hot water. In this diet there is a very strict limitation of nitrogenous food, while the elimination of the pro- ducts of nitrogenous waste is facilitated by the inges- tion of considerable quantities of hot water. If this gentleman " indulges either in meat or game, or drinks copiously of claret, or omits one or two glasses of hot water, he feels gouty and gravelly the next day." Cantani's views as to the dietetic treatment of gout are somewhat different from those of his con- temporaries, but they certainly contain an element of truth. He considers it best, instead of severely restricting the consumption of animal albuminates, which are so necessary to the nutrition of the body and so com- paratively easy of digestion, rather to aim at securing their complete combustion within the system by withdrawing from the dietary whatever substances are known to interfere with their oxidation or check their metabolism. He recommends a moderate amount of nitrogenous food fish, eggs, broth ; and the free use of green vegetables. He forbids all starchy and saccharine foods bread, rice, potatoes, sweets, and sweet fruits ; he 438 FOOD IN DISEASE. [Panii. pi'ohibits all alcoholic drinks, all pungent condiments, and coffee ; all acids and acid foods, milk, and es- pecially cheese, as he considers the injurious effects of lactic acid and the fatty acids in cheese can be directly established. He advises the consumption of large quantities of fluid, and especially of pure aerated waters. 439 CHAPTER VI. THE DIETETIC TREATMENT OP OBESITY. VARIOUS dietetic methods have been advocated for the cure of obesity, but they have, most of them, had the same end in view, viz. the reduction of the total amount of food taken. In a very large propor- tion of the cases of excessive corpulence a reduction in the quantity of food taken is the essential con- dition of its cure ; and that reduction must be sufficient to remove all excess of fat-forming food (and there is scarcely any form of food, as we have seen in previous chapters, from which fat cannot be formed) from the dietary. Let us take a hypothetical case. A person with a tendency to obesity, who appears to be a very moderate feeder, happens to take, in excess of his wants, half an ounce of sugar daily, which we will assume is converted into and is stored up in his body as fat. This is adequate to a yearly increase in weight of over eleven pounds, or in five years to four stones ! Let us, then, bear this fact in mind in dealing with cases of obesity, that a patient weighing twelve stones may add four stones to his weight in five years, simply by the daily deposition within his body of half an ounce of fat derived from this small daily excess of fat-producing food. The most common cause of obesity is an excess of food, although in some cases it may be difficult at first to discover in what particular there is excess ; for we must also recognise a peculiar constitutional, and often inherited,* aptitude for fattening observed * "Statistics permit the assumption that among the corpulent patients coming under observation at least fifty per cent, have an hereditary tendency to disturbances of nutrition." Oertel, "Nineteenth Century Practice," 1895. 440 FOOD IN DISEASE. [Partii. also in many animals which leads to the development of obesity from an almost inappreciable excess of food or drink. There is, also, another impoi'tant preliminary consideration to be kept in view, and that is, that different obese persons may, and probably do, possess different faculties for the conversion of different kinds of food into fat, so that one person may derive his excess of fat from one class of food, and another from another class ; and, therefore, that the remedial measures appropriate and successful in some cases may not be those best calculated to lead to a successful result in others. Each case of obesity, therefore, must be made the subject of individual study and analysis, although certain general principles are doubtless applicable to the great majority. The frequent occurrence of obesity about and after middle age points also to another very important consideration, viz. that the need of food naturally di- minishes with advancing years, just as the capacities for digesting and assimilating and duly utilising food diminish also. Ignorance or insufficient recognition of this fact is the chief reason why it is so difficult to deal successfully with many of these cases. It is difficult to make a man of forty understand that he cannot properly utilise and adequately dispose of as much food as he used to when thirty, or a man of fifty as much as when he was forty ; so that a diet which would not be, in any way, excessive at the former age, becomes distinctly excessive and pro- vocative of undesirable corpulence at the latter. Even some physicians have overlooked this important point in estimating the average diet needed by corpu- lent persons at and beyond middle age. It is an error to apply the ordinary average ration, especially to persons of sedentary habits and occupations, at, approaching, or beyond middle age. With advancing age there should be a diminution in the average amount of food taken. It cannot be too clearly understood that it is to Chap. vi.j CAUSES OF OBESITY. 441 the neglect of this consideration that so many in- stances of undue corpulency are attributable in advancing life. The capacity for muscular exertion is also lessened, and there is no longer either the disposition or the ability to engage in those active physical exercises which in earlier years dispose of much of the surplus food supply, as has been already explained. There is, however, a certain small or moderate proportion of cases of obesity that appear to arise independently of any excess of food, and to be deter- mined by some morbid state of system leading to defective oxidation and imperfect combustion of certain elements of the food within the body. To this class must be referred some of the "fat ansemics " alluded to by Dr. Weir Mitchell ; the cases of obesity associated occasionally with the hysterical state, and other nervous disorders ; as well as the gravest cases of all, viz. those cases in which fatty degeneration of the nitrogenous tissues accompanies the excessive deposition of fat. These cases must, of course, be carefully differen- tiated from the ordinary common form of obesity, and their treatment must be determined by other considera- tions. The chief of these are to endeavour to raise the tone of the organs of circulation to improve the quality of the blood by enriching it with oxygen carrying blood corpuscles, and so to promote healthy oxidation and metabolism. In carrying out these objects we shall be assisted by the administration of suitable tonics, by an out-of-door life, by exercise, active or passive, according to the strength and capacity of the patient, by a dietary largely composed of nitrogenous and readily digestible foods, and by regular aperients and by the judicious use of baths and frictions. Dr. Weir Mitchell suggests that climate may have much to do with the tendency to obesity, and he says the first thing an American in England is struck with is "the number of inordinately fat 442 FOOD IN DISEASE. [Partii. middle-aged people, and especially of fat women."* But it is very doubtful if England has a greater proportion of very fat people than other European countries, and an American visitor to Carlsbad or Marienbad would probably discover that the fattest people undergoing a cure at these places would be of other than English nationality. Allusion has already been made to the association, in some rare cases, of ansemia with obesity. This is somewhat difficult of explanation ; but we believe it will be found, as we have already suggested, that even in these cases some fault of diet often lies at the root of the condition.! Weir Mitchell points out that the hysterical constitution, when associated with in- disposition to exertion and prolonged rest, together with the morphia habit, " makes up a group of con- ditions highly favourable to increase of fat." Many systems have been devised for the cure of obesity, and more or less success has been claimed for all of them. We shall pass briefly in review the chief of these, and point out what we consider to be their respective merits and defects. One of the first to call attention to the importance, in these cases, of diminishing the amount of water taken, or of foods containing water, was Cancel, a French military doctor, who had been struck by the remarkable influence that water and watery foods had in causing great abdominal development in horses. His method of reducing obesity was to pre- scribe as dry a diet as possible. The food taken should contain very little water, and very little drink should be taken at any time. Soups and fluid foods were forbidden. Not more than from six to twelve ounces of fluid was allowed at each meal. Abstinence * "Fat and Blood." Fifth edition, p. 21. t Oertel says, ' ' One of the chief causes which produce these conditions lies in the hypoplastic anaemia, in the slight haemoglo- bin contents of the blood, in the decreased absorption of oxygen, and in the lessening of the oxidation processes in the body." "Nineteenth Century Practice," vol. i. p. 638. Chap, vi.] THE BANTING METHOD. 443 from fatty and farinaceous foods was also enforced, frequent purges were enjoined, and much exercise on foot. This system, rigorously carried out, was in many instances attended with remarkably good results. The Banting method, so widely adopted in England at one time, agreed to some extent with the preceding, in the strict limitation of the amount of fluid taken, and the exclusion of farinaceous foods, as well as sugar and fats. But in the Banting diet the quantity of food of every kind was strictly limited. Breakfast at 9 a.m. consisted of 5 to 6 oz. of animal food meat or boiled fish (except pork or veal) ; a little biscuit, or 1 oz. of dry toast ; 6 to 7 oz. of solids in all. A larg-e cup of tea or coffee (without milk or sugar) = 9 oz. of liquid. Dinner at 2 p.m. Fish or meat (avoiding salmon, eels, herrings, pork, and veal), 5 to 6 oz., any kind of poultry or game. Any vegetables, except potato, parsnips, beetroot, turnips, or carrot. Dry toast, 1 oz. Cooked fruit, unsweetened. Good claret, sherry, or Madeira, 10 oz. Total of solids, 10 to 12 oz. Tea, 6 p.m. Cooked fruit, 2 to 3 oz., a rusk or two ; 2 to 4 oz. of solids. 9 oz. of tea, without milk or sugar. Supper, 9 p.m. Meat or fish, as at dinner, 3 to 4 oz. Claret, or sherry and water, 7 oz. This diet allowed only from 21 to 27 oz. of solids per diem, of which 13 to 16 oz. consisted of animal food, and only 2 oz. of bread ; the rest consisted of fruit and fresh vegetables. There was the strictest possible exclusion of starches and sugar. The total fluid was limited to 35 oz. i.e. about a pint and three-quarters. With this diet Mr. Banting reduced himself in a year from 1 4 st. 6 Ib. to 1 1 st. 2 Ib. The Ebstein method, which has been largely applied in Germany, differs from the preceding in recognising the possible transformation of albuminates into fat ; and Ebstein considers that this transformation is chiefly dependent on the simultaneous free use of carbo- hydrates, but that the consumption of fat has little or no influence in this direction. He recommends 444 FOOD IN DISEASE. [Pan n. the use of fat because it produces a feeling of satiety or satisfaction, and so leads to the consump- tion of less food ; and also, by diminishing thirst, lessens the desire for fluids. Dujardin-Beaumetz points out that Hippocrates anticipated Ebstein in this matter, and he quotes his advice to the obese that they should eat fat on account of its satisfying effects and its influence in lessening the consumption of food. Ebstein maintains that it is precisely owing to the presence of fat in food that the accumulation of fat in the body is prevented, and he consequently advises all kinds of fatty food the fat of meat, butter, cream, and fatty sauces and soups ; but he rigorously forbids the carbohydrates, such as sugar, potatoes, and all forms of starchy food, and he only allows 31 oz. of bread per diem. He permits aspa- ragus, spinach, cabbage, peas and beans, and all kinds of meat in small quantity. The following is an example of tlie Ebstein regime : Breakfast (6 am. in summer, 7.30 a.m. in winter). White bread, well toasted, rather less than 2 oz., and well covered with butter. Tea, without milk or sugar, 8 or 9 oz. Dinner, 2 p.m. Soup made with beef-marrow. Fat meat, with fat sauce, 4 to 5 oz. A moderate quantity of the veget- ables mentioned above. Two or three glasses of light white wine. After the meal, a large cup of tea, without milk or sugar. Supper, at 7.30 p.m. An egg, a little roast meat, with fat. About an ounce of bread, well covered with butter. A large cup of tea, without milk or sugar. It will be observed that this is a very spare dietary, although it contains a considerable propor- tion of fat. The large cup of tea three times a day is, no doubt, intended to enable the small amount of food to be borne without a feeling of exhaustion. Oertel, however, contends, and we think justly, that Ebstein's view, " that fat in the food does not give rise to fat formation, is one directly opposed to all physiological investigations," and that the transition Chap. VI.] THE OERTEL METHOD. 445 of food fat into body fat has been settled beyond a doubt.* One of the most popular systems for reducing obesity is that advocated by Oertel, and adopted, with some modification, by Schweninger. It will be desirable, therefore, to describe it in detail. Oertel claims for his system that it not only provides for the removal of fat, but also prevents its re-accumulation ; it also maintains the amount of albumin, and, at the same time, restores tone to the organs of circulation, which so often, in cases of excessive obesity, is lost. He distinguishes two de- grees of obesity one, the slighter form, in which the organs of circulation are unaffected, and vigorous bodily exercise is possible ; and another the graver form in which the muscle of the heart is invaded and weakened, and other functional derangements connected therewith are developed. Adopting Voit's statement that the human body decreases in fat if the daily food consists of the three great groups of food in the following proportions : Albuminous food, about 4^ oz. ; fatty food, about 1^ oz. ; and carbohydrates, about 5J oz. the follow- ing comparative table shows the relations of the Banting, Ebstein, and Oertel methods to the above theoretical estimate and to one another : Banting . . Ebstein . . Oertel . Albuniinates. Fats. Carbohydrates 6 oz. 3-i oz. 5J to 6 oz. Jew. 3 oz. 1 to \\ oz. 2? oz. If oz. 2 to 3J oz. They all agree in reducing largely the carbo- hydrates, so that there is a general consent that these foods greatly contribute to the excessive de- posit of fat. Oertel's formula differs from the Banting formula * Oertel on Obesity. "Nineteenth Century Practice," voL ii. p. 642. 446 FOOD IN DISEASE, [Partii. simply in allowing considerably more fat and slightly more starchy food. It differs greatly from Ebstein's in allowing nearly twice as much albuminous food, less than half as much fat, and about twice as much carbohydrates. This amount of fat and carbohydrates is admissible in those cases where active exercise can be and is taken, as muscular exertion is attended with a considerable destruction of fat, and the relative excess of albuminous food in this formula leads to the displacement of the fat accumulated in the substance of the muscles, and to a new formation of muscular tissue in its place. At the same time this diet protects the nitrogenous tissues from waste a neces- sary condition of health which is lost sight of in Ebstein's method. Indeed, the central idea in this "cure" is to strengthen tJie muscle of the heart, and this is aimed at, not only by a carefully-considered dietary, but by the prescription of regular, active bodily exercise and suitable gymnastics. This method is somewhat modified in the manage- ment of those graver cases where the accumulation of fat about the heart has led to great embarrassment of that organ, and to consequent visceral congestion and even to dropsy. In such cases the fat and carbo- hydrates of the food are still further reduced, and the amount of fluid consumed is severely restricted, and perspiration is promoted by, if possible, long-continued bodily exercise, especially in climbing graduated as- cents ; if this is not possible, the fluids are reduced by inducing perspiration by means of vapour and other baths. The beneficial effect of this treatment is soon felt ; the dropsy and congestions decrease, the pulsations of the heart become stronger and more regular, and the patient feels himself getting stronger day by day at least, such is the author's account of the results of this method. The following, then, are the objects aimed at in this "cure " : 1. To improve the muscular tone of the heart ; chap, vi.] THE OERTEL METHOD. 447 2. To maintain the normal composition of the blood; 3. To regulate and restrict the quantity of fluid in the body ; and 4. To prevent the deposit of fat. And these objects are attained by the following means : 1. The muscle of the heart is strengthened by enforced exercise by walking or, better, by climbing freights. The patient should walk slowly uphill until palpitation comes on, when he must stop until he can again breathe easily, but he must not sit down. He must walk several hours a day, and climb as much as possible. He should go upstairs now and then by way of exercise. Of course the capacity for taking exercise will be found to differ in different cases. Too much must not be required, but also not too little. Oertel has "established sanatoria in various hilly and mountainous regions of Germany, Austria, and Switzerland, where methodical and strictly supervised exercises in the shape of walks or mountain-climbing can be performed so as to permit the necessary mechanical labour and ensure the combustion of fat which is its object." 2. To preserve the normal composition of the blood, the food should be chiefly albuminous. It may consist of the lean of roast or boiled beef, veal, mutton, game, and eggs. Green vegetables, such as cabbage and spinach, may be taken ; fat and carbo- hydrates only in very limited quantities; from 4 to 6 oz. of bread per diem. 3. To regulate the quantity of fluid in the body, the amount of fluid drunk daily must be limited. One cup (rather less than 6 oz.) of coffee, tea, or milk, morning and evening, and about 12 oz. of wine, with from 8 to 16 oz. of water, should comprise all the fluid consumed in twenty-four hours. In the hot season the amount of fluid may be slightly increased, if the case is not one of the graver kind. Beer is entirely forbidden. 448 FOOD IN DISEASE. [Partii. The discharge of fluid from the body is promoted by such exercise as has been described ; and if this is not possible, a course of baths with packing should be taken several times in the year. Each course should last four or five weeks, and the baths should be taken about twice a week. 4. To prevent the deposit of fat, the principles of diet already set forth must be carried into practice as follows : Morning. One cup of coffee or tea, with a little milk altogether about 6 oz. Bread, about 3 oz. 3'oo. 3 to 4 oz. of soup, 7 to 8 oz. of roast or boiled beef, veal, game, or not too fat poultry, salad or a light veget- able, a little fish (cooked without fat), if desired, I oz. of bread or farinaceous pudding (never moro than 3 oz.), 3 to 6 oz. of fruit, fresh preferred, for dessert. It is desirable at this meal to avoid taking fluids, but in hot weather, or in the absence of fruit, 6 to 8 oz. of light wine may be taken. Afternoon. The same amount of coffee or tea as in the morning, with at most C oz. of water; an ounce of bread as an exceptional indulgence ! Even ing. One or two soft-boiled fggs, an ounce of bread, perhaps a small slice of cheese. !>alad and fruit ; 6 to 8 oz. of wine with 4 or 5 oz. of water. A larger quantity of liquid than that prescribed should never be taken at one meal. It is best to drink the quantity allowed in small portions at different times in the day. In simple corpulency, without any disturbances of the circulatory organs, the quantity of fluid may be gradually increased ; one or two glasses of wine may be permitted at the midday meal, and half a bottle of wine and half a pint of water in the evening. Such is the so-called " Schweninger " or " Oertel cure." What, however, especially characterises Schwen- inger's modification of this method is the entire sup- pression of any beveraye at meals. Whatever fluid is taken must be drunk two hours after food. Schleicher, of Antwerp, has, however, published a l yi>ical diet of Schweninger, which was adopted with Chap, vi.] BEVERAGES IN OBESITY. 449 great success, in which the exclusion of fluid at meals was not insisted on absolutely : Breakfast, 7 a.m. A mutton or veal cutlet, or a portion of sole as big as the palm of the hand the same quantity of bread, without butter. 8 a.m. A c'up of tea, with sugar. 10.30 a.m. A sandwich of bread and meat, or sausage. Noon. Meat, eggs, green vegetables, cheese, an orange. Two glasses of white wine. (No soup, no potatoes.) 4 p.m. Tea, with sugar. 7 p.m. A small quantity of bread and cheese. 9 p.m. Cold meat, eggs, salad. Two glasses of wine, and sometimes more. Germain Se*e protests against the limitation of beverages in some of the foregoing systems. He maintains, on the contrary, that an abundance of water is most useful. "I have been able,'' he says, " to treat and to cure a great number of cases by a regime of albuminates and fats, together with a great quantity of drink, especially of warm aromatic drinks."* Hot tea is the beverage he especially favours. Water, he urges, aids digestion by its solvent power, stimulates organic changes in the tissues, and promotes the elimination of waste ma- terial. The strict limitation of water, he points out, must be very injurious in those gouty constitutions with a tendency to uric acid deposits, which so often show a disposition to corpulency. " The most useful beverages," he says, " are infusions of tea and coffee ; and the preference should be given to tea, taken at breakfast in considerable quantity and at a high temperature. All obese persons who take this beverage habitually at or between their meals obtain better results than from pure water, even taken cold." Alcoholic drinks he strictly forbids on account of their well-known tendency to favour fattydegeneration. A little wine and water is the most he permits. He approves of Ebstein's system, with the modifi- cation here indicated, and reports excellent results * " Du Regime Alimentaire. Regime des Obfeses." D D 45 FOOD IN DISEASE, [Panii. from its application. He lias, however, observed some difficulty in digesting the fats, and some dyspepsia provoked in certain instances. Weir Mitchell* advocates " rest, milk dietetics, and massage in people who are merely cumbrously loaded with adipose tissues, and also in the very small class of anaemic women who are excessively fat." He maintains that on skimmed rnilk i.e. milk without cream fat people lose flesh, and that a large amount of weight may be got rid of rapidly and safely by the following means. " The person whoso weight we decide to lessen is placed on skimmed milk alone, with the usual precautions ; or at once we give skimmed milk with the usual food, and in a week put aside all other diet save milk, and all other fluids. When we find what quantity of milk will sustain the weight, we diminish the amount by degrees until the patient is losing half a pound of weight each day, or less or more, as seems to be well borne. Meanwhile, during the first week or two rest in bed is enjoined, and later, for a varying period, rest in bed or on a lounge is insisted upon, while at the same time massage is used once or twice a day, and later in the case Swedish movements. At the same time, the pulse and weight are observed with care, so that if there be too rapid loss, or any sign of feeble- ness, the diet may be increased. In many such cases I allow daily a moderate amount of beef, or chicken, or oyster soup, more as a relief to the unpleasantness of a milk diet than for any other reason. When the weight has been sufficiently lowered, we add to the diet, beef, mutton, oysters, etc., and finally arrange a full diet list, to include but a moderate amount of hydrocarbons. Meanwhile, the milk remains as a large part of the food, and the active Swedish move- ments are still kept up as a habit, the patient being directed by degrees to add the usual forms of exercise. Tf we attempt to make so speedy a change in weight while the patient is afoot, the loss is apt to be * " Fat and Blood," pp. 104-106. Chap. VI.] DIET IN OBESITY. gravely felt ; but with the precautions here advised it is interesting arid pleasant to see how great a reduction may be made in a reasonable time without annoyance, and with no obvious result except a gain in health and comfort." The great difficulty in applying this method lies in the enforced rest in bed for a week or two which it requires, and which few men engaged in any kind of occupation would be willing to adopt. It is more applicable to women without serious occupation. In reviewing these various dietetic methods of treating obesity it will be seen, as we have already pointed out, that they all aim at reducing the average quantity of food taken. If we compare the normal average daily ration with that permitted in these methods, this fact becomes very evident : Normal average \ (grammes)* . j Banting Ebstein Albnminates. Fat Carbohydrates. 130 170 100 84 10 85 404 80 .50 Oertel . 155-179 25-40 70-110 The carbohydrates are especially attacked in all these methods, and very largely reduced. There would seem to be a far greater tendency to excess in this class of food than in the other classes. In two of these methods there is an excess of albuminates ; this excess has been considered to favour the reduction of obesity by promoting the oxidation and combustion of the excess of deposited fat. This view of the effect of an excess of albuminates has been carried to an extreme in a method recently introduced from America, and sometimes spoken of as the "Salisbury" method. It is usual in this method to restrict the diet absolutely for a time to large quantities of rump-steak, Moleschott's. D D 2 45 2 FOOD IN DISEASE. [Partii. cod-fish, and hot water. One of the strongest advo- cates (Towers-Smith) of this method gave three pounds of rump-steak and one pound of cod-fish, together with six and one-third pints of hot water, as the daily diet for the first fortnight. The next three weeks the hot water is reduced to four pints, and other kinds of lean meat and fish are allowed, as well as a little green vegetable, and unssveetened rusks. During the following month the hot water is reduced to about a quart a day, and some crusts of stale bread, captain's biscuits, grilled meat, or poultry, or game of any kind, and hock or claret with seltzer water, are allowed. A slice of lemon may be used to flavour each tumbler of hot water. Five grains of bicarbonate of potash are also prescribed night and morning. This diet would be absolutely impossible of application in many cases, from utter inability to consume so large an amount of animal food. Inordi- nately large eaters might, however, find it successful. But in the application of this method it is not always necessary that such large quantities of meat should be eaten. Remarkable results have been obtained from the limitation of the food to one pound of cooked fish and one pound of cooked lean meat daily, together with the consumption of a pint of warm water every two hours the water to be taken as warm as it can comfortably be drunk, and sipped slowly. The fish and meat are distributed into various meals according to the inclination of the patient ; no bread, vegetables, milk, or any other article of diet must be allowed. A patient who took this diet, with five to six pints of warm water daily, was reduced in four months from 20 stones 4| Ibs. to 17 stones 1 Ib. The diet was then slightly modified. He was allowed two small slices of bread-and-butter with breakfast and tea, and milk and sugar were added to his tea morning and evening. His weight still con- tinued to diminish, and reached 1C stones 7 Ibs. He then was allowed to return to ordinary meat diet, omitting potatoes, and at the end of six months he Chap, vi.] DIET IN OBESITY. 453 weighed 16 stones, 6 Ibs., and had therefore lost 4 stones. For four months he was kept on a strictly nitrogenous diet, and for six weeks on ordinary diet, without potatoes. This reduction was maintained on ordinary diet, with the avoidance of beer* and with draughts of water. The success of this system is accounted for by the supposition that the patient supplies the necessary hydrocarbons and carbohydrates (absent in his diet) from his own store that he consumes his own fat. It is, of course, necessary in the application of this method to secure the hearty co-operation of the patient. This diet is, we think, improved by the addition of some fresh green vegetables, such as watercress, lettuce, and the like. It is by no means of universal applicability, but seems to be especially useful in those cases of obesity which are due to over- feeding. It must, however, be recognised that some of the most striking results in the reduction of fat have been observed in the employment of this method. Ebstein's method has the recommendation, no doubt, of diminishing the desire for food, and is applicable .to the strong and vigorous with large appetites. The deficiency in albuminates and excess of futs render it unsuited to feeble subjects with weak digestions, and it is not a system likely to become popular. Schweninger's system is fairly applicable to many cases; but the absolute exclusion of all drink during meals, although it no doubt has the effect of diminish- ing considerably the desire to eat in excess, disagrees with many persons of feeble digestion, and should not be incautiously prescribed. In Banting's system there is too rigorous an exclusion of fats, which are essential to healthy nutrition. Certain cases undoubtedly do well with a strict limitation of beverages; others, on the contrary, as pointed out by G. See, are better for the free use * Lancet, July 15th, 1893. 454 FOOD IN DISEASE. [Panii. of hot, diluent drinks, and these are, especially, the gouty cases with a tendency to defective elimination. It is in such cases that a teacupful or more of hot water taken half an hour before each meal and at bedtime answers well, and enables them to do with much less fluid at meal-times than is usually taken. The two principal objects of all these methods is, first, to make the corpulent person consume the excess of fat deposited in his body by restricting the food- supply, or augmenting its combustion by increased physical exercise or other means ; and, second, to establish a dietary which shall prevent its re- accumulation. None of the methods described is appropriate to the treatment of all cases of obesity indiscriminately, while any one of them may prove successful in suitable instances. In conclusion, the following is the method which we recommend to be generally adopted : a very careful examination should be made of each case in order to ascertain the presence or absence of any organic disease, especially of any cardiac degeneration, and if we are satisfied that the obesity is not secondary to any other morbid state, or associated with any general degeneration of organs, we may proceed with confidence to prescribe an appropriate regime. The albuminates in the form of animal food should be strictly confined within the limits necessary for healthy nutrition. Farinaceous and all starchy foods should be reduced to a minimum. Sugar should be entirely prohibited. A moderate amount of fat, for the reasons given by Ebstein, may be allowed in some instances. Only a small quantity of fluid should be permitted at meals ; but enough should be allowed to aid in the solution and digestion of the food. Hot water, or warm aromatic beverages, may be taken freely between meals, towards the end of the digestive process, especially in gouty cases, on account of their eliminative action. Chap, vi.] DIET IN OBESITY. 455 No beer, porter, or sweet wines of any kind are to be taken ; no spirits, except in very small quantity. It should be generally recognised that the use of alcohol is one of the most common provocatives of obesity. A little hock, still Moselle, or light claret with some alkaline table-water is all that should be allowed. The beneficial effects of such a diet will be aided by abundant exercise on foot, and by the free use of saline purgatives, so that we may insure a complete daily unloading of the intestinal canal. It is only necessary to mention a few other details. Of animal foods, all kinds of lean meat may be taken, poultry, game, fish (eels, salmon, mackerel are best avoided), eggs. Meat should not be taken more than twice a day, and not more than 6 oz. of cooked meat at a time. Two lightly boiled or poached eggs may be taken at one other meal, or a little grilled fish. Bread should be toasted in thin slices and com- pletely, not browned on the surface merely. Soups should be avoided, except a few table- spoonfuls of clear soup at dinner. Milk should be avoided, unless skimmed or when taken as the chief article of diet. All milk and farinaceous puddings and pastry of all kinds are forbidden. Fresh vegetables and fruits are permitted. It is important to bear in mind that the actual quantity of food permitted must have a due relation to i\i > physical development of the individual, and thot '.vhat would be adequate in one case might be altogfcther inadequate in the case of another person of larger physique. NOTE ON THE "SALISBUUY" METHOD. We have spoken, in connection with the Treatment of Obesity, of the "Salisbury " method of feeding-. This method, however, is not limited to the treatment of obesity, but is considered to be widely applicable to many dyspeptic states, and it needs, we think, a little further exposition. The essential idea of this system when strictly applied id to 456 FOOD IN DISEASE. [Panii. limit the food and drink (o the lean of meat, preferably beef, and an abundance of hot water. This reduces the problem of digestion to an extreme simplicity, arid its laudable object is to require of the enfeebled or disordertd digestive organs one k'nd of work only, viz. the digestion of nitrogenous food in its most readily assimilable form. It requires also, and this is a condition of great iinporlanco, tha 1 , the nuat should be minced or finely divided in a specul manner, as we shall see ; so that this work of extreme subdivision is done out of the body, and the work of digestion thereby greatly lightened. The merit of this diet in the mind of the inventor is that it gets rid of all "fermentative " food-, as he terms most of the common aiticles of ordinary diet. The large quantities of hot water which it is considere i necessary to consume act, of course, as a solvent and eliminative agent; BO that whatever excess of nitrogenous wa^te may resu't from this highly auimalised regime is readily carr'ed away by the secretions of the liver and kidneys, the eLminative functions of whi h (as well, doubtless, as that ci the skin) are powerfully promoted by this large ingestion of hot water. In carrying out this method it is usual to begin with and for a time to adhere to the following rule : The diet to be restricted to animal fjod, minced preferably beef and four pints of hot or warm water to be drunk daily a pint an hour and a half before each of the three meals, and the last pint half an hour before bedtime ; the idea being that the stomach sho aid be empty at the time of drinking the hot water, so that it may cleanse or wash clean the gastric mucous membrane. The temperature of the water should be just pleasantly hot about 100 to 120 F. and it is permitted to a Jd to the water, if desired, a little sal volatile, or a pinch of fcalt, or a squeeze of lemon- j nice, or a little clear tea ; it should be sipped slowly, not swallowed quickly. Those who find a difficulty in drinking so much water at a tim-3 may begin with a teacupful and slowly increase the amount to the full pint. The times appointed as best for the metis are 8 a.m., 1 p.m., and 6.30 p.m. (five hours between each m al). It must not be understood that this is suggested as a permanent diet; it is only intended to be adopted " while the necessity for it lasts." The meat is first minced and then cooked, as we shall immediately describe. It is contended that this mince gives the " very greatest nourishment along with the least possible strain and labour to the stomach ; it is digested and assimilated with great ease and rapidity." The only food at breakfast, dinner, an 1 supper is, at first, to ba minced beef, and for beverages clear tea or coffee (no milk or sugar), or beef-tea. Those who crave for something to chew may have a small piece of nicely -broiled tender steak along with the mince, or " a bit of broiU'd beef-cake." Chap, vi.) THE "SALISBURY" METHOD. 457 With the minced beef it is permitted to add such condiments as black pepper, salt, and mustard, and Chutnee sauce is also approved of; but no vegetable is to b>3 taken, except ;\ little raw or \v ell-cook', d celery (we cannot see why this permission should not be extended to lettuce and watereresses). If, owing to the rapidity with which this minced meat is digested, any hungry cravings occur, especially in the night, they maybe allayed by a few mouthfuls of meat-soup or a little mince, or both. As to the quantity of minced meat consumed, " each patient's own digestive power must be his law." He may begin with 1 to 2 oz. at each meal, and increase gradually to 3 to 4 cz., and then to 5 to 6 oz., and then to 8 oz. or more if it is well and easily digested. " One pound of good lean beef or mutton at a meal is as much as any male patient, in best condition, should eat." In addition to this, if still hungry, he may be allowed to take the ichitts of one or two eggs between meals beaten up or lightly poached up to half a dozen a day. The eft'ect of this diet is usua'ly to induce a considerable loss of weight and a temp rary feeling of weakness in some cases. But the loss is chiefly useless lumber, and the strength is soon recovered and augmented. Some simple aperient may also be needed owing to the small amount of faecal residu *, from this diet ; it is recommended that a teaspoonful of fluid extract of senna or rhubarb in a little water be taken at bedtime. An occasional change is allowed from mince to tender under- cut of sirloin, whole steaks, or nicely broiled tender mutton of which the lean only should be eaten, freed from ski'i, fat, and connective tissue. Very little fluid should be taken at meal-times, and very little will be needed, as thirst will ba quenched beforehand by the large draughts of hot water. A little hot water may be sipped at meals, or good beef-tea. After a time the following adjuncts are allowed (minced, however, in most cases before cooking) .-Mutton, lamb, sweetbread, poultry, whitj fish, soft-boiled or poached eggs baked potato, well-boiled rice or macaroni, wheaten bretd (?tale or roasted crisp in an oven), adhering, however, to what is termed a two-third diet, viz. two mouthfuls of meat to one of other kinds of food. As relishes, it is allowable to take a small bit of cheese, a baked apple, stewt.d prunes, or fresh fruit. The above is a brief summary of the chief requirements of the Salisbury system, to which we add the instructions for preparing the minced beef aud the " beef cakes " We are disposed to regard this method as having much to recommend it in many cases and as very well adapted, with a few modifications 'in the direction of admitting more fresh 458 FOOD IN DISEASE. [Partii. green vegetable* or fruit from the start, to the reduction of corpulency in many persons. Its fault lies in being too absolute and exclusive for the majority of patients in its strict form. The following are the directions given for cooking the minced* beef: "A slice or steak from the top side of the round without fat is the proper part. The meat to be cut into strips, and all skin, connective tissues, gristle, fat, etc., as far as possible scraped away with a sharp knife. The meat is to be i.ut through the mincer at least twice. The pulp must theu be well beaten up in a roomy saucepan with cold water, or plain, well-skimmed beef-tea, in which no vegetables have be- n cooked, to somewhat the consistency of cream. The right proportion is about one teaspoonful of liquid to one ounce of pulp. Pepper (black) and salt to taste. The mince must then be stirred briskly with a wooden spoon the whole time it is cooking, over a very slow fire or on a cool pail of a covered range till perfectly hot through and the red colour disappears. It will probably take from twenty minutes to half an hour to cook if done as slowly and carefully as it should be; and the stirring must be continued all the time, so that the mince may never settle at the bottom of the saucepan, but be constantly turned up. It must be thoroughly cooked through, but never approach simmering even. When done, it should be a soft, smooth, stiff puree, of the consistency of a thick paste wiihoutany lumps or hard bits. It is always to be served in a very hot bowl and eaten with a teaspoon. Almost every patient is allowed at the first two meals a stick of raw or very nicely stewed celery." The " beef-cakes " are directed to be made thus : " Take minced beef pulp, stason it with black pepper and salt, and with two forks form it lightly and quickly into round flat cakes about half an inch thick, and grill them over a clear but moderate fire, turning the griller (an American grilkr) once every minute till the cakes are lightly broiled through. They take about five or six minutes, and must not be overcooked. The pulp must be loosely made up, not hard or tightly pressed." * The mincer recommended is named "The Enterprise," to be obtained of the "Enterprise Hardware Company," tstj and 88, Dale Street. Liverpool. 459 CHAPTER VII. DIET IN ANEMIA, CHLOROSIS, NEURASTHENIA, AND ALLIED DISTURBANCES OP NUTRITION. THE due and adequate nutrition of all the organs and tissues of the body and their maintenance in a stable state of normal functional activity are essentially dependent upon the integrity of the circulating fluid, the blood, which brings to each of them the elements necessary for the support of their structure and the development of their functional energies. Any defect in, or deviation from, the normal composition of the blood will, therefore, tend to disturbance and deteriora- tion in the condition and functions of all the organs of the body ; and it is obvious, and needs no demonstra- tion, that the reception, digestion, and assimilation of a sufficient quantity of suitable food are requisite to maintain the needful healthy quality and quantity of the blood, and to restore them when lost. It is clear, then, that the morbid states of the blood known as auumiia and chlorosis cannot be successfully remedied without due attention to diet. Those troublesome states of disturbed health and nutrition, commonly described as cases of neurasthenia or nervous exhaustion, are generally associated with an anaemic condition, and their dietetic treatment may be conveniently considered in this chapter. In some of the latter morbid affections it seems not unlikely that the defective nutrition observed in them may be, in part, due to original disturbances in the functional activity of the cellular elements brought about, directly or indirectly, by nervous influences, and that the altered condition of the circulating fluid which ensues may be referred, primarily, to some disorder of the nervous system ; hence, no doubt, the 460 FOOD IN DISEASE. [Panii. necessity of directing remedial measures to the restora- tion of a healthy tone in the nervous system in those cases, and the success which has attended the applica- tions of such methods in combination with appropriate dietetic expedients. Amongst the various causes of anaemia or hydraemia by which is meant an alteration in the composition of the blood, so that it becomes poorer in red corpuscles and more watery a defective or unsuitable supply of food must be regarded as one of the most frequent. It has been proved that with a diet composed of exclusively non-nitrogenous food the percentage of haemoglobin in the blood undergoes a notable diminution, while it is augmented by a diet rich in albuminates. It is certain that much of the chlorosis, antenna, and associated nervous disturbances observed amongst young girls at the age of puberty are referable to improper or insufficient feeding at school, together with the imposition of educational tasks to winch they are unequal. Defective nutrition from in- sufficient food, combined with educational strain, we are disposed to regard as responsible for the breakdown in health observed in many young persons of feeble or sensitive organisation at this time of life. It is too commonly forgotten by those who are charged with the care and education of youth that growth and development, which are often exceedingly rapid in the female at the period we refer to, can only take place by the agency and at the expense of the nutrient fluids and their active elements, es- pecially the red corpuscles, and that these require a frequent and abundant supply of nutritious food for their constant regeneration ; while the processes of digestion and assimilation to be carried on with wholesome and needful activity require a certain repose of the nervous system which is inconsistent with severe mental tasks. The more acute forms of anaemia may be caused by Chap. vii.] THE ANAEMIC STATE. 461 haemorrhages, or be the result of severe illnesses, and in the latter case considerable emaciation generally accompanies it. With suitable food recovery is very rapid in most of these cases, and a moderate loss of blood is soon made up ; the fluid part is, however, more quickly restored than the corpuscles. In some chlorotic females it has been said that the heart and blood-vessels are abnormally small, so that they suffer from a congenital weakness in the blood-forming and blood- propelling apparatus; in such instances, not only must great care be observed in the regulation of the diet, but all the organs of the body should be safeguarded from undue strain or any over-exertion. In all cases of anaemia not only must we see that the supply of food is adequate and its quality suit- able, but we must also watch over its digestion and assimilation. The functional disturbances which are associated with poor and watery blood are especially marked in the digestive organs, the secretions of which become defective both in quantity and quality, and dyspeptic troubles are, therefore, common accom- paniments of the anaemic state. Disturbances of the nervous system from an imperfect blood-supply are likewise frequent, such as languor, depression of spirits, giddiness, headache, neuralgia, etc. ; while the whole muscular system is enfeebled from defective nutrition, so that muscular fatigue and aching of the muscles are often induced by comparatively slight exer- tion ; and in no muscle is this more evident, or more distressing, than in the heart muscle, which shows its distress by palpitation on the slightest exertion, by a tendency to fainting, and not infrequently by becoming sensitive to pain as can be readily proved by pressing with the finger in the intercostal space over the apex of the heart, when, in many cases of chronic anaemia, a distinct sense of pain and tenderness in the cardiac muscle can be excited. CEdema of the feet and ankles is also a symptom often present in 462 FOOD IN DISEASE. [Panii. anaemic states, due to the disturbances in the functions of the circulatory organs. Germain See appears to us singularly at fault in denying the possibility of oedema occurring as a consequence of simple anaemia, and concluding, as he does, that when oadema of the feet is observed in cases of chlorosis, it is due to a co-existing valvular cardiac lesion, and especially to mitral stenosis.* It has been noticed that in anaemic persons the conditions of normal metabolism are somewhat modified, and especially that there is increased meta- bolism of the albuminates, so that the excretion of urea is increased ; and we have ourselves noted the high specific gravity of the urine (1028 to 1035) in some of these cases, from the presence of a great excess of urea. The metabolism of fat appears, however, to be diminished, and it may often be observed in anaemic persons that while their muscles are feeble and wasted, they wear a generally plump aspect, from the presence of a considerable amount of adipose tissue. This has been referred to defective oxygena- tion from the decrease in red-blood corpuscles, the carriers of oxygen, and consequent imperfect com- bustion of the hydrocarbons and carbohydrates. From these preliminary considerations we are able to deduce the following indications for the dietetic treatment of cases of anemia and chlorosis : 1. The food should contain the elements needed for the restoration of the deficient blood corpuscles, and of the general normal in- tegrity of the circulating fluid. 2. It should be directed to restoring tone to the enfeebled muscles, and especially to the cardiac muscle. 3. It should be supporting and soothing to the exhausted and irritable nervous system. * Germain See, "Regime Alimentaire: Des Chlorotiques et Anemiques," p. 416. Chap, vii.] DIET IN ANMMIA. 463 4. It should be of a kind, and in a mode of preparation, which renders it easily and quickly appropriated by the organs of di- gestion and assimilationprocesses especially languid and feeble. At the outset of the treatment, rest of the exhausted organism should be particularly enforced. The tend- ency to urge the young who are feeble and anaemic to take abundant exercise, and to make them follow the same mode of life as their healthy associates, cannot be too strongly condemned. It interferes with the success of all our remedial measures. To insist, as is so often done, that a chlorotic young girl shall rise at the same hour in the morning as the rest of the family, partake of the same meals at the same hours, engage in the same pursuits, and conduct herself as if she were strong and well, is most unreasonable and harmful. Instead of such a routine, she should be given her breakfast in bed ; she should not be allowed to rise much before mid-day ; she should be encouraged to rest as much as possible, in the recumbent position, in an airy apartment, or be swung in a hammock during fine weather in the open air. As soon as some improvement in the blood condition is observ- able, and some return of healthy functional activity is apparent, a moderate amount of gentle exercise may be permitted, and this should be gradually increased with each increasing gain in health and strength. The food given at first should be in small or moderate quantity, so as not to overtax the feeble digestive powers, and in a form that can be readily digested. Milk, skimmed if necessary, is most useful when it is easily digested ; but it must not be persevered with when it is digested with difficulty, and is on that accoxmt distasteful to the patient. A good substitute for milk is a mixture of equal parts of cream and hot water (2 oz. of each), to which a little bicarbonate of 464 FOOD iff DISEASE. [Pan n. soda and a teaspoonful of brandy or sal volatile may be added. This is a good food to begin the day with. All forms of animal food, prepared in a manner easy of digestion, are useful and appropriate. Raw or slightly-cooked meat, pounded or scraped, and mixed with agreeably flavoured consomme* or meat broth, or made into sandwiches, or mixed with chocolate or Burgundy and water, or given in any wholesome form approved of by the patient, is of great value as a blood restorer. G. See states that he has often cured cases of chlorosis without iron, or after iron has failed, by the administration of 400 grammes (about 14 oz.) of raw meat daily, together with hydrotherapy ; and he con- siders those two means as indispensable in the treat- ment of dyspeptic chlorotics who cannot take iron, and the former also in those cardiac cases which cannot tolerate either iron or hydrotherapy.* The digestive power for nitrogenous or other foods must be carefully watched, and, if necessary, aided by the addition of some appropriate digestive ferment. A teaspoonful of Liquor Pepticus or three or four grains of pepsin may be given with each meat meal. Peptonised milk a breakfastcupful twice or three times a day will be useful when unprepared milk disagrees. To obviate the tendency to constipation, well- made whole-meal bread may be given, watching again carefully for any signs of indigestion which it is apt occasionally to provoke. For the same purpose, oat- meal porridge may be taken at breakfast, and some fruit compote. Green, fresh vegetables, especially in the form of purges, are also to be recommended for the same pur- pose. Macaroni, vermicelli, polenta, and the various Italian pastes, cooked with meat-juice or gravy, are excellent. Animal albuminates should predominate in the * "L'Hygi&ne Alimentaire, " p. 420. Chap. VII.] DlET IN ANsEMJA. 465 diet at first, given in quantity proportionate to the digestive capacities. Some easily digested fat par- ticularly in cases where there has been loss of nesh should soon be added ; indeed, progress in blood- making will often fail to take place until some diges- tible fat be added to the dietary. A dessertspoonful of cod-liver oil once a day will frequently suffice, and should be ordered when it is not objected to. When this is objected to, some other form of fat should be introduced into the daily dietary. Butter is one of the best ; so is cream. They may be Agreeably mixed with some farinaceous food in the form of light puddings, and served with fruit- sauce or jelly. Broiled fat bacon at breakfast is, with many persons, an easily-digested form of fat. Eggs in any form are a very suitable food, as they present a concentrated and generally easily- digested form of nutriment rich in iron. One or two egg.s, beaten up with a little boiling water, with or without milk, to which a little sugar, nutmeg or other spice, and a tablespoon ful of brandy may be added, are an excellent and nutritious restorative in those cases of anaemia with cardiac feebleness and loss of appetite. Bauer * is decidedly in favour of a liberal proper tion of nitrogenous food in the dietary of anaemic patients. "It is probable," he says, "that the re- production of the most essential components of the blood, especially of the red corpuscles, would be greatly favoured if relatively more albumen were contained in the food of such patients than is proper under physiological conditions." Anaemia in infants and young children often arises from an insufficient amount of fresh animal food i.e. fresh milk or some equivalent for it. Anaemia is common in all starch-fed children and in those brought up on purely vegetable foods ; and it would seem that desiccated milk loses some of the antiscorbutic quality * "Dietary of the Sick: Diet in Aiuemiu and Hydneniia," p. 275. E E 466 FOOD IN DISEASE. [Part n. of fresh milk, and therefore its capacity for making red blood. In these cases the best remedy is to add to the milk (or other food) some raw meat juice or meat pulp, the haemoglobin in which is probably used directly in the formation of new red-blood corpuscles. It is very necessary, in these cases, that great attention should be given to the manner of preparing and serving the food prescribed, so as to make it as palatable and attractive as possible, for in a great number of these patients we have to contend with entire loss of appetite and indisposition to take food ; and our chief resources, at first, will be found in pleasantly-flavoured fluid or semi-fluid foods, which can be swallowed without previous mastication. Con- diments in moderate amount are very useful to render the food agreeable; and a certain amount of wine of which, perhaps, a good sound Burgundy is the best should be given, and is useful as a stimulant to the circulatory and a sedative to the nervous systems. We have found porter or stout useful and well borne in some instances, and, if taken at bedtime with a little bread and butter or a biscuit, it will frequently have the effect of inducing sleep in cases complicated with insomnia. It has been recommended, on the authority of Moleschott, that chlorotics should partake freely of salt with their food, on the ground that it favours, directly and indirectly, the restoration of the blood corpuscles as well as the blood plasma. Bauer's caution against the excessive use of vinegar, as causing "a high degree of anaemia and emaciation, since the acid lessens the alkalinity of the blood and the number of the blood corpuscles," has already been quoted. For the appropriate dietetic and other manage- ment of those cases of neurasthenia or nervous exhaustion in which the general nutrition is so gravely affected that quite phenomenal states of emaciation and muscular feebleness are observed in connection therewith, we are mainly indebted to Chap. VH.J DIET IN NEURASTHENIA. 467 Dr. Weir Mitchell. These cases cannot, however, be restored to health by appropriate food alone, but other curative agencies have to be simultaneously and systematically employed. These are complete isola- tion, rest in bed, and the regular application of massage and electricity. To use Weir Mitchell's own words, the method consists of " a combination of entire rest and of excessive feeding, made possible by passive exercise obtained through the steady use of massage and electricity." * He insists on the inti- mate association between the gain and loss of fat and the gain and loss of blood corpuscles. " The loss of fab . . . nearly always goes along with conditions which impoverish the blood ; and, on the other hand, the gain of fat, up to a certain point, seems to go hand in hand with a rise in all other essentials of health, and notably with an improvement in the colour and amount of the red corpuscles To gain in fat is nearly always to gain in blood." It may also be well to let Dr. Weir Mitchell himself describe the cases to which he considers his method especially applicable. They are "people who are kept meagre, and often also anaemic, by constant dyspepsia in its varied forms, or by those defects in assimilative processes which, while more obscure, are as fertile parents of similar mischief ; . . . . that large group of women especially, said to have nervous exhaustion, or who are denned as having spinal irrita- tion, . . . cases in which, besides the wasting and anaemia, emotional manifestations predominate, and who are then called hysterical, whether or not they exhibit ovarian or uterine disorders ; . . . women who have lost flesh and grown colourless, but have no hysterical tendencies, . . . hopelessly below the standard of health, and subject to a host of aches and pains, without notable organic disease." The large amounts of food given in this method, while the patient takes no exercise, are absorbed and * "Fat and Blood. An Essay on the Treatment of certain forms of Xeurasthenia and Hysteria. " Fifth edition (1688). E '2 468 FOOD IN DISEASE. [Partii. utilised through the influence of massage "kneading the muscles, and by moving them with currents able to effect this end." To insure the most absolute rest in cases of great weakness, -the patient is fed by a nurse ; and when well enough to sit up in bed, the meats are cut up, so as to make it easier for the patient to feed herself. The treatment is begun by putting the patient on milk diet three or four ounces every two hours, increased in a few days to two quarts, given in divided doses every three hours. This, says Dr. Weir Mitchell, "nearly always dismisses, as by magic, all the dyspeptic conditions." The bowels are regulated by giving a cup of coftee, without sugar, on waking, or a grain of watery extract of aloes at bed- time ; or, in more obstinate cases, a quarter of a grain of watery extract of aloes and two grains of dried ox- gall thrice a day. After four to seven days a light breakfast is per- mitted ; a day or two later, a mutton chop as a mid- day dinner ; and again, in a day or two, bread and butter thrice a day. After ten days, usually, the patient is allowed three full meals daily, as well as three or four pints of milk, given at or after meais, in place of water, and two to four ounces of fluid Malt Extract before each meal. "No troublesome symptoms usually result from this full feeding, and the patient may be made to eat more largely by being fed by her attendant. 1 like to give butter largely, and have little trouble in getting this most wholesome of fats taken in large amounts. A cup of cocoa or of coffea with milk on waking in the morning is a good preparation for the fatigue of the toilet. At the close of the first week i like to add 1 Ib. of beef, in the form of raw soup. This is made by chopping up 1 Ib. of raw beef, and placing it in a bottle with one pint of water and five drops of strong hydrochloric acid. This mixture stands in ice all night, and in the morning the bottle is set in a pan of water at 110 Fahr., and kept two hours at about this temperature. It is then thrown on to a stout cloth, and strained until the mass which remains is nearly dry. The filtrate is given in three portions daily. If the raw taste prove very objectionable, the beef to be used is quickly roasted on Chap, vii.] DIET IN NEURASTHENIA. 469 one side, and then the process is completed in the manner above described. The soup thus made is for the most part raw, but has also the flavour of cooked meat. " In difficult cases I sometimes add, at the third week, i oz. of cod-liver oil, half an hour after each meal. If it lessens appetite, or causes nausea, I employ it thrice a day as a rectal injection, and in cases where the large doses of iron used cause intense constipation, I find the use of cod-liver oil enemata doubly valuable, by acting as a nutriment, and by disposing the bowels to act daily. When given thus, I like to use it in an emulsion made with the June drained off, after crushing the fresh pancreas of the beef in warm water. Enough of water to cover \ Ib. of chopped pancreas is allowed to stand for an hour in a warm kitchen, and then squeezed through a towel. An ounce is mixed with half that amount of oil and injected slowly thrice a day." ( Weir Mitchell.) As to stimulants, when there is no question of breaking off the alcoholic habit, a small amount of stimulant has been found to assist in the rapid in- crease of fat ; such as an ounce of whisky daily in milk, or a glass of diy champagne, or Burgundy, or other red wine. It increases the capacity to take food at meals. Alcohol, however, is not essential. With the administration of solid food, iron is given in large doses; and when the patient is able to sit up, " rather full doses of sulphate of strychnia thrice a day, with iron and arsenic." As to the consumption of this " vast amount of food," Dr. Weir Mitchell observes : " I have watched again and again, with growing surprise, some listless, feeble, white-blooded creature learning by degrees to consume these large rations, and gathering under their use flesh, colour, and wholesomeness of mind and body." When the patient is taking the full diet, it is necessary to watch the urine. When u rates begin to be deposited, it must be regarded as a sign of over-feeding, and some reduction in the quantity of food must be made. Attacks of dyspepsia (which are apt to occur) or diarrhoea are met by reducing the diet one-half, or returning to a milk diet for a day or two. 470 FOOD IN DISEASE. [Partii. Two or three detailed examples of the diet em- ployed in the treatment of these cases will be the best conclusion to this chapter. CASE 1. (WEIR MITCHELL.) Mrs. C., kept in bed, fed by ar, attendant, rose only to relieve bladder and rectum. 1st day. One quart of milk, in divided doses, every 2 hours. 2nd day. Cup of coffee on waking. Two quarts of milk, in divided portions, every 2 hours. Aloetic pill at night. 3rd to 6th days. Same diet. 7th, 8th, and 9th days. Same diet, with a pint of raw soup, in three portions. 10th day. 7 a.m., coffee. 7.30 a.m., f pint milk. 10 a.m., ditto. 12 noon, 2, 4, 6, 8, and 10 p.m., ditto. Soup at 11 a.m., 5 and 9 p.m. 14th day. Egg and bread and butter added. 16th day. Dinner added, and iron. 19th day. The entire diet was as follows: 7 a.m., coffee. 8 a.m., iron and malt extract ; breakfast, consisting of a chop, bread and butter, a tumbler and half of milk. 11 a.m., soup. 2 p.m., iron and malt ; dinner of anything she liked, with 6 oz. of Burgundy or dry champagne, and at the end one or two tumblers of milk. 4 p.m., soup. 7 p.m., malt, iron, bread and butter, usually some fruit, and commonly 2 glasses of milk. 9 p.m., soup. 10 p.m., aloetic pill. (At 12 noon, massage for an hour. At 4.30 p.m., electricity applied for an hour.) At 6tk week, soup and wine were dropped, iron lessened one half, massage and electricity only on alternate days, -j^th of a grain of sulphate of strychnia thrice a day at meals (continued for several months). At 9th week, milk reduced to a quart. All mechanical treat- ment ceased. Result. Gain in flesh about face in 2nd week. Weight rose in two months from 96 to 136 Ib. ; gain in colour equally marked. At 30th day patient had normal catamenial flow, after 6 years of failure to menstruate. At 9th week, drove out Cure complete and permanent. CASE 2. (DR. PLAYFAIR.) A. B., age 32. Rest in bed, isolation. 1st day. 22 oz. of milk, in divided doses. 2nd day. -50 oz. of milk, in divided doses. 3rd day. 50 oz. of milk, in divided doses. (Massage, J an hour.) Chap, vii.] NEURASTHENIA DIETARIES. 471 4th day. 50 oz. of milk, in divided doses ; egg and bread and butter ; dialysed iron, 40 minims, in 2 doses. (Massage, 1 \ hour.) 6th day. 50 oz. of milk, in divided doses ; mutton chop. (Massage, 1 hour 50 minutes.) 8th day. 50 oz. of milk, in divided doses ; mutton chop ; por- ridge, and a gill of cream ; maltine twice daily. (Massage, 3 hours ; electricity, \ an hour ; continued to end of treatment. ) 15th day. Three full meals daily of fish, meat, vegetables, cream, and fruit; 2 quarts of milk and 2 glasses of Burgundy. 22nd day. Amount of food lessened. Result. On 22nd day sat in a chair for an hour, after a month walked downstairs and went out for a drive. "Enor- mous increase in size." Cure complete and permanent. CASE 3. (DR. PLAYFAIR.) Dietary on 10 th day. 6 a.m. Raw moat soup, 10 oz. 7 a.m. Cup of black coffee. 8 a.m. Plate of oatmeal porridge, gill of cream, a boiled egg, 3 slices of bread and butter, and cocoa. 11 a.m. Milk, 10 oz. 2 p.m. Rnmp-steak, J Ib. potatoes, cauliflower, a savoury omelette; milk, 10 oz. 4 p.m. Milk, 10 oz., 3 slices of bread and butter. 6 p.m. Cup of gravy soup. 8pm. A fried sole, roast mutton (3 large slices), French beans, potatoes, stewed fruit and cream ; milk, 10 oz. 11 p.m. Raw meat soup, 10 oz. Same scale of diet continued through whole treatment. Consumed with relish and appetite. No dyspeptic symptoms. Result. Gain in weight in six weeks from 4 st. 7 Ib. to 7 st. 8 Ib. = 3 st. 1 Ib. CASE 4. (DR. JOHN KEATING.) P. D., a male, age f>3 (loss of nervous muscular force, defective memory, insomniu, convulsive muscular twitching!", frequent cough, emaciation, slight night sweats, impaired re- sonance right apex). Treatment. Allowed to be out of bed once a day for four hours, one of which was spent in business. Food. 6 a.m. A tumbler of strong, hot beef-tea, made from Australian extract. 8 a.m. Half-tumltler of iron-water, and breakfast of fruit steak, rjotatoes, coffee, and u goblet of mil';. 47 2 FOOD IN DISEASE. [Partii. 8.30 a.m. A goblet of milk, with a dessertspoonful of Loefkmd's Malt Extract, 6 grains of citrate of iron and quinine. 10 a.m. Electricity. 12 noon Goblet of milk and malt. 2 p.m. Dinner (preceded by half-tumbler of iron -water and a third goblet of milk and malt). 6 p.m. Third dose of iron -water. Light supper of fruits, bread and butter, and cream ; a fourth goblet of milk and malt. 10 p.m. Beef soup, 4 oz., preceded by massage with cocoa oil for an hour. Two quarts of milk were taken daily, in addition to all other food. Result. A gain of over 15 Ib. in weight, cough gone, became and remained strong and well. This method, as adopted by Ley den, is thus described by Germain See : At 7 a.m. Half a litre of milk, slowly sipped in \ an hour, a small cup of coffee with cream, 80 grammes (nearly 3 oz. ) of cold meat, a plate of fried potatoes. 10 a.m. A litre of milk, with 3 biscuits. 12 noon. The same. 1 p.m. Broth, 200 grammes (about 7 oz.) of fowl, puree of potatoes, green vegetables, 120 grammes (about 4 oz.) of compote and pastry. 3.30, 5.30, 8, and 9.30 p.m. Half a litre of milk, making a diily consumption of 3J litres of milk. In the after part of the day, two metis each of 80 grammes (3 oz.) of roast meat, with bread and 3 biscuits. The class of fat anaemic people mostly women are alluded to by Dr. Weir Mitchell as of the "utmost clinical interest." They are rare, as he remarks, and must be dependent on conditioiis not common to all antemics. The cases that we have seen have been apparently traceable to long continued faults of diet, especially to the avoidance of nitro- genous food and the consumption of a vastly- increased proportion of carbohydrates. One of the most remarkable cases of this kind we ever observed was in a patient who had a perfect mania for pastrycooks' sweets. She spent large sums of money habitually at the pastrycook's ; and when any impediment was put in her way, she would succeed, by all sorts of ingenious contrivances, in Chap, vii.] NEURASTHENIA DIETARIES. 473 getting her usual supply of sweets. This enormous consumption of carbohydrates in combination with fat (as in pastry) was, of course, associated with entire indifference to animal food. " Obesity with thin blood " is certainly, as Dr. Weir Mitchell maintains, a " most unmanageable condition." The most useful treatment he believes to be a combination of an exclusively milk diet well-skimmed milk with rest and massage. " In old cases of this kind, the best plan is to put the patient at rest, to use massage, restrict the diet to skimmed milk, or to milk and broth free from fat, and with them, when the weight has been sufficiently lowered, to give iron freely, and, by degrees, a good general diet, under which the globules rise in number, so that even with a new gain in flesh there comes an equal gain in strength and comfort." He gives as an example the case of a lady, aged forty-five, who weighed 190 lb., her height being 5 ft. 4 in. ; she was also annemic, feeble, and breathless. " She was kept in bed five weeks. Massage was used at first once daily, and after a fortnight twice a day, while mil'c was given, and in a week made the exclusive diet. Her average of loss for 30 days was a pound a day, and the diet was varied by the addition of broth after the third week, so as to keep the reduction within safe limits. . . . After two weeks I gave her the lactate of iron every three hours in full doses. Tn the 4th week additions were made to her diet-list, and Swedish movements were added to massage, which was applied but once a day ; and during the 5th week she began to sit up and move about. Her weight at the 7th week had fallen to Ho Ibs., and her appearance had decidedly improved. . . . Now, after two years, she is a well and vigorous woman." In all these cases the milk should be well skimmed, and slowly taken in small mouthfuls at a time. It may, when necessary, be flavoured with a little tea or coffee, or caramel or salt. Its digestion is often aided by scalding with one-fourth the quantity of boiling water ; and a few grains of bicarbonate of soda or a little alkaline water (Vichy, Vals, Apollinaris) may be added. 474 CHAPTER VIII. FOOD IN RICKETS, SCURVY, SCROFULA, CONSUMPTION, AND CHKONIC FEBRILE CONDITIONS FORCED FEEDING (SURALIMENTATION). Rickets is a malady arising in infancy from mal- nutrition, and its remedy is mainly dietetic. In some instances it is believed to originate in intra-uterine life from the inferior nutrition of the mother, and as a prophylactic measure, attention to the diet and nutrition of a mother who has previously borne children that have become rickety is certainly advisable. It has been experimentally shown that rickets can be produced in young animals by depriving them of animal fats and earthy salts especially of calcium phosphates and in looking to the feeding of a pregnant woman, care should be taken that an adequate amount of fat and of lime salts enters into its composition. The same considerations apply to the diet of the mother who is suckling her own infant, or to the wet>nurse. Much that has been said in the chapter on Infant Feeding is of importance in con- nection with the dietetic treatment of infantile rachitis. The common error upon which the production of rickets often depends is the too great reliance by the poorer classes on farinaceous foods. Infants fed almost entirely on farinaceous foods are pretty certain to become the subjects of rachitis. In order to avoid this in the case of hand-fed infants, it is of the first importance to introduce the full quantity of fats and proteids into their diet as calculated from the composition of healthy mother's milk, and as fully explained in the chapter on Infant Chap, viii.] DIET IN RICKETS. 475 Feeding. The milk must contain a full proportion of cream, and this may, in most cases, be added in excess with advantage ; the addition also of cod-liver oil to the dietary is decidedly valuable this may be made into an emulsion by shaking up with lime-water and some syrup if the child objects to it in the pure state. Raw meat juice is an excellent addition to the food of such children, as it is rich in salts, and a little phosphate of lime may usefully be added to some of the milk taken. If skimmed milk is used for feeding infants it may actually tend to the development of rickets from its not containing the necessary amount of fat. Haw meat pulp has been given with great advan- tage to rickety children, to the extent of 2 oz. daily, according to the age of the child. The milk supplied to such children should be abundant (so long as it is well digested), and, as we have already said, it should be of good quality. For the older children, milk puddings made with " entire wheat flour" are suitable. It sometimes happens amongst the poor that prolonged suckling (for economical motives) leads to the development of rickets ; under such circumstances immediate weaning of the child and the substitution of an adequate nourishing dietary on the principles already laid down are of the first importance. Farina- ceous foods alone are unsuitable for the notmshment of such children, because they are not only poor in lime salts, but they readily undergo lactic acid fermentation, and this has been shown to aggravate the rachitic state. When the child is older, sand- wiches of raw meat pulp, meat juices and broths, eggs beaten up with milk or lightly boiled, the juice of fresh fruits, or fruit jellies, may be added to the dietary from time to time. Meat juice is very valuable in anaemic cases ; an easy mode of preparing it is to take a piece of good lean beef, rapidly brown the outside over a quick fire and express the juice with a lemon-squeezer ; or 47 6 FOOD IN DTSEASE. [Partii. Valentin's meat juice, well diluted, may be used instead. Scurvy is another disease which is caused by defective nutrition, and is dependent on the absence of certain necessary constituents of food. It has been found to occur amongst persons such as sailors, prisoners, and soldiers on active service, who have been deprived of fresh meat and vegetables and fed on a monotonous diet such, for example, as salt meat and biscuit. Prophylactic and curative measures consist in the maintenance of a due supply of fresh animal food and especially of fresh vegetables. In the navy and the mercantile marine, lemon or lime juice served out daily in certain quantity is found to serve as a prophylactic against outbreaks of this disease. It has been stated by Garrod that the occurrence of scurvy is due to the absence of potash salts in the food, and that the remedial value of fresh meat, fresh milk, fresh vegetables, and of fruit juices, depends on their supplying the potash salts necessary for healthy nutrition. Infants fed exclusively on what are termed " proprietary foods " have been observed to become scorbutic. Cheadle remarks that he has found scurvy in children brought up on peptonised milk and on patent pancreatised farinaceous foods. " Clearly the process of peptonising or pancreating in some way impairs the virtue of the anti-scorbutic element in milk." To the diet of such children should be added, as anti-scorbutics, potato-pulp, fresh milk, and raw meat juice. The following is a method for making fine, potato gruel for this purpose : Rub steamed flowery potatoes through a fine sieve, beat this up well with milk till smooth and of the consistence of thin cream. A teaspoonful of this may be added to each bottle of food, at first, and gradually increased to a dessert- spoonful Chap, via.] DIET IN SCURVY. 477 Well-boiled carrots may be used in the same way. Broths in which such vegetables as carrots and potatoes have been boiled and strained out are also useful. The juice of oranges and other fresh fruits is also of much service. In all tliese fresh foods their anti-scorbutic in- fluence is believed to be due to the presence of potash in combination chiefly with organic acids such as citric, malic, aud tartaric acid. When fresh vegetables cannot be obtained, a certain amount of lime juice or lemon juice may be taken instead. In certain forms of the disease, when there is persistent haemorrhage, it has been main- tained that neutral citrates and tartrates act better than fresh lemon juice the latter seeming to favour the uozing of blood.* The state of the mouth in some of these cases must be taken into consideration in determining a suitable dietary. When there is stomatitis and the gums are tender, swollen, and bleeding, we must give soft, unirritating food that does not need mastication such as fresh milk, eggs, meat broths and soups, purees of fresh vegetables, together with orange or lemon juice. For patients who are able to masticate, a choice amongst any of the following foods may be permitted, as they all possess anti-scorbutic properties: fresh meat, potatoes, fresh green vegetables of all kinds, pickles, as well as the foods already referred to. The close pathological relationship, if not identity, between scrofula and consumption makes it ap- propriate to discuss their dietetic management together. Consumption is also the type of chronic febrile disorders, and the progressive emaciation, which is its characteristic feature, and from which it derives its name, is chiefly dependent on the presence in the great majority, or, at some time or other, in all cases, of more or less fever. It is the progressive * Wright : British Midical Journal, vol. ii., 1SD4, p. 37. 478 FOOD IN DISEASE. [Partii. destruction or consumption of the tissues caused by this chronic fever that we are called upon to antagonise or compensate for by appropriate food. And the dietetic measures which are expedient and useful to check the wasting of consumptives are applicable also to other cases in which a chronic pyrexial state is present. When a child shows the well-known signs of a scrofulous constitution, or when he is known to in- herit a tendency thereto, it becomes a matter of great importance that he should be well and carefully fed. It is not, however, necessary to repeat here what has already been said in the chapter on Food in Infancy and Childhood : the principles of wholesome feeding during this period and the means of carrying them out have been there fully dwelt on. There can be no doubt that an insufficient or inappropriate diet in the early years of life predisposes to the development of scrofula, not only in those who have a hereditary tendency thereto, but in others also. A poor, coarse, innutritions vegetable dietary, involving much diges- tive effort for its assimilation, and often causing irritation of the organs of digestion, and yielding little nourishment in proportion to its bulk, is, no doubt, provocative of many of the manifestations of scrofula observed amongst the children of the poorer classes ; while, on the other hand, a sound and rational diet in infancy and early life acts as a most efficient prophylactic against the development of this disease. We should be careful in all such cases to avoid the administration of food calculated to set up irri- tation of the child's digestive organs ; or, if such already exists, we should at once supply a bland, unirritating diet calculated to remove it. In poor families it is often the custom to allow quite young children to partake of the same coarse food as the grown-up members of the family. This is a most pernicious custom, and often proves highly injurious even to the most robust children. How Chap, viii.] DIET IN SCROFULA. 479 much more so must it, therefore, be to the delicate and scrofulous? Such children should have an abundant supply of good milk as the basis of their diet, also sound whole- meal bread and plenty of butter. Easily-absorbable fats are especially valuable to the scrofulous. Cod- liver oil is one of the best, and it has the advantage, if regularly given, that it tends to overcome the constipation so common in scrofulous children ; but many other forms of fat are extremely useful, such as butter, cream, bacon fat, dripping. Bread lightly toasted and soaked in fluid bacon fat or dripping is generally liked by children, and is most wholesome. Suet puddings, served with treacle, sugar, or jam, are also generally popular with children, and may be made the means of introducing a considerable amount of fat in the food, which would be rejected if presented in its natural form. Mutton suet, chopped fine and boiled in milk and sweetened, is another useful expedient of the same kind. It is always necessary to pay much attention to the digestion, and at once to modify the diet if it is found to be attended with signs of dyspepsia. In scrofulous children of the fat and flabby type it is not so important to administer fatty foods. It is better in such cases to give a diet rich in al humi- liates, but small in bulk. The common error is to keep such children too exclusively on farinaceous foods, and to give them a very insufficient supply of animal food. In children with very delicate digestions it is often difficult to get them to take fats or oils of any kind. In such cases inunction with oil cod-liver oil or olive oil after washing the surface with hot water and soap, is a good plan. All these cases require also an abund- ance of respiratory food, an abundance of active oxygen, which they should be allowed to obtain by a life in the open air in the country or by the sea. 480 FOOD IN DISEASE. [Partii. In cases of a disease like pulmonary consump- tion, attended with a chronic febrile condition, and consequent continuous loss of weight, unless this progressive wasting is counterbalanced by the supply and annexation of an adequate amount of food, the patient must, in course of time, succumb to the disease. But not only is it necessary in such cases to arrest the loss of weight, we must also strive t o to improve the nutrition that the body may gain in weight ; for it is well known that if we are able to establish an improved state of nutrition, the disease itself becomes favourably influenced thereby. Our success in this effort will depend much on the amount and type of the febrile state which accompanies the malady. When there are distinct intermissions or remissions in the febrile movement, and when this is quite moderate, we may succeed in procuring the assimilation of a considerable quantity of food, pro- vided great care and discretion be employed in its selection and preparation. But when the fever is considerable and persistent, and the digestive func- tions (as is usually the case under such circum- stances) are greatly impaired and appetite is entirely absent, it may be difficult or even impossible to obtain the appropriation of a sufficient quantity of food to exercise any adequate check on the wasting process. In such cases we are compelled to have recourse wholly to fluid and easily-absorbable foods in much the same manner as in the dietetic manage- ment of acute febrile diseases. It is a generally-accepted rule that, in the diet of the consumptive, fats and carbohydrates i.e. the especially fattening forms of food should be at any rate adequately, if not superabundantly, represented. A proper proportion also of albuniinates must be included in their dietary. One of the greatest difficulties we encounter in providing a suitable and adequate diet for consump- tives is the frequency with which they complain of digestive troubles, want of appetite, and occasionally Chap, vin.] DIET IN CONSUMPTION. 481 of positive disgust for food. Under such circumstances it is most important to provide well-cooked, appetising, and attractively-served food, varied as much as possible, and, so far as is consistent with whole- someness, agreeable to the tastes of the patient. In the distinctly febrile forms it will be advisable to give small quantities of nutritious food at short intervals. Some suggestive observations as to food in Dr. H. Weber's lectures on the " Hygienic Treatment of Phthisis " may be here quoted. He directs attention to " the possibility that there may be important rela- tions between the life of the tubercle bacillus and the quantity of the food that we take, especially the saline materials which enter into the composition of the blood, the cells, and tissues Microbes require mineral food in the same way as plants and animals do; and if we knew exactly which mineral substances the tubercle bacillus requires, and could without harm to ourselves deprive our blood, and cells, and tissues of these salts, by abstaining from food containing them, we should deprive the bacillus of the means of existence." * The difficulties attending such an investigation are, of course, very great. A hint in the right direction may possibly be gained from the fact " that the food of carnivorous animals i contains a larger quantity of soda and smaller of : potash than that of herbivorous animals, and carni- vorous animals are on the whole less subject to tuber- culosis than herbivorous animals. If it could be proved that the potash salts are more conducive to the growth of tubercle bacillus than soda salts, articles of food containing excessive proportions of potash ought to be taken only sparingly." G. Se*e also suggests that the use of cod-liver oil may produce a condition of the tissues hostile to the propagation of the tubercle bacillus ; this may be due, he thinks, to the oil appropriating some of the oxygen required for the active multiplication of the microorganism. * "Croonian Lectures," p. 47. F P 482 FOOD IN DISEASE. [Partii. " The oil then acts as a protective agent to our organism, it acts as a destructive agent to the micro- organisms ; our waste is lessened, which is useful ; the nutrition of the bacillus is interfered with, which is still more useful." "* Phthisical patients, whose digestive functions are unimpaired, may be allowed to partake of the various nourishing forms of food that enter into the ordinary dietary of the healthy, in addition to which two or three glasses of milk should be taken at convenient intervals between meals, and one of these glasses of milk should be taken the last thing at night, or even preferably during the night if the patient is awake. Milk is a most valuable food for the consumptive, and we have already mentioned the several expedients which may be adopted for promoting its digestibility when it is not well borne. By adding to each glass of milk two tablespoonfuls of hot water in which about six grains of bicarbonate of soda and five gi'ains of common salt are dissolved, we can often remove the difficulty in the digestion of milk, particularly when the milk is very rich. When we find evidence that the patient really cannot digest the casein of milk i.e. when we find hard curds of milk rejected by vomiting, or giving rise to intestinal troubles and forming the chief part of bulky white motions then we should make use of whey as a beverage. Its mode of preparation has already been described. A little cream may be added to it if desired. Cream may also be made more digestible and more acceptable to many patients by mixing it with an equal quantity of hot water, and adding to each teacupful of the mixture a teaspoonful of the aromatic spirits of ammonia ; some prefer a teaspoonful of brandy. In other cases we may use peptonised milk, and I have found patients able to digest Savory and Moore's peptonised milk when they have rejected oiilk in every other form. * " Regime des Phtlmiques. Du Regime Alimentaire," p. 400. Chap, vino MILK IN PHTHISIS. 483 Some physicians consider it impoi-tant that the milk should be drunk almost immediately after it has been drawn from the cow, and that it is more diges- tible and nutritions when perfectly fresh than after it has been boiled. Jaccoud * makes a great point of phthisical patients who dwell in the country drinking the milk in the cow's stables, not only that they may thus get the milk perfectly fresh, but that they may breathe the atmosphere of the stables for a short period two or three times a day. He says he is very sure that this atmosphere has the effect of allaying bronchial and laryngeal irritations, and of relieving cough. He also considers that the addition of some form of alcohol (brandy, rum, or kirsch) presents the double advantage of being useful in itself and promoting the digestibility of the milk. Germain Se"e considers the peculiar value of milk in phthisis to depend upon the fat it contains, and he argues that when enough milk is taken to provide the requisite amount of the other elements necessary for the nutrition of the body, the fatty constituents are in large excess, and this he regards as its great recommendation. For an exclusively milk diet, he estimates the necessary quantity at three litres daily (105 ounces), rather more than five imperial pints. In many summer health-resorts in Switzerland and Germany provision is made for following a "milk or whey cure," and in most of these sheep's, goat's, and ass's milk, as well as cow's milk, can be procured. There is no reason, however, for believing that goat's milk is more digestible than cow's milk ; but, in the case of diarrhoea, it is thought to be preferable on account of the lime salts it contains. Ass's milk, howevei*, like mare's milk, can often be taken when cow's milk has proved indigestible. Some of the older physicians, who highly prized ass's milk in the treatment of phthisis, took great pains in seeing to the feeding of the animals that * "Curabilit^ et Traitement de la Phthisic Pulmonaire." P P 2 484 FOOD IN DISEASE. [Part n. yielded the milk pains which we may well believe were not wholly wasted ; * more recently Latour added large quantities of common salt to the food of goats in order to obtain milk largely charged with what he considered a valuable remedy in the treatment of phthisis. It is, perhaps, well to remember that the con- sumption of large quantities of milk, to the exclusion of other food, occasionally leads to troublesome con- stipation, and that this may often be remedied by mixing a little seltzer-water with the milk. Koumiss, or fermented mare's milk, has acquired a great reputation in Russia in the treatment of pulmonary tuberculosis, and the Russians resort in considerable numbers to those stations on the borders of the Caspian Sea, amongst the Kirghis and Tartar tribes, where the koumiss cure is carried on. How much of the good results obtained at these stations is to be attributed to the' pure aseptic air breathed in these extensive plains and how much to the koumiss it is not possible to estimate ; but there can be no doubt that many phthisical patients derive much benefit from following this course. t The Russian koumiss is prepared from animals kept at liberty, and not worked. Mare's milk, owing to the large amount of lactose it contains, readily undergoes fermentation, the result of which is the production of a sour, highly gaseous fluid containing alcohol, carbonic acid, and lactic acid. In Europe it is now lai-gely prepared from cow's milk. The cows should be fed in open pastures, and special means are adopted to diminish the relative amount of casein and increase the relative amount of sugar contained in cow's milk. It must be regarded as a food intermediate in character between milk and alcohol more stimulating than the former, more * Vide Fonssagrives, " The'rapeutique cle la Phthisie Pulmon- aire," p. 235. t The establishments kept by Dr. Postnikoff and Dr. Annaeff at Ssamara can be recommended to those who may wish to try the Koumiss cure in the Russian steppes. Chap, viii.] FOOD IN PHTHISIS. 485 tonic than the latter. Unfortunately, many persons cannot overcome their dislike to it as a beverage. When it is well borne, it is found to be easy of digestion, often relieving dyspepsia and vomiting, and producing increase of weight. It is appropriate to febrile cases, as it quenches thirst, and can often be retained in the stomach when all other food is re- jected ; indeed, its especial value is in those cases of inveterate dyspepsia and gastric irritability in which all attempts at giving other kinds of food have failed. Galazyme and kefir, employed for the same purpose as koumiss, have been already described. The utility of fatty substances in phthisis is undoubted, and in those cases in which we encounter an insuperable difficulty in procuring the acceptance or the digestion of cod-liver oil, we may encourage our patients to consume as much fresh butter and good cream as they can digest. Excellent results have been obtained, even in some advanced cases, from the administration of cream. We have already mentioned a suitable mode of giving it. Some order a little rum or brandy to be mixed with it. The addition of sugar or salt is said to aid its digestion ; or it may be mixed with a little tea or coffee, when these beverages do not disagree. Cocoa and chocolate are useful forms of food, and contain a notable quantity of fab. Savory and Moore's peptonised cocoa and milk is very useful. Cocoa, as a beverage, is more digestible when made with water than when made with milk. Pancreatic emulsion will be found of service in many cases where there is difficulty in tolerating other forms of fatty food. Of the various forms of animal food, well-cooked beef, mutton, chicken, and game ; clear turtle soup ; oysters ; many kinds of tish soles, whiting, turbot, cod, herrings, flounders, smelts, brill are all suitable to vary the diet of the phthisical. The use of raw meat has been highly extolled, 486 FOOD IN DISEASE. [Part n. especially by some French physicians, and Professor Faster, of Montpellier, has claimed the most brilliant results from its administration in cases of phthisis. These results have not, however, been confirmed by other observers, although it is generally admitted that in many cases of troublesome dypepsia and loss of appetite, especially when associated with diarrhoea, raw meat has rendered real service. Various expedients have been adopted to overcome the repugnance which most patients at first manifest for this form of food. In all cases it should first be reduced to as fine a state of subdivision as possible by scraping or cutting and pounding, or, better still, by the use of the little machines now made for this purpose.* Raw meat may also be reduced to a fine dry powder by first drying and then grinding it. Pounded raw meat can, moreover, be made up into small round pellets, and covered with powdered sugar or gum or any other innocent covering, and swallowed with a little wine and water or brandy and water ; or it can be mixed with a little hot clear soup. And it goes especially well mixed with light tapioca soup ; this can be flavoured with any agreeable flavouring and drunk readily, and the mouth cleansed by drink- ing a few mouthfuls of weak brandy and water or claret and water after it. The sending of phthisical patients to slaughter- houses to drink the raw blood of animals as they are killed is more sensational and whimsical than rational and efficacious. Loomis (H. C.) has strongly advocated the use of beef juice in phthisis, obtained in the manner he thus * Pebove recommends that it should be "scraped with a knife, so as to detach all the muscular fibres and separate them from the fibrous tissues ; " and he points out that what renders it so valu- able as a food is its extreme subdivision, which multiplies the surfaces of contact and allows each fibre to be completely bathed by the digestive juices ; also, as it has not been hardened by cooking, it allows these juices to penetrate it more readily. "La Tuberculose Parasitaire, p. 77. Chap, viii.] FOOD IN PHTHISIS. 487 describes : "To obtain from the meat the maximum amount of juice, a meat-squeezer is absolutely essential. The best kind of meat from which to squeeze the juice is a thick round steak, free from fat. This should be seasoned with pepper and salt, broiled over a quick tire, then cut in pieces two inches square, and then put into the meat squeezer. About 8 oz. of juice can be obtained from each pound of meat. No heat can be applied to this juice, as the albumin would be at once coagulated and the juice rendered more than useless. If the juice becomes cold and it is advisable to heat it, this can be best accomplished by placing the cup in hot water. It is necessary to go fully into the preparation of this beef juice, because of its importance as one of the most essential items in the diet of phthisis. Freshly-squeezed beef juice is the best of the artificial preparations of meat known, and the trouble of preparing it is well repaid by the marked improvement in the patient." In some parts of Germany the roes of salted herrings, and in France several species of snails, are thought to be especially useful as food for the phthisical. The different kinds of farinaceous foods are all useful and appropriate articles of diet. Whole meal or well-made brown bread is, on account of the phos- phates contained in it, better suited to young con- sumptives, if they digest it well, than white bread. Lentil flour is also valuable, as it contains notable proportions of phosphates and iron. Oatmeal is rich in fatty matters, and the flour of maize is still richer a fact which renders them both very suitable additions to the diet of the tuberculous. Malt Extract is now largely employed as an addi- tion to farinaceous food, the digestion and assimila- tion of which the diastase contained in it doubtless facilitates. It is possible also to procure malt bread and malt biscuits. With regard to the use of alcoholic beverages much difference of opinion exists. 488 FOOD IN DISEASE. [Partii. Some advocate the consumption of large quan- tities of alcohol in phthisis. Flint* quoted cases which appeared to have been benefited by the con- sumption of as much as a pint of whisky daily ! We shall find, practically, that the use and need of alcohol vary greatly in different individuals. Tn some it diminishes appetite and retards diges- tion ; in others it promotes both ; and we shall encounter very few cases of phthisis which are not benefited, at some period of their course, by the dis- creet administration of alcoholic stimulants. Germain See deduces from experimental data the following conclusions as to the use of alcohol in tuberculosis : (a) If there is fever it moderates it. (b) If there is no fever it supports the strength. (c) In all cases it diminishes bodily waste and emaciation. It is noteworthy, also, that physicians, likeBrehmer of Gobersdorf and Dettweiler of Falkenstein, who have quite exceptional experience of the daily needs of phthisical patients, use alcohol largely. Every additional year's experience convinces us that most of the reputed harm accruing from the use of alcoholic stimulants in phthisis is due to the want of care and discrimination in the choice of the beverage used. It is exceedingly necessary that the beverage, whether wine, spirits, or beer, should be pure and of the best quality. When the patient is able to drink fermented malt liquors, he may be allowed one or two pints daily of good sound bitter beer, or porter, or stout ; of wines, a half a pint to a pint of really good Bordeaux or Burgundy, or of some of the better descriptions of Hungarian, and Italian, or Greek wines. Port and sherry we have found objectionable in most cases, dis- turbing digestion, and often causing headaches ; a pro- portionate quantity of whisky or brandy is preferable * In bis work on "Phthisis." Chap. VIII.] SURALIMENTATION IN PHTHISIS. 489 to either of these wines. Avoid, with the greatest care, cheap, bad, acid clarets, the extended consump- tion of which does infinite mischief ; most Australian wines also are heavy and difficult of digestion. In febrile cases, small quantities of alcohol given frequently have an excellent effect in supporting the strength ; and especially during the night is it im- portant to give two or three tablespoonfuls of brandy or whisky, alone, or with a little fluid food, such as milk, or beef-tea, or a whipped egg. What is termed by the French physicians " ali- mentation forcde " i.e. forced feeding is an expe- dient suggested by Dr. Ddbove of Paris for intro- ducing food in large quantities into the stomachs of phthisical patients who have lost all appetite, or even acquired a positive repugnance for food. D^bove also maintains that his method of artificial alimentation, with or without a previous washing out of the stomach (" lavage de I'estomac ") with iced water, is a most efficacious measure for arresting the vomiting of phthisical patients. Debove discovered, by accident, that in cases in which all food introduced into the stomach in the ordinary way was rejected by vomiting, food intro- duced by the cesophageal tube was, strange to say, retained ; and on this observation he founded his method of artificial " sur alimentation." He finds he is able to introduce by this means into the stomach an " excess " of food which is retained and digested ; and he truly observes that a person with phthisis re- quires considerably more food than a person in health on account of the considerably greater bodily waste taking place. He has also observed that the digestive power of the patient has no relation with appetite. " A patient who has no appetite, or who has a marked disgust for all food, will digest perfectly a large meal introduced by the tube, and even at the end of a certain time will recover appetite." * * Lemons Cliuiques et Therapeutiquea BUT la Tuberculose Tarasitaire," p. 82. 490 FOOD IN DISEASE. [Panii. As the results of suralimentation, or excess of food, he has observed disappearance of night sweats, diminution and disappearance of cough and expectora- tion, increase of strength, rapid gain in weight, and at the same time a considerable amelioration in the physical signs. By the use of powdered raw meat, Debove, and Dujardin-Beaumetz in Paris, and Peiper in Griefs wald, have been able to apply the principle of sur alimentation without the necessity of using the cesophageal tube. Dujardin-Beaumetz gives the following instructions for making this powder : Take the lean of beef, cut it up into small pieces, dry it in a water-bath ; when thoroughly dried reduce it to powder in a coffee-mill, or by means of a ^lachine constructed by Galante (No. 2, Rue de 1'Ecole de Medecine, Paris). This powder can be mixed with lentil flour, an I taken in the form of soup, or, better still, it may be mixed with chocolate, or with grog " grog de la poudre de viande." To make the latter, you place in a bowl two tablespoonfuls of meat powder, to this you add three dessertspoonfuls of " syrup of punch " (essence of rum punch), and enough milk to make a perfectly fluid mixture. By these means you can give from 1,500 to 6,000 grains of meat powder daily;* the latter quantity would be equivalent to 24,000 grains, or three and a half pounds of raw meat. Or it may be given, as recommended by Debove, simply mixed with milk ; first adding just enough milk to make a smooth paste, and then mixing in the remainder so as to make a uniform fluid mixture that can be readily drunk. It is necessary in using these powders to see that they are genuine, and not over dried. De'bove attempts to explain the beneficial effect of " suralimentation " in the following manner: "The tubercle bacillus develops in a certain soil, a soil which becomes less favourable to its culture when it is modified by suralimentation [excess of food ] ; this, * Dujardin-Beaumetz, "L'Hygiene Alimentaire," Paris, 1887. Chap, viii.i DAILY DIETARY IN PHTHISIS. 491 indeed, augments combustion, as is shown by the amounts of urea excreted in the twenty-four hours amounts which reach 900 grains, 1,200 grains, and even more. We may also say that by this method we give our patients the power to resist their disease ; as when the vine is attacked by the phylloxera, one of the best remedies is to manure well the land ; by so doing, we do not destroy the parasite, but we give the plant the force necessary to struggle against it." Since the adoption of powdered raw meat for sur- alimentation, the introduction of food into the stomach by means of the oesophageal tube is reserved for those cases in which, owing to irritability of the gastric mucous membrane, food taken in the ordinary way cannot be retained in the stomach. While we should do all in our power to encourage our phthisical patients to take an abundance of nourishing food (and for this purpose we should make their diet as varied and attractive as possible), we must be careful not to admit into their dietary forms of food which, although attractive to the patient, tend to exhaust his digestive forces without rendering him an equivalent amount of support and nourishment. We should, therefore, exclude pastry, uncooked fruits, salads, pickles, and all forms of indigestible food. H. Weber objects to potatoes on account of the amount of potash they contain. " Experience shows that the exclusive or even preponderating use of potatoes favours scrofula." It would be undesirable to tix too rigidly the daily dietary of the phthisical, but the following scheme may serve as a general guide a sort of plan of route from which wide excursions may be made under the guidance of a discreet physician : On waking in the morning, a tumblerful of milk should be taken mixed with a little hot water, to which it is often useful to add a few grains of common salt and bicarbonate of soda, especially when a certain amount of accumulated mucus has to be got rid of by expectoration. There is no objection to 492 FOOD IN DISEASE. [Partii, taking a little tea, coffee, or cocca at this hour, with milk or cream, if preferred. Sometimes the stimulus of a tablespoonf ul of brandy, rum, or whisky is needed at this time. The first meal is often best taken in bed. About an hour afterwards a substantial breakfast should be taken, consisting either of broiled bacon and lightly-boiled eggs, or some fresh fish, or some cold meat or game or poultry, and with this meal milk, or cocoa or coffee or tea, or some good sound light wine and water may be taken, according to taste. Supposing this meal to be taken about nine or ten o'clock, a glass of milk or a cup of beef-tea should be taken about noon. Half-past one or two o'clock is a good hour for the chief meal of the day. This should consist of some fish when it can be procured fresh and good, together with some meat, chicken or game, and fresh vegetable ; and some light milk-pudding with a little marmalade or other cooked fruit. With this meal half a pint of good Hungarian wine, light claret, or Burgundy, or an equivalent quantity of brandy or whisky and water, may be taken. At five in the afternoon another glass of milk should be taken, or a cup of thin chocolate, or tea with plenty of milk or cream ; or the yolk of an egg beaten up with a little brandy and water may be substituted, if preferred. It is rarely desirable to order any solid food at this hour if it is intended that the patient should make another substantial meal at seven. At this hour a meal similar in all respects to that taken at 1.30 or 2 o'clock should conclude the substantial feeding of the day. About half an hour before bed-time (which should not be later than 10 or 10.30 p.m.) another glass of milk, prepared in the same manner as that in the ruorning, together with one or two tablespoonfuls of brandy or whisky ; or a cup of arrowroot, or beef-tea, or tapioca soup, according to taste, may be taken. And, finally, some provision of light nourishment Chap, vin.) DAILY DIETARY IN PHTHISIS. 493 mixed with a little stimulant should be arranged in order to be taken during the night when woke by coughing or after perspiration, or when merely restless. A glass of Vichy water, taken warm, half an hour before meals, as recommended by G. S6e, may be found useful in some cases and to promote the secretion of gastric juice. In distinctly febrile cases a much more fluid dietary will have to be followed, and the food will require to be taken at shorter intervals. 494 CHAPTER IX. DIET IN AFFECTIONS OF THE CIRCULATORY AND RESPIRATORY ORGANS. THE diseases to which we shall refer in this and the following chapter are, speaking generally, less directly amenable to dietetic treatment than those we have previously had under consideration. Some of them, such as acute rheumatism, for example, and its complications, would naturally fall under those general dietetic instructions which we have given for the management of febrile maladies. The same remark will, of course, also apply to acute affections of the respiratory organs and to acute febrile dis- turbances of the circulatory system. It is on this account that we shall be able to deal somewhat briefly with the dietetic management of most of these maladies. With regard to affections of the circulatory system. In chronic cardiac valvular disease, when compensation is well maintained, no very rigorous dietary is necessary, but a few general rules may be laid down, with advantage, for the guidance of these cardiac patients. They should avoid, for the most part, all foods which tend to excite an undue amount of gastro-intestinal fermentation for by causing flatu- lent distension of the abdomen, and so pushing up the diaphragm, the cardiac region is encroached upon and the circulatory difficulties are thereby greatly in- creased, and palpitation or a sense of oppression at the heart, and dyspnoea are apt to be excited. Pastry, entrees, stews of all kinds, saccharine and farinaceous foods, should be avoided. The meals should not be too copious, so as to over-distend the stomach. They Chap, ix.j DIET IN CARDIAC DISEASE. 495 should be strictly moderate in quantity, well cooked, and in an easily digestible form. The meals also should not be in too quick succession, but ample time should be given for the digestion of one meal before another is taken. Tea" and coffee should be only taken in small quantities at a time, not strong, and not with food. China tea is to be preferred, for reasons already given. It is best to take but very little fluid while eating, but to drink what is needed slowly, after a meal. All malt liquors should be avoided, and very little if any alcohol taken. The principal meal is best taken in the middle of the day ; the evening meal should be a light one. When in these cases dyspeptic troubles arise from temporary portal obstruction and congestion of the gastro-intestinal mucous membrane, the patient should be put on very light food, and the drinking a glass of Vichy water half an hour before each meal is often very useful. The physicians of the Paris school often have recourse for a time to an exclmive milk diet in these cases of cardiac dyspepsia : this gives rest to the stomach, and by promoting free diuresis tends to lower vascular tension, and to regulate the circula- tion. After a time the ordinary diet may be resumed, avoiding always those fermentable foods already referred to. Tobacco should be prohibited, as its use is apt to hasten the approach of the stage of loss of compensation. When compensation fails, attention to dietetic rules becomes more necessary. In these cases the French physicians are very greatly in favour of an exclusive milk fliet for a time partly because it favours diuresis, and so tends to obviate the occurrence or aggravation of dropsical effusions. Alcohol in some form, and in moderate quantity, is often now needed occasionally, and two or three tablespoonfuls of whisky or sound brandy in the twenty-four hours, well diluted with water, is, on the whole, the most suitable. 496 FOOD IN DISEASE. [Partii. It is especially important in these cases care- fully to avoid an excess of fluid, for an excessive ingestion of fluid over-distends the blood-vessels, heightens arterial tension, overtaxes the heart, disturbs the efforts at compensation, and promotes congestion, oedema, and anasarca. But in avoiding an excess of fluid we must not go to the other extreme too little fluid has also its dangers. It may lower arterial pressure dangerously, and may retard the elimination of excretory sub- stances through the renal and other channels. A certain amount of water is absolutely necessary for solvent and excretory purposes. The amount of fluid permitted must be estimated in each case accoi'ding to its special features, the condi- tion of the vessels, and the character of the excretions. We have already alluded to the tendency in chronic valvular diseases to the occurrence of dyspeptic troubles; these are necessarily more prone to arise in non-compensated cases than in compensated ones, and are closely dependent on the hepatic engorgement and gastro-intestinal catarrh caused by the back- pressure of the blood. What we have said in another chapter of the dietetic treatment of chronic gastric catarrh will apply to these cases. Concentrated fluid foods or predigested foods are often best suited to many of these cases. Milk, whipped eggs, light clear consomme*, may be taken at moderately short inter- vals three or four hours ; then, when improvement of the gastric functions has set in, we may give some pounded underdone beef or other meat, chicken, or white fish. The object should be to give small quantities of concentrated and easily digested food, and to take care that the stomach is never over- distended by too copious a meal, or by the frequent repetition of meals. All coarse and readily fermentable foods are to be eschewed, and particularly saccharin, farinaceous, and fatty foods. All wines, beers, effervescing drinks, are, as a rule, best avoided. Chap, ix.] DIET IN ARTERIO-SCLEROSIS. 497 Occasionally a small cup of coflee or China tea, taken by itself, may be permitted ; but in some cases these beverages are apt to excite flatulent dyspepsia, and must then be abandoned. Some attention must be paid to the tendency to constipation which is usually present in these cases, and some cooked fruit pulp, or stewed prunes or tigs, or some vegetable puree made without meat gravy may be advantageously added to the dietary. It is necessary in children with chronic valvular disease to watch carefully their food habits. All gorging must be provided against, and the diet should be of extreme simplicity milk and light milk- puddings, with a little fruit juice are suitable, but pastry and sweets should be strictly forbidden. Cases of artcrio-sclcrosis may, no doubt, be favourably influenced by diet, especially those cases in which renal changes are present or imminent. In many of these cases, again, the French school approve of the adoption of a milk diet especially with the view of eliminating toxic substances by the kidneys but it is only necessary in a limited number of cases to apply an exclusive milk diet. A mixed diet may be taken by the greater number, and this may consist of milk, fresh vegetables, a few eggs, and well-cooked fresh meat. But it is to be borne in mind that meat is the chief source of "alimentary toxins," and its consumption should be reduced to a minimum. Pork, high game, all meat stews and twice-cooked meat, meat gravies, greasy soups, soups that may contain ptomaines, preserved meats, shell-fish, and Crustacea, must be avoided. An exclusive milk diet has been found of value in those cases that are accompanied with rebellious headaches and grave dyspnoea. Its value depends upon the fact that, as a food, it brings into the or, if desired, substituted for the tea. If oat- meal porridge be taken, nothing else must be taken with it, and not more than 3 or 4 oz. of oatmeal and 4 or 5 oz. of cream. Dinner at 1.30 to 2 o'clock, of two courses only : fish and meat, or fish and pudding, or meat and pudding ; no soups, pastry, pickles, or cheese. Half a haddock, or its equivalent in any other white fish, boiled in milk, steamed or broiled, never fried. Wing and part of the breast of a chicken, or its equivalent in sweetbread, tripe, game, or mutton ; one potato, or a little spinach. The pudding should be a simple milk pudding, or about -*- Ib. of such fruit as pears, apples, grapes, etc., instead, either cooked or uncooked. 4 or 5 oz. of water may, if wished, be sipped during this meal. Tea. 5 to 6 p.m., 3 to 4 oz., no paiticle of solid food with it, but cream and sugar, if wished. Hot water, 4 to 5 oz., may be taken instead of it, with, if needed, a teaspoonful of Liebig's Extract. Supper. 7 p.m. White fish and a potato, or toast with butter, or some milk pudding, or Revalenta made with milk or with Liebig's Extract. At bed-time, 4 or 5 oz. of water. Chap, ix.] DIET IN ANEURYFM. 501 " On such a dietary a weak digestion from a feeble heart will gradually recover its tone, and the patient will feel comfortable instead of being puffy and oppressed after meals, with an irregular and trembling heart." * If the patient loses flesh too rapidly, the diet must be made more nutritious ; if the patient is obese, and slow in. thinning, a little more self-denial, especially in the fluids, will be re- quired. The following are the four dietetic rules Balfour formulates for all those with weak hearts, and they agree in the main with our own experience : 1. There must never be less than 5 hours between each meal. 2. No solid food is ever to be taken between meals. 3. All those with weak hearts should have their principal meal in the middle of the day. 4. All those with weak hearts should have their meals as dry as possible. It is especially necessary with these patients that there should be a sufficiently long interval between meals, for in persons with weak hearts and feeble circulation, digestion is slower than in the healthy and strong, and at least 5 hours is needed for the digestion of a meal. For the same reason it is most important that no solid food should be taken between meals, as it tends to arrest the incompleted digestive process and provokes flatulence and acidity. It is, however, often an advantage to take some hot fluid 3 or 4 hours after a meal, as it will often start afresh a flagging digestion a7id wash the remains of the meal out of the stomach. A few remarks on the dietetic treatment of aneiirysm will conclude what we have to say with regard to feeding in disorders of the cii-culation. The severe and rigorous dietetic treatment which used formerly to be applied in cases of internal aneurysm is rarely employed now. Our own ex- * "Tbp ^nile Heart," p. 248. 502 FOOD iff DISEASE. perience has shown that so far from uniformly quieting the circulation and slowing the action of the heart, in some cases it produces a sort of nervous excitement of the circulation and a quick and weak heart-beat is often the result. At the same time the anaemic and depressed nutrition, following the extreme abstention and enforced repose, has seemed to us often to lead to further distension of the aneurysmal sac. Better results are certainly obtained now in the treatment of aortic aneurysm by the administration of potassium iodide, together with a quiet restful life and a moderate amount of food, avoiding especially too much fluid, so that there shall be no over-distension of the vessels. TiifnelVs diet, which has very frequently been applied to the treat- ment of aneurysm associated with prolonged absolute rest in bed in the horizontal position is constructed as follows : Breakfast. 2 oz. of bread with a little butter, and 2 oz. of milk. Dinner. From 2 to 3 oz. of meat without salt, and 4 oz. of milk or claret. Supper. The same as breakfast. This diet has been found useful in certain forms of aneurysm probably of traumatic origin, but it is rarely useful in those cases which depend on de- generative changes in the vessels ; in such cases a dietary limited to simple forms of food, and suf- ficiently moderate in amount to avoid any risk of vascular over- distension or cardiac excitement, is best; and especially should we ensure a careful restriction in the quantity of fluids permitted, even if the patient should suffer somewhat from thirst, which may usually be appeased by sipping a little acidulated water. We now pass to the consideration of diet in diseases of the respiratory organs. There are few diseases of the respiratory organs that are in any Chap, ix.j DIET IN RESPIRATORY DISEASES, 503 direct sense under the special influence of diet, and such general rules as our readers must now be familiar with will serve for their guidance in most acute and many chronic respiratory affections. What we have said elsewhere* on this subject, we may repeat here ; and, first, with respect to diet in acute pneumonia. In this disease the diet should be fluid and light, and adapted to the enfeebled digestive powers and to the febrile state. Milk, well diluted with water, or some effervescing alkaline water when there is any tendency to sickness, is a good and convenient food. The occasional vomiting of coagu- lated milk should be carefully noted, for it then usually requires further dilution with some alkaline water, or it should be peptonised. Light, clear soups and broths may also be given, and there is no harm in a cup of well-made tea or coffee now and then, and they are both cardiac stimulants. Strong coffee is too little used in these cases. It has a tonic effect on the heart. Thirst may be allayed and the mouth kept clean and moist by sipping iced lemonade, toast- and- water, or barley-water, according to choice. When more stimulating food seems called for, eggs may be given beaten up with boiling water and one or two dessertspoonfuls of brandy or whisky added. Strong beef-tea or meat juice, and thin arrow- root may also be given, with some added spirit, in the same way. If there is co-existing bronchial catarrh, and the expectoration is viscid and difficult of ex- pulsion, hot milk and seltzer-water in equal parts, with 2 or 3 teaspoonfuls of brandy, serves both as a stimulating food and a useful expectorant. With regard to the use of alcoholic stimulants, we are con- vinced that in more than two-thirds of the cases of acute pneumonia, as they are generally encountered, there is no need of them whatever. The routine administration of alcohol in pneu- monia, especially in the early stages, with the idea of * "Manual of Medical Treatment," fourth edition, Part III., chnp. 5. 504 FOOD IN DISEASE. [Partii. preventing cardiac failure, is, we think, a serious error. Alcohol produces vaso-motor paresis and causes dilatation of the vessels and it must therefore ag- gravate or induce tendencies to vascular engorgement. It acts like a poison to many persons, and causes considerable nervous and general depression after its first stimulating effect passes off; it increases the amount of toxic substances in the blood, and the elimination of considerable quantities of alcohol must impose a severe strain on the already overtaxed organs of excretion. When we further consider the large quantity of impure spirit brandy and whisky which must be used in hospital practice for the pure and best kinds are costly we are disposed to believe that some of the more serious forms of cardiac failui-e, with albuminuria and gastric and hepatic congestion, encountered in the later stage of pneumonia are, to a certain extent, contributed to by the excessive and premature use of impure alcohol. The early routine use of alcohol takes from iis also the power of resort- ing to it as a fresh resource in advanced stages, when in exceptional cases it may be of undoubted use. In well-marked adynamic cases, however, the use of alcohol is indicated, and we should make some efforts to obtain it pure. In the pneumonia of drunkards and the aged it is especially needed. We should begin with moderate amounts 4 to 6 oz. of whisky or brandy in twenty-four hours and increase them if necessary. Dr. Wilson Fox thus formulated the indications for its use: ''Rapidity, irregularity, intermittence, and dicrotism of the pulse, great rapidity of respiration, cyanosis with a rapid, feeble pulse, irregularity of breathing, and signs of pulmonary redema, tremor, subsultus, muttering delirium, or delirium in patients addicted to alcohol- ism, and profuse sweating during the febrile period, are all indications for alcohol. When these symptoms are severe, alcohol must occasionally be used un- flinchingly and unsparingly." * * " Diseases of the Lungs," p. 372. Chap, ix.] DIET IN RESPIRATORY DISEASES. 505 A moderate amount of alcoholic stimulant in the form of good sound wine, such as port or Burgundy, or champagne if it is preferred, or 2 to 3 oz. of whisky or brandy in the day, is often needed after the crisis and during convalescence. It will then be of much help in restoring the strength of the patient. In acute broncho-pneumonia alcohol will be needed in most cases to prevent prostration and to maintain the strength. In very young children 10 or 15 drops of brandy or whisky may be given in a few teaspoonfuls of hot milk and water every hour, and this dose may be increased to half a teaspoonful, or a teaspoonful in older children. When collapse is threatened, brandy and whisky may be given hypodermically or by the rectum, mixed with some fluid food. The food must be light and nourishing, good broths, good beef-tea, gruel, milk, whipped eggs with milk or whey, may be given. If there should be much gastric irritability and difficulty of swallowing, from great dyspnoea, nutrient enemata must be administered. In acute bronchitis the diet during the attack, if it be a severe one, should be, in the main, fluid. Milk, when it is well borne and easily digested, is excellent ; it should usually be given warm. Nourish- ing, clear soups, grael and bi-oths, which favour diaphoresis and expectoration, should also be given. Beaten-up eggs, the yolks of lightly -boiled or poached eggs, and custard puddings, are all useful. Light puddings, tapioca, ground rice, or arrowroot, are permissible, and if the tongue is fairly clean, a little pounded meat or chicken may be added to the animal broths. An occasional cup of light tea is refreshing and stimulating. In the slighter cases fish and chicken are permissible. In convalescence we should prescribe a nom-ishing diet, carefully adapted to the digestive capacities of individual patients. In pleurisy with a considerable amount of fluid effusion, the adoption of a diet from which fluids are 506 FOOD IN DISEASE. to a great extent excluded has never become popular or largely practised in England, and although one would naturally counsel a strict limitation of fluids to what is simply necessary to allay thirst, we can see no good reason for tormenting the patient with distressing dietetic restrictions when, if it is important to remove the effused fluid, it can readily be done, to any extent, by puncture and aspiration. In such cases, if free from fever, we should allow easily digested solid foods, such as pounded meat, chicken, white game and fish, some light puddings or bread and milk, and bread-and-butter, and some stewed fruit pulp. If we limit the amount of fluid taken in the twenty-four hours to 30 oz. to consist of milk and water, weak tea, or light soup and if at the same time the functions of the kidneys, bowels, and skin are promoted by suitable medicines, the loss of water by the excretory organs should be in excess of the intake, and the absorption of the fluid exuded may thus be promoted. We should avoid a fluid diet if possible, and feed the patient on nourish- ing and easily digested solids. In Germany some physicians have advocated the adoption of Schrotts's dry diet, consisting of lean roast veal and stale rolls, with no fluid but a little water for three days, and then half a pint of red wine is allowed, and this, at the end of the week, is in- creased to a pint. In the management of cases of asthma attention to diet is of much importance, and the same may be said of cases of advanced emphysema attended with dyspnreic attacks. It has repeatedly been observed that the occurrence of asthmatic paroxysms frequently follows carelessness in feeding and is commonly induced by disturbances of digestion. Subjects of asthma should therefore be advised to take great care to avoid indigestible forms of food, and especially those things which they have learnt by experience tend to provoke a paroxysm of asthma. Suppers and late dinners should be firmly prohibited, and the chief chap, ix.] DIET IN ASTHMA. 507 meal should always be taken in the middle of the day, and nothing but a little light fluid food in the evening about two or three hours before bed-time. Asthmatics should avoid all coarse and indigestible articles of diet. They should select the lean of tender mutton and beef, and the best parts of chicken, white game and white fish ; or such meats may be reduced to pulp in a mincing machine before cooking, as described in our account of the Salisbury method (page 458). While it is not desirable they should do without fresh vegetables, these should be cooked in the form of purees, and a well-made pure'e of spinach or lettuce is very wholesome. A little light pudding with the pulp of cooked fruit is also useful. Saccharin, farinaceous and fatty foods, as tending to excite fermentation, should be restricted to very small amounts, and should consist of such light puddings as sago, rice, tapioca, macaroni, vermicelli, and the like, and these may be eaten with a little fruit pulp or jelly. Eggs lightly cooked or whipped up with hot milk are a very convenient form of food. The meals should be small and concentrated, and only a small quantity of fluid sipped at meal-times just sufficient to enable the patient to eat his food in comfort. It is, however, a good plan to order a glass of hot water in which a few grains of sodium bicar- bonate have been dissolved to be drunk slowly half an hour before meals, and again at bed-time. This will diminish the desire to drink at meals. It will be found that most asthmatic patients require a certain amount of ulcuLu J, especially in catarrhal cases, for a tablespoonful of spirit (whisky or brandy) with a little hot milk and seltzer-water often acts as a good expectorant. Strong coffee is well known to be often of use in allaying the asthmatic paroxysms ; it is therefore advisable in these cases to reserve it for that purpose. So8 CHAPTER X. FOOD IN ACUTE AND CHRONIC RHEUMATISM, AND IN RHEUMATOID ARTHRITIS IN SKIN DISEASES IN INSANITY AND CERTAIN OTHER AFFECTIONS OF THE NERVOUS SYSTEM BENEKE's DIET FOR CANCER. THE diet in acute rheumatism must be to a great extent the same as is suitable in other acute febrile maladies. While the fever and joint inflammation are present the food should be of the lightest possible kind, cooling, and entirely fluid. We have elsewhere* recommended that a jug containing a pint of milk diluted with a pint of boiled water, and containing 30 to 40 grains of sodium bicarbonate and 10 to 20 grains of common salt, and cooled by a lump of ice, should be kept near the patient, and a tumblerful given frequently. In this way 3 to 4 pints of milk may be taken in twenty-four hours. Fresh lemonade made to effervesce, and neutralised by the addition of potassium bicarbonate, may also be drunk freely. The free consumption of these pleasant alkaline, cooling, and at the same time sufficiently nutritious drinks, answers the important purpose of altering and improving the blood condition by diluting noxious substances in it, while it supplies the great loss of water that is taking place from the skin, and it helps to maintain the alkalinity of the fluids. Whey may be taken instead of milk if the latter should by chance disagree, which it is not likely to do if given in the manner here suggested. Thin oatmeal gruel and barley-water may also be taken as well as milk but all meat extracts or animal broths are particularly * "Manual of Medical Treatment," 4th edition, vol. ii. p. 455. Chap, x.] DIET IN RHEUMATISM. 509 counter-indicated in the febrile stage and when the urine is dense and high-coloured. A cup of weak tea may be taken from time to time if desired. After the febrile stage, light clear soups and broths may be given, flavoured with fresh vegetables and savoury herbs. A little pounded beef or chicken and some crumb of stale bread may be mixed with the soups ; light puddings, bread and milk, and such foods, are also suitable, but saccharine things are to be avoided. There is no need for alcohol except in exceptional cases. In unduly protracted cases some form of light animal nourishment may have to be given, although the temperature may still be febrile. We prefer pounded fresh meat added to light broth rather than strong meat extracts. If a prolonged convalescence is associated with marked symptoms of anaemia, it may be advisable to give a little wine ; one or two glasses of dry port, that has matured in the wood, or the same quantity of a sound Burgundy diluted with water, may be prescribed. Caution must be observed in permitting a return to solid food. A relapse has sometimes been traced to the premature indulgence in meat. It is as well to allow from a week to a fortnight to elapse after the temperature has fallen to normal before intro- ducing moat or fish into the dietary. Then the food may be gradually changed to solids, of which eggs, white fish, and chicken are the best to begin with ; pounded lean beef, mutton, or veal may also be taken. Such vegetables as stewed celery, a little mashed potato, spinach, sea-kale, and asparagus may be permitted, and the pulp of fresh fruit, such as baked apples, etc. No pastry, sweets, or fermented drinks should be allowed. In anaemic cases requiring extra food a few sandwiches of pounded meat may be introduced between meals if the digestive powers are active. Chronic rheumatism occurs in such a variety of forms and under such varying circumstances that it 510 FOOD IN DISEASE. [Partii. is not possible to prescribe a diet that shall be equally suitable to all cases ; but, speaking generally, one may say that the food of such patients should be light, nutritious, and readily digested. The digestive peculiarities of individual patients must be observed, and as nutritious a diet prescribed as is consistent with the maintenance of healthy digestion. What- ever food tends to cause assimilative difficulties a good test of which is the occurrence of deposits of lithates in the urine should be prohibited. Fresh tender meat, poultry, game, and fish in strict moderation ; fresh vegetables, stewed celery, Spanish onions, lettuce, watercress, and broccoli, and ripe and cooked fruits ; rice, tapioca, and other farinaceous foods ; butter, cream, and milk all these are admissible, provided that there exists no digestive peculiarity which might cause any of them to disagree. A purely vegetarian diet has been found suitable by some patients. Fermented alcoholic drinks are best wholly avoided. Home-made lemonade and plenty of pure water are the best beverages. In the disease known sometimes as rheumatoid arthritis, and better as osteo- arthritis and the affinity of which with rheumatic affections is doubtful as generous a diet is needed as the enfeebled digestive functions will permit of. Animal food of the best quality may be freely introduced into the dietary of such patients, and mutton, chicken, fish, eggs, butter, cream, milk, and a moderate amount of alcohol stimulant, may all be partaken of. Cod-liver oil is often well borne by these patients, and is of undoubted service, as well as the fats we have mentioned above. When febrile exacerbations occur the food must, of course, be modified accordingly. Diseases of the skin are in a very limited degree under the influence of diet. In speaking of the treatment of eczema, Malcolm Morris maintains that " dietetic treatment is utterly useless " in parasitic diseases of the skin, and these form a very large proportion of the whole group of skin affections. He Chap, x.] DIET IN SKIN DISEASES. 511 further says in respect of eczema: "Patients have been most carefully dieted for long periods without their eczema being in the slightest degree benefited ; whereas on removing all restrictions of diet and treating the affection by local remedies, a cure has speedily followed. It is only in acute forms of eczema that beer and other stimulants need be forbidden." In gouty cases the same dietetic rules will apply as in other gouty manifestations. Cheadle considers that infantile eczema is often greatly benefited by substitution of raw meat juice and cream for milk and farinaceous substances. With regard to those diseases of the skin which are especially connected with nervous disturbance, such as hyper- sesthesia, pruritus, erythema, rosacea, herpes, pem- phigus, lichen, and many others, most authorities forbid all food of a stimulating or constipating character ; " avoid whatever causes flushing of the face lasting for some time after a meal." Total abstinence from alcohol should also as a rule be enjoined. Certain skin eruptions, as urticaria and some forms of erytliema, are undoubtedly connected with the ingestion of certain articles of diet in some individuals, and these must, of course, be sought out and strictly avoided. The disfiguring eruption acne is believed by some physicians to be particularly under the influence of diet. An American authority* states that it is caused by " eating buckwheat cakes or oatmeal," or " by greasy food doughnuts, sausages, cheese, fried meats, ill-cooked and rich pastry excess of sweets, nuts, and other indigestible substances." These things should be prohibited. He would also forbid all forms of alcohol, as well as tea and coffee. "A tumblerful of hot water or a glass of Vichy should be drunk before each meal." If Vichy water is drunk it should be taken quite half an hour before the meal. In other words, these dietetic directions *" Practical Dietetics," by Prof. W. G. Thompson, M.D. London : Knapton, 18%. 512 FOOD IN DISEASE. [Partii. amount to this : if dyspepsia accompanies these skin disorders, the dyspepsia must be treated by the usual dietetic measures. It is also quite possible that many sufferers from skin affections will be found to be addicted to dietetic excesses generally, or in respect to some particular articles of diet ; these excesses must, of course, be arrested. Eczema in sucking infants may be to some extent dependent on errors of diet in the mother, and these should be sought for and rectified. If the mother is bilious, dyspeptic, and constipated these conditions must be treated on general principles. The infant is sometimes nursed too frequently and so overfed, or for economical reasons the child is suckled too long. The occurrence of eczema in young children generally should lead us to investigate their diet and to correct any errors we may discover in the general principles fully laid down in the first part of this work. The chief practical point to be considered in con- nection with the feeding of the insane is the best method of introducing food into the system when, as in cases of acute mania, melancholia, etc., the patient obstinately refuses to take nourishment. When by means of "forced feeding " large quantities of nutri- tious, concentrated, and easily digested food are introduced into the patient's alimentary canal, a very remarkable amelioration in his mental and general condition is often observed. It is a somewhat debated question whether in " forced feeding " it is best to use an resophageal or a nasal tube. Dr. Niel* of the Warrieford Asylum, Oxford, who is an advocate of the cesophageal tube for feeding the insane, thus clearly and minutely describes the process to be followed. He premises that " the repugnance to food, the constipation, the dry mouth, and the foul breath "of the violent lunatic "are symptoms of deficient innervation," which disappear when the * British Medical Journal, January 27th, Chap, x.] FEEDING THE INSANE. 513 nutrition of the nervous centres is restored," and he supports the opinion by the observation that food, although given forcibly and rapidly, does not cause vomiting, and that the digestive organs gradually return to their healthy condition under a simple course of abundant alimentation. " A melancholiac," he says, " should be weighed once a week, and if the weight is falling, too little nourishment is being given. When refusal of food is absolute and wasting is. rapid, one entire day of fasting is all that should be allowed. In cases where some food is taken, but not enough, we should not temporise, but boMly resort to forcible feeding." The following is his method. The food must of course be liquid such as custard of eggs and milk but variety is needed, and especially the introduction of some vegetable. He begins by giving two eggs in a quart of new milk morning and evening. For dinner, about the middle of the day, a ration of meat pounded fine in a mortar, with two or three good-sized potatoes, which is added, with two eggs \ nd a cup of cream, to the liquor in which the meat was boiled, the whole being made into a smooth piir^e with all the solid particles strained off. If this last point is not attended to, the feeding-tube will be choked and an awkward interruption to the operation caused. To each of these three meals a dose of cod-liver oil should be added, gradually increased to a tablespoonful. If symptoms of exhaustion are at all marked, from half an ounce to one ounce of brandy should also be added. If after a week of this regimen the body weight is still falling, another egg must be added to each meal. The operation must be performed in a well-lighted room, with a mattress on the floor, in the full light of the window, and a pillo\v on the end of tne mat- tress farthest from the window. There must be a clear space of three feet all round the mattress. The feeding tube should be of flexible material, as thick as a smallish finger and soft throughout to the H II 514 FOOD IN DISEASE. [Partii. very tip. An accident can hardly happen with such a tube. It is too large to enter the larynx and too soft to perforate the stomach or oasophagus. It is best to have the cup for receiving the food made in one piece with the tube and of the same material. A screw gag of plated metal, thin at the tips and serrated to prevent it from slipping off the teeth, is required. The food should be contained in a jug with handle and spout for convenience of pouring into the funnel. The patient is prepared by removing his boots and loosening the clothing about the body and neck if a woman, the stays are unfastened and the petticoats slackened. Four assistants are required at the opera- tion one at the head, one at the feet, and one at each side. The patient is made to stand on the mattress, near the window and with his face to the light. The chief assistant stands close behind the patient and puts his arms through the armpits of the latter. Those at the sides grasp the arms of the patient at the wrists with one hand and at the elbow with the other. The assist- ant at the feet, standing at one side, puts his arms round the patient's ankles and snatches his feet from under him, while the others, especially the chief assist- ant, support the body and let the patient gently and quickly down on the mattress on his back, the feet being towards the window and the head being on the pillow. The light must fall on the patient's face. A doubled counterpane, kept in readiness, is now thrown across the patient's body so as to cover him from shoulders to waist, the arms being under the counter- pane and close to the sides. The chief assistant takes the head firmly between his knees, kneeling behind the patient, the back of whose head rests on the pillow. * The second assistant kneels astride the patient's legs, and grasping the knees with his hands, presses them downwards. Those on the sides kneel on the loose ends of the counterpane close to the patient's body, grasp the elbows with one hand and the chap, x.j FEEDING THE INSANE. 515 wrists with the other through the counterpane, and press downward on the mattress. In this way the patient is completely controlled in a few seconds, and a prolonged struggle causing terror and exhaustion is impossible. The chief assistant tucks the towel under the chin to prevent the clothes being soiled. The assistants must avoid kneeling on the patient and must not grasp his bare wrists. That must be done through the counterpane or the sleeve of the coat or dress. The operator now kneels at the right-hand side of the patient's head, having the instruments and vessels on the floor at his own right hand. He oils the tube and lays it across the patient's chest, on the towel, to be ready. He then inserts the gag between the molars and opens the mouth widely with the screw. When the mouth is well opened, the gag is entrusted to the chief assistant to keep steadily in position. The operator then takes the oiled tube with his left hand near the cup end, and with his right hand about eight inches from the point. Introducing the point into the pharynx, he guides it gently down the gullet into the stomach. The stomach is known to be reached by the feeling of resistance ceasing and by a puff of gas that comes through the tube with a slight gurgling sound. If the point should hitch against the back of the pharynx, the tube doubles forward at its weakest part, where the eyes are pierced, and pressing on the larynx causes violent dyspnoea. This is less likely to happen if the patient's head is kept a little flexed. The tube should, if this happens, be with- drawn, the head flexed, and then the tube re-introduced and with the right fore -finger in the pharynx, guiding the point into the oesophagus. Sometimes the tube is grasped by spasm of the gullet ; in that case hold the tube against the obstruction for a few seconds, when the spasm will relax and the tube will pass down. Then holding the tube upright with the left hand, with the right pour the food into the cup as fast as it will go down. If the flow is checked, it is because H H 2 516 FOOD IN DISEASE. [Partii the eyes of the tube are closely applied to the gastric raucous membrane and are thus blocked, or because the tube is doubled in the stomach. Withdraw the tube for a couple of inches and the food will flow. In some cases there is much regurgitation of food, causing troublesome or even alarming symptoms of suffocation. Lay down the jug and suspend the ad- ministration of food by pinching the soft stem of the tube with the right lore-finger and thumb till the regurgitation subsides; then go on again. When all the food is given, withdraw the tube gently, keeping it, while doing so, towards the roof of the mouth to avoid tickling the epiglottis. The patient is then released. Allow him to lie for a short time to lessen the risk of vomiting. If this method be followed with care and skill it ought not to take more than four and a-half minutes. Some lunacy specialists prefer feeding by the nares, and contend that feeding by the nose has the following advantages over mouth-feeding : No injury is done to the mouth or teeth, whereas the screw- gag must cause more or less soreness and injury, especially when used for any length of time in a determined subject, and moreover it has an embarrass- ing tendency to slip, and in feeding by the nose the patient seems to realise sooner that he is mastered. To these objections Dr. Niel* replies that the nares are sometimes so plugged with inspissated mucus that it is difficult to pass the tube that there is much uncertainty where the slender nasal tube may go, and that the risk of sending such a tube into the larynx and passing the food into the patient's lungs instead of into his stomach is a real one, and is greatest with acute melancholiacs, who always resist to some extent, and often frantically. Mouth-feeding is therefore safer. He also maintains that the screw- gag does not slip if properly held that the danger to the teeth has been exaggerated, provided the gag be carefully introduced and carefully withdrawn. * British Medical Journal, April 21st, 1894. Chap, x.j DIET IN APOPLEXY. 517 With regard to the dietetic management of other diseases of the nervous system, there is little that need be said. We have entered fully into the subject of feeding in neurasthenic cases, and in most other cases of nervous disease the diet has to be arranged on general principles, and modified and adapted to individual cases and to the various phases of the disease. In acute meningitis the diet must be of the simplest milk mixed with ice-water is the best food. In the later stages, with much general depression, beef-tea, wine, and other stimulants and restoratives may be called for. Rectal feeding will, of course, be necessary when it is not possible to give food by the mouth. In apoplexy in the stage of unconsciousness the tendency on the part of anxious friends to administer food by the mouth, when the patient is really unable to swallow, must be restrained. It must be explained that no harm can arise from abstention from food for a day or two. There is, however, no objection to rectal feeding if the general condition of the patient points to the need of nourishment or stimulant. In cases of hcmiplegia occurring without loss of consciousness the diet should be simple but nutritious. On the recovery of consciousness in apoplectic cases the diet should be very light and unstimulating, and should consist of milk and farinaceous foods chiefly. Later, when the hemiplegia becomes complicated with rigidity and muscular contractions, the diet should still be light and nutritious, but not exciting. It is best to avoid animal food, or, at any rate, limit it to a little chicken or fish. No alcoholic drinks, save for exceptional reasons, should be permitted ; and strong tea and coffee are best avoided. But the digestive peculiarities of each patient must be studied, and no attempt made to carry out a hard-and-fast rule as to diet. A strictly vegetarian diet, with milk, has been advocated, and this, where it agrees well, is sound advice, but where, from individual peculiarities, 518 FOOD IN DISEASE. [Partii. this is not the case, it is worse than useless to insist on such a strict regime. Those who have had an apoplectic seizure, in order to avoid the tendency to recurrence, should be cautioned that it is needful to observe great moderation in eating and drinking ; the diet should consist of white meats, green vegetables, and ripe fruits, while butcher's meat, fats, and saccharine substances should be avoided. In arranging the diet in cases of locomotor :il:i\ia the chief considerations are adequately to maintain the nutrition of the patient without disturb- ing his digestive functions. As generous a diet should be presented as the patient can comfortably digest; and any digestive feebleness should be carefully studied, and the diet adapted to it accordingly. When they are readily digested, a free consumption of fats should be encouraged, such as butter, bacon, cream, or cod- liver oil, for a tendency to emaciation is usually encountered in chronic cases. Water taken freely is useful for purposes of elimination ; and light wines with water, or light beer, may be permitted ; also tea and coffee, if they do not lead to digestive disorder. In cases of insomnia certain food habits may need modification and correction, such, for instance, as are calculated to disturb that physical and organic calm, at the time of retiring to rest, which is needful, in the hyper-sensitive, in order to ensure sleep. The consumption of cardiac excitants, such as tea, coffee, and, with some persons, tobacco, late at night, will sometimes effectually prevent sleep by the circu- latory disturbances produced. The excitement of digestive activity, or the disturbance of gastric function caused by taking a full meal late in the day, especially in persons prone to dyspepsia, is also a frequent cause of insomnia. Flatulent distension of the stomach, the irritation ,of gastric acidity, the upward pressure on the heart, and the palpitation thus excited, due to such improper habits of feeding, Chap, x.] DIET IN EPILEPSY. 519 give rise to sleeplessness, which will be avoided by adopting different habits. In cases of chorea some attention must be paid to diet. The food should be nutritious, but simple, and such as can be easily digested. While the patient is confined to bed an exclusive milk diet may be appro- priate ; and if milk is not well borne, koumiss has been found to answer well ; but a mixed diet of eggs, fish, meat, and milk is often well tolerated. Sweets must be avoided, and so must too much farinaceous food. In those severe cases in which feeding by the mouth is difficult, nutrient eiiemata must be given. Finally, with regard to epilepsy, it is generally admitted that a careful attention to diet is often attended with great improvement in the condition of epileptics. Epileptic attacks in childhood seem occasionally due to errors in diet, or, at any rate, to be aggravated by them. Epileptics should have nourishing and easily digested food, limited, however, strictly to the quantity necessary for nutrition ; and all sweets should be avoided. The meat should be eaten slowly, and the food well masticated, and the chief meal should be in the middle of the day. Most authorities consider that meat should not be taken more than once a day, and some epileptic children have been said to improve rapidly on a strictly vegetarian diet, consisting of milk, bread, and butter, and other farinaceous- foods, a return to a meat diet being followed by a return of convulsions. It has also been noticed, that if adult epileptics are given a diet containing much meat, they become mentally duller. There exists a tendency in epi- leptics to gorge themselves with food, and this must be carefully guarded against. The regular use of fresh vegetables and fruits is advantageous, especially as it tends to promote free action of the bowels. Strong tea and coffee, as well as all alcoholic drinks, should be avoided. In the epileptic colony at Chalfont St. Peter the following is the daily dietary : Breakfast : oatmeal 520 FOOD IN DISEASE. [Part n. porridge with new milk or sugar, tea, and bread and butter ; Dinner : roast, or boiled, or hashed beef or mutton, with cabbages and potatoes, followed by rice, sago, tapioca, suet, or jam- roll pudding ; Tea, with bread and butter or dripping, and sometimes golden syrup, or currant, cake ; Supper : some pudding, generally with milk and bread, varied occasionally with souj) instead of pudding. On Fridays fish is given instead of meat. All the inmates are there engaged for a number of hours a day in out-of-door woi'k, and able, therefore, to support a larger diet than if without active muscular work. It has been said that an animal dietary favours the tendency, where it exists, to the development of -cancer, just as it promotes gouty manifestations in those who are constitutionally predisposed to such maladies, and F. W. Beneke introduced a special diet for the treatment of cancer, in which nitrogenous food is reduced to a minimum. This dietary is here given : BREAKFAST. Bread, with plenty of butter. Potatoes, cooked in their skins, and eaten with butter. A strong infusion of black tea, with sugar and cream ; or cocoa may be substituted for tea. LUNCH. Fruit, raw or cooked. English biscuits, or a little bread and butter. A glass of wine. DINNER. Potato soup, or fruit soup, or wine soup, with sago or Indian corn. Meat, freshly minced, 50 grammes (rather less than 1 oz.). Potatoes, mashed ; fricassee ; in puree ; or plain boiled. Vegetable roots of every kind (turnips, parsnips, carrots, etc.). Fruit, stewed (apples or plums, with rice ; or rice flavoured with rumj. Salads and fruit ices. Wines (light Khenish, or Moselle, or Champagne). AFTERNOON TEA. Black tea, with sugar and cream. A little bread and butter, or some raw fruit and biscuits. Chap. X.] BEX EKES DlET FOR CANCER. 521 SilTEll. Soup, as at dinner. Potatoes, Loiled and eaten with butter, or potato salad. Sardines in oil, anchovies, or fresh herrings, in small quan- tities. Buckwheat gruel, with wine and sugar. Light wines. Beneke maintained that by means of this diet he reduced the proportion of nitrogenous to non-nitro- genous aliment from 1 to 5, which is the common one, to 1 to 8 or 9. Moreover, there will be a distinct reduction of phosphates, for the necessary salts of potash will be taken chiefly in combination with the vegetable acids, malic and tartaric ; the urine will consequently have a less acid reaction. He restricted the consumption of cereals and pulses as much as possible. It has been questioned whether a person could subsist on a diet so defective in albumen and phos- phates. Beneke replied that he had proved, by prac- tical experience, that it was possible, and that persons so treated manifested no loss of strength or disturbance of functions. It must be noted, however, that in this diet for carcinomatous patients, the predominance of vegetable foods is simply designed in order to supply the least possible amount of albumen and phosphoric acid, and is not founded on any strict vegetarian principles as to the source of the foods, whether from the animal or vegetable kingdom ; regard is only had to the chemical composition of the food. The value of a diet in which as little albumen and salts of phosphoric acid as possible are introduced into the system in the treatment of cancer was founded by Beneke on the following considerations. The pro- toplasm of the cells consists essentially and in general of water, albumen, cholesterin and lecithin, with smaller quantities of neutral fats and fatty acids, phosphates of potash and lime, and chlorides of the alkalies ; that these constituents exist in different cells in relatively different quantitative proportion. 522 FOOD IN DISEASE. [PartiL Beneke believed the cells of carcinoma to be relatively rich in cholesterin and in lecithin, and since cholesterin is a product of albuminates, which are, again, rich in alkaline and earthy phosphates, he concluded that the growth of the tumours in question may be checked by the use of a diet which, while just answering the needs of the body in other respects, shall contain as little as possible of the constituents specially required for cell -formation i.e. cholesterin, lecithin, and earthy and alkaline phosphates ; and with this object in view he avoided vegetable as well as animal foods which are relatively rich in these substances, and chose those vegetable substances in which the carbo- hydrates largely predominate. 523 CHAPTER XI. CERTAIN SPECIAL DIETETIC CURES. THE "DRY" CURE MILK AND WHEY CURES THE KOUMISS CURE THE GRAPE CURE. IN Germany, the land of systematic and occasionally fantastic " cures," a certain John Schroth has pro- mulgated a " dry " cure, and established an institution in which it can be practised, and it has received the notice of physicians as eminent as Bartels and Jiirg- ensen an attention its intrinsic value scarcely merited. It has been applied, amongst other cases, to the cure of gastric dilatation, to the removal of chronic peritoneal effusions and rheumatic effusions into joints, and to cases of inveterate syphilis. It consists in gradually depriving the patient of fluid to an extent which is said to be absolutely in- tolerable in many instances, causing intense suffering from thirst, and exciting in most cases a considerable amount of fever, the temperature rising as high as 104 F. The body is at the same time submitted to warm, moist packing. Fatal cases of scurvy have been induced by this treatment, and the results obtained have been by no means brilliant ; it is there- fore not necessary to occupy space by describing it in detail. There are undoubtedly many morbid affections in which a judicious limitation of fluids is calculated to be advantageous, and in which a diet as dry as can be conveniently tolerated is advisable. This is the case in circulatory disturbances with a tendency to venous engorgement and to exudation into the serous cavities ; in cases of chronic inflam- matory effusion which is slow to disappear ; in gastric 524 FOOD IN DISEASE. [Panii. dilatation ; in cases of flatulent dyspepsia induced by too free use of tea, coffee, and other beverages ; and in certain cases of excessive corpulence. In consider- ing the dietetic treatment appropriate to the last condition, we have pointed out how and to what extent the limitation of fluids may be applied. It must, however, be borne in mind that in gouty cases, with a tendency to uratic deposits, a deprivation of water is calculated to do harm. In some of the preceding chapters we have had occasion to dwell at some length on the application of a milk diet to the treatment of certain morbid states, and it will be unnecessary to repeat here what has been fully considered elsewhere. But the so-called "Milk cure" has been systematically applied to the relief of many other ailments, and the method adopted we shall now briefly describe. Karell, of St. Petersburg, has been one of the chief advocates of an exclusively milk diet in certain diseases, and Weir Mitchell has to some extent adopted his views and extended their application. In connection with this subject Weir Mitchell observes : " The study of the therapeutic influence and full results of exclusive diets is yet to be made ; nor can I but believe that accurate dietetics will come to be a far more useful part of our means of managing certain cases than as yet seems possible."* The following are the diseases in the treatment of which an exclusively milk diet has been found of value : Dropsies of all kinds cardiac, renal, and hepatic ; obstinate intestinal neuralgias ; incorrigible dyspepsias with grave disturbances of nutrition ; chronic colitis ; hepatic disorders, such as hypersemia, simple hypertrophy, and fatty liver ; asthma, when the consequence of pulmonary catarrh and emphysema; neurasthenic, hysterical and hypochondriacal states associated with serious disturbances of nutrition ; and especially in disorders of nutrition dependent on * " Fat and Dlood." Fifth edition, 1888. Chap. xi.] THE " MILK CURE" 525 latent catarrhs of the stomach and intestine ; also in obesity. Karell considers the methodical application of the milk cure produces its curative effects by acting as a regulator of nutrition ; and he maintains that it is highly beneficial not only in the cases already enu- merated, but also in rheumatic and gouty affections, in organic diseases of the heart and advanced renal degeneration, and especially in degeneration of the arteries.* Both Karell and Weir Mitchell direct that the milk used should be well skimmed as ci-eamless as possible and it should be obtained fresh twice daily from country-fed cows. They also agree that at first the doses should be small. Weir Mitchell prescribes 4 oz. every two hours, and as the dose is increased the interval between the doses is lengthened to three hours ; he also allows a glass during the night to which a little lime-water is added to keep it sweet. Karell commences with 3 oz. to 6 oz. three or four times a day. He insists on the doses being rigorously fixed and scrupulously adhered to, and that no other food be taken. The doses should be taken at equal intervals, and drunk slowly in small mouthfuls, so that the saliva may mix with it. Taken in this way it will be readily digested, whereas drunk ad libitum it would cause indigestion. In winter the milk should be warmed by standing the glass in hot water ; in summer it should be of the temperature of the apartment. It should not be boiled except in rare cases of diarrhoea. If the milk is well digested, as indicated by small solid motions, the dose is slowly increased. The first week is the difficult one to get over ; during the second week two litres a day may be taken, at fixed intervals viz. 8 a.m., 12 noon, 4 p.m., and 8 p.m. These hours may be changed, but the intervals must be maintained. When there is great objection on the part of * " Archives G^n^rales de Medecine." 18G6. 526 fOQD IN DISEASE. [Part II. the patient to its use, with nausea or disgust, Weir Mitchell allows it to be flavoured with a little tea, coffee, caramel, or salt. He also advises, in certain cases, that the general diet should be displaced slowly until the exclusive milk diet can be tolerated. When it provokes acidity some alkali may be added, such as lime-water or Vichy water ; or it may be scalded with a quarter boiling water and a little carbonate of soda, and salt added ; or a little barley- or rice-water may be mixed with the milk to prevent firm clotting, as described in the section on " Food in Infancy." Karell asserts that, although he commences with such small doses, the patients never complain of either hunger or thirst ; and he adds that, if patients who are seriously ill attempt to take, instead of the four cups of skimmed milk, four large glasses of milk direct from the cow, they will certainly not be able to digest it, and the treatment will be discredited. In obstinate sickness and diarrhoea he has obtained the best results from these small doses, and he cites one such case in which he gave only four tablespoonfuls of skimmed milk three times a day. No doubt, in a case of this kind, the almost absolute rest of the digestive organs which such treatment affords is an important agent in the cure. Constipation he considers a natural consequence and a good sign a sign that the milk is absorbed. It may be remedied by a simple enema of water, or by a small dose of castor oil or rhubarb ; and if obstinate a little coffee should be mixed with the morning milk, or some stewed prunes or a baked apple may be eaten at 4 p.m. Flatulence is, as a rule, completely relieved by this diet; if, however, any flatulence or diarrhoea should be complained of, it is owing either to im- perfect skimming of the milk or to its being taken in too large a quantity. Thirst may be relieved by simple water or seltzer water. If during the second or third week there should be a great desire for solid food, a little stale bread chap, xi.] THE " MILK CURE" 527 with salt, or a small portion of a salted herring, is permitted ; and once a day a little soup made with milk and thickened with groats. After five or six weeks some modification is admissible ; milk, however, should still be taken three times a day, and some other suitable food at dinner. Weir Mitchell allows Nestle's or some other similar food to be substituted as the case progresses. To objectors Karell says : "Milk is a food easy of digestion for everybody, provided it is given with precaution in strictly measured doses and is of good quality." He states that he has obtained excellent results in desperate cases where other remedies had proved useless, and especially in chronic gastric and intestinal disorders. Weir Mitchell points out the importance of com- bining rest with this treatment at the commence- ment, as the patients lose weight at first and feel weak on account of the small amount taken ; after long use, however, they increase in weight. For the first week or two it also causes sleepiness. The tongue becomes covered with a white, thick fur. and the patients complain of an unpleasant sweetish taste in the mouth on waking. The stools are of a yellowish colour, and have a peculiar odour. There is usually a large flow of urine which may exceed in quantity the fluid ingested, and so lead to the removal of drop- sical effusions. Weir Mitchell has also observed that uric acid disappears almost entirely from the urine, which assumes " a singular greenish tint," and when hot nitric acid is poured upon it, it no longer gives the usual mahogany tint at the plane of contact ; and it would seem that, during a diet of milk, " the ordi- nary pigments of the urine disappear, or are singularly modified." The substances which give rise to the ordinary faecal odours also disappear. et The changes here pointed out are remarkable indications of the vast alterations in assimilation, and in the destruction of tissues which seems to take place under the influence of this peculiar diet." * * " Fat and Blood," p. 103, 5th edition. 528 FOOD IN DISEASE. [Part n. The duration of the cure is ordinarily about six weeks. At the end of this period the quantity of milk should be gradually reduced and solid food slowly introduced in the place of the milk meals. Karell begins with raw scraped beef and stale bread. But for several months the diet should consist largely of milk. In many of the German and Swiss Spas, and espe- cially in those with alkaline and salt springs, where chronic catarrh of the respiratory organs is treated, such as Ems, Ischl, Reichenhall, etc., the so-called ""Whey cure" is applied. This consists in drinking warm whey, either alone or mixed with the mineral water, in definite quantities, at set times. Many physicians regard this practice as, in all respects, similar to the use of skimmed milk, and in no respect preferable except in persons who find the casein of milk indigestible. About 20 oz. daily are taken. It relieves irritable laryngeal coughs and exercises a favourable influence over chronic laryngeal and bronchial catarrhs. It has been found useful in certain forms of dyspepsia, intestinal catarrhs, and in chronic phthisis. It acts also as a diuretic, especially in combination with the saline mineral waters, and recent observations have shown that lactose possesses distinctly diuretic properties. It has been recom- mended in the treatment of chronic Bright's disease. The " whey cure " is not an exclusive diet cure, but it is usual strictly to limit the quantity of animal food taken, and to augment the amount of fruit and vegetables ; it adds, however, to the diet a certain amount of milk-salts and milk-sugar. There are various methods of .preparing whey, and these have been described in former chapters. Other methods will be found in the Appendix. At the health- resorts mentioned, whey is prepared from the milk of the sheep and the goat, as well as from cow's milk. Chap, xi.j THE KOUMISS CURE. 529 Koumiss, the fermented milk of the Steppe mares, which is used as a food and as an intoxicating beverage by all the nomadic tribes of the South- Eastern Steppe country of Russia, has been already referred to in previous chapters. It is as a systematic cure in various maladies that we now refer to it again. It is in the Steppes them- selves that the best koumiss and the best results of the koumiss treatment are obtained, although at Moscow and St. Petersburg institutions exist. for the application of this cure, where koumiss prepared from Steppe mares is employed. A specially selected breed of mares yield the milk made use of. The summer climate of the Steppes seems to be especially favourable to the treatment of pulmonary complaints, but the winters are extremely severe. The nomads appear to possess the art of making koumiss in the greatest perfection ; but its composition is by no means stable. It is comparatively rich in sugar, and poor in casein and fat. Large quantities of koumiss can be easily digested, and it has been observed to exert a diaphoretic or a diuretic action, according as the external temperature is high or low. Its use is constantly attended by a gain in weight. Many cases of phthisis are reported to have been cured by this treatment when followed in the Steppes of Orenberg or Ssamara, where doubtless the dry climate has also a curative influence. The best koumiss is made from the milk of light- coloured unbroken mares, pasturing in the Steppes, near mountain ranges, where they can get running water and salt-beds. They should be able to bathe frequently, and they must not have either hay or oats. There are two kinds prepared, one light and slightly fermented, the other strong and highly fermented. The patients are made to rise early and take a glass of koumiss every half-hour, except during the two hours preceding dinner and supper. Meat and I I 530 FOOD IN DISEASE. [Partii. fats form the chief part of the ordinary food ; sweets, fruit, and salads are avoided, as well as ices, coffee, and spiiits. Lime-water is used to arrest the diarrhoea koumiss often causes. At first a few glasses only are taken daily, so as to accustom the patient gradually to the cure. Most invalids digest it well ; it relieves constipa- tion and acts as a diuretic. They gain in weight and show signs of increased blood-formation. Tent-life and much exercise in the open air are, no doubt, im- portant adjuncts to the cure. We have already mentioned, in a former chapter, AnnaefFs and PostnikofFs establishments at Ssamara, as the best places for following this cure. Good koumiss is a milky-looking, frothy liquid, with an agreeable, slightly acid taste. It contains about 1 per cent of alcohol and lactic acid. Its ready digestibility has been referred to the alcohol in it stimulating the digestive secretions, and the carbonic acid allaying gastric irritability. The proportion of alcohol in koumiss is too small to produce any symptoms of intoxication ; but a tend- ency to sleep and to mental and bodily languor has been noticed to follow its use. Excitement of the sexual organs has also been noted by several observers to follow the use of koumiss. The treatment in the Steppes lasts two or three months, and is often renewed the following summer. Annaeffs establishment stands in a park on a hill on the banks of the Volga, three versts distant from Ssamara. It is proyided with a library, theatre, and other comforts. The koumiss is prepared by a Tartar family in the sight of the patients, and with due regard to cleanliness. In its manufacture the milk- sugar is converted into alcohol, carbonic acid, and lactic acid. The casein is in a state of fine subdivision most easy of digestion. Dr. Stange, of St. Peters- burg, who studied the koumiss cure in Aniiaeffs establishment, gives the following : Chap. XI.] THE KOUMISS CURE. S3 1 TABLE OF THE KELATIVE COMPOSITION OF THE SEVEKAL STRENGTHS OF KOUMISS. Carbonic Acid Mate's Milk. Koumiss Duration of Fermentation. 6 hours. 18 hours. hours. 4 clays. 3-8 6-0 70 11-0 Alcohol 185 19-5 30-0 30-0 Lactic Acid 39 5-6 6-4 6-4 Milk-sugar | 51 Albumen . \ 23 18-8 22-5 16-3 22-6 20-0 16-0 Fat . 19 18-9 20-0 19-0 190 Salts . 6 4-5 4-0 4-0 4-0 An analysis of koumiss, made in Moscow after two clays' fermentation, gave alcohol, 1'65 per cent. ; fat, 2-05; milk-sugar, 2-20; lactic acid, 1'15; finely divided casein, 1'12 ; salts, 0*28 ; carbonic acid, 0'70. Dr. Stange came to the conclusion that " favourable results can only be obtained from the koumiss cure in the Steppes, since, besides the employment of a genuine koumiss, a hot and dry climate is absolutely necessary ; " that it is especially beneficial in catarrhal conditions of the respiratory and gastric mucous membrane ; that it is often successful in the first stage of phthisis, in the second stage it simply im- proves the general condition, in the third stage it is badly borne ; that it is especially curative in cases of defective nutrition generally cases of anaemia, chlorosis, malarial cachexia, scrofula, etc. Artificial koumiss is prepared in England by the Aylesbury and other dairy companies. The koumiss cure has been well and briefly defined as " essentially nothing more than a high nutrition of the sick." * The grape cure is another dietetic cure of which a brief account must here be given. n2 Bauer, " Dietary of the Sick," p. 357. 532 FOOD IN DISEASE. [Partii. The nutritive value of grapes is not great ; they, however, contain much sugar as well as potash salts. They are an agreeable form of food, and afford one of the few means at our disposal between nutritive substances on the one hand and medicinal substances on the other. Much of the benefit referred to this cure may doubtless be attributable to the climatic advantages presented by those agreeable localities, such as Meran and Montreux, where it is usually followed. Professor Lebert speaks of the grape cure as essentially a dietetic cure, notwithstanding its re- freshing and aperient effects ; and he is quite opposed to the consumption of very large quantities, as has been advised by some authorities, and considers that only moderate quantities should be prescribed. The effect of the cure is aided by a good supporting diet. Pulmonary patients should not take more than an average of 2 Ib. daily, beginning with about a pound ; and other patients should not exceed 4 Ib. In cases of gastric catarrh 3 Ib. a day may be eaten, the diet at the same time being carefully regulated. Consti- pation, with hepatic congestion and " abdominal plethora," may be benefited by 3 Ib. to 4 Ib. daily ; and in these cases the dose may, exceptionally, be increased to 5 or 6 Ib. The laxative influence of 4 Ib. to 6 Ib. of grapes eaten daily has been found beneficial in hseraorrhoidal affections and in cardiac diseases with a tendency to visceral congestion and venous engorgement, in hyperaemia of the liver and in chronic constipation. The tendency to renal and hepatic concretions is often advantageously modified by this cure. Professor Lebert remarks, as the result of his own observations at Montreux, that the grape cure is very valuable " to those who are neither ill nor well, who are fatigued by a too exciting and somewhat intemperate life ; or, weakened by severe illnesses, are convalescing slowly ; or who, leading habitually a too sedentary and too laborious existence, find in our country, Chap, xi.] THE GRAPE CURE. 533 besides the grapes, which regulate the digestive functions, all thoso hygienic conditions which they most need. In this way the passage of debility and fatigue into real diseases may often be prevented. ' It is best to begin with half a pound of grapes in the morning fasting (or an hour or two after a light breakfast if they disagree when taken fasting) and another half a pound at 5 p.m. After two or three days a third half a pound should be taken between 1 1 and 1 2 noon. Little by little the dose is increased to about a pound each time. In cases of chest disease Lebert rarely exceeded the smaller quantity. In other cases which bear the cure well larger quantities may be prescribed. In some cases of dyspepsia a bunch or two at dessert may be substituted for the midday close. The aperient effect may not be manifest at first, but it usually shows itself after a few days. Figs and pears are also permitted with the cure at Meran in order to diminish the repugnance to one kind of fruit alone. Some irritation of the gums is apt to be excited during the cure ; this may be relieved by rinsing the mouth with cold water, to which a little bicarbonate of soda is added. It has also been recommended that the patient should, while eating the grapes, take from time to time a small piece of fine white bread to remove the acid adhering to the teeth. Towards the end of the cure, which lasts from four to six weeks, the quantity of grapes should be gradually diminished. The mean composition of grapes, according to Konig, is water, 78'17 per cent. ; sugar, 14'36 ; free acid, 0'79 ; nitrogenous substances, O59 ; non-nitro- genous extractives, 1-96; stones and woody fibre, 3 '60 ; total ash, 0-53. The ash consists chiefly of potash salts, together with salts of lime and mag- nesia. We have already indicated certain cases in which the grape cure may prove beneficial. It is also pre- scribed with success in those cases of " abdominal 534 FOOD IN DISEASE. [Partii.- plethora " associated with a deposition of much super- fluous fat ; much of this fat may be removed if the laxative influence of the grapes is aided by a spare diet in which the fats and carbohydrates are strictly limited. It cannot be credited with any real curative influence in phthisis, but it appears to be useful in cases of chronic bronchial catarrh and emphysema; and it may no doubt relieve the bronchial catarrh which accompanies most cases of phthisis. It has been found beneficial in cases of gastric and intestinal catarrh in anaemic persons, in vesical catarrh, in gouty concretions, and in cases of malarial cachexia. 535 CHAPTER XII. ON ARTIFICIAL DIGESTIVE AGENTS AND ON ARTIFICIAL ALIMENTATION. ONE of the most remarkable developments of modern therapeutics, and one which has rendered great service in the treatment of many troublesome maladies in which the functions of the various organs of digestion and assimilation have been directly or indirectly im- paired, has been the artificial preparation, out of the body, of the several digestive ' ferments, or active agents of the digestive secretions, by means of which it has been possible either to administer pre-digested food, i.e. food ready for immediate absorption into the circulating fluids, or to aid digestion by supplying with the food the deficient digestive ferments. The utility of these expedients in the dietetic management of many morbid states has been alluded to in some of the preceding chapters. The amylolytic ferment of the saliva can be re- placed by the diastase of malt, which possesses the property of converting starches into dextrin and maltose, and this pi'operty of malt is largely utilised, either in the administration of the various "Ulalt Extracts," or by the addition of the meal of malt to other farinaceous foods. The pepsin of the gastric juice, obtained from the gastric glands themselves of certain animals, was the earliest employed of all the digestive ferments, and it- is now largely given to increase the activity of gastric digestion when impaired, and to promote the solution and peptonisation of the albuminates in the stomach. But the most extensively used of all these ferments is that extracted from the pancreas, for this has a far wider-reaching digestive action than either of the 536 FOOD iff DISEASE. [Pan n. others, as it not only digests nitrogenous foods and converts albuminates into peptones, but it has the power of converting starch into dextrin and sugar, and it further possesses the property of emulsifying fats ; so that nearly all the pre-digested or partially pre-digested foods i.e. all the peptonised foods now in use are peptonised by the addition of the pancreatic ferments. We propose to examine briefly the properties and uses of each of these three artificial digestive agents. An objection, it seems to us, of a somewhat singular character has been made to the employment of pre-digested foods, viz. that they usurp the gastric and duodenal functions, and that their use is demoral- ising (!) to the healthy stomach. No one dreams of objecting to crutches on the ground that they are de- moralising to those who are not lame, because no one imagines they will ever be ordered for persons with sound limbs. So with these artificial digestive agents they are intended and devised for the sick, and not for the sound ; for the abnormal stomach, not the normal one ; to supply what is defective, not to add to what is already abundant, and it is a perfectly gratuitous objection to assert that they ai'e demoralising in certain healthy conditions, in which it was never in- tended they should be used ! No valid objection, that we are aware of, has been made to their use in those disorders of the digestive functions for which they are especially appropriate. And first, with regard to the use of Malt extracts and Malted food in general. It must be borne in mind that these are simply pre-digested starches, together with other nutritive substances, and it must not be concluded that they can supplement or reinforce the pancreatic digestion of starch in the small intestine, for the amylolytic ferments are wholly inactive in the presence of free acid, and the salivary (diastasic) ferment is under ordinary conditions de- stroyed in the stomach. The diastase of malt, like the salivary ferment, exerts its amylolytic action most Chap, xii.] MALT EXTRACTS. 537 energetically in a neutral fluid ; the addition of an alkaline carbonate retards it, while a very slight amount of acid (such as the hydrochloric acid of the gastric juice) puts a stop to it. In the feeding of very young infants who cannot digest milk, and who, as we have seen, naturally lack the salivary and pancreatic secretions, when malted foods are used it is for the purpose of supplying pre-digested starch, which they are unable to digest from the lack of these ferments. It is possible that we might in older subjects convey the diastasic ferment safely through the stomach into the small intestine, if we desired to, by previously neutralising the acid of the stomach by giving a little carbonate of lime or magnesia ; but we should then be interfering with the action of one digestive ferment in order to reinforce that of another. The diastasic power of malt extracts has been found inferior to that of ground malt itself, and these, as we have said, must be regarded rather as prepara- tions of soluble foods than as digestive agents. They contain, besides the diastase of the malt and pre- digested starch (dextrin and maltose), some of the albuminates and salts of the barley. Like ground malt, when added to farinaceous foods and kept at a temperature below 150 F., they promote the trans- formation of the starches into dextrin and sugar ; but it is an error, as we have just pointed out, to suppose that they continue this amylolytic action when taken into the stomach. Many varieties of " malted foods " are now in common use, but " Liebig's Infant's Food " may be taken as the prototype of all these. It contains ground malt, wheat flour, potassium bicarbonate, and milk, and it is directed to be made in the following manner : Mix well i an ounce of ground malt, with \ an ounce of wheat flour, and 7^ grains of potassium bicarbonate ; add 1 ounce of water, and 5 ounces of fresh cow's milk. Warm over a slow fire, and keep stirring until it gets thick. Remove from fire, stir 538 FOOD IN DISEASE. [Partii. five minutes, replace it on the fire, and again remove it as soon as it gets thick. As the starch gets con- verted into dextrin and sugar by the diastase of the malt it will become a thin and sweet liquid. Then finally boil it well. Strain through muslin. This food is highly nutritious; besides the con- stituents of the milk, it contains pre-digested starch (dextrin and maltose) and the albuminates (gluten and albumen) of the wheat flour and of the malted barley. Foods composed (as some malted foods are) of malted flour and desiccated milk, when mixed with water, are defective as the sole food for children, as they do not contain the adequate proportions of fats, proteids, and salts ; but these can be readily in- creased by the addition of a little cream, or rich milk, or some raw meat juice. In preparing the various malted foods it is usual to bake the wheat flour, so as to render the starch granules more soluble. Mellin's, Nestle's, Savory and Moore's, Allen and Hanburys' infant foods are examples of these malted preparations. The two latter are not completely pre- digested, so that something is left to exercise the child's digestive organs ; and Savory and Moor-e use " whole wheat meal," and their food, therefore, con- tains more of the nutrient constituents of the grain. Pepsin, the proteolytic ferment of the gastric juice, acts only when in combination with an acid, and preferably hydrochloric acid. In contact with a dilute solution of sodium carbonate, at the temperature of the body, it is quickly destroyed, and it is also quickly destroyed by the alkaline secretions of the small intestine, aided by the action of the pancreatic ferment, trypsin. Pepsin is rarely used for the preparation of arti- ficial peptones or pre-digested foods, but it is largely given to promote the activity of stomach digestion in the stomach itself. For this purpose many excellent preparations exist, but some are very uncertain, and many pro- bably quite inert Chap, xii.] PANCREATIC EXTRACTS. 539 Professor Chittenden, of Yale University, found the following remarkable differences in the proteolytic power of different pepsins* : Relative proteolytic action. 1. Parke Davis andCo.'s Pepsinum Purum in lamellis 100 2. Fairchild's Pepsin in Scales . . . . .52 3. Schcffer's Dry Pepsin Concentrated . . .48 4. Jensen's Crystal Pepsin 35 5. Boudault's Pepsin 14 6. Royal Chemical Company's Pure Pepsin . . 9 In England there are especially reliable pepsin preparations in Benger's liquor pepticus and Bullock's acid glycerine of pepsin ; and Burroughs and Well- come supply Fairchild's " pepsin in scales " in the form of convenient tabloids. Thirdly, we come to the pancreatic extracts and peptonised foods, in the preparation of which pancreatic extracts play the principal parts. We have already, in a former chapter (page 140), estimated the value of peptones in nutrition, and con- sidered to what extent they can replace albuminates. We must again point out that the value of those preparations depends on their being pre-digested foods, and it would be an error to suppose that in adminis- tering them we are introducing an active digestive ferment into the small intestine ; for the proteolytic action of trypsin is arrested in an acid medium like the gastric juice, and the gastric pepsin aids in the destruction of the ferment. " Hence, it is obvious that pancreatic extracts or ferments given . by the mouth can be of no value whatever, since the proteo- lytic ferment, at least, will undoubtedly be destroyed in the stomach before reaching its normal sphere of action." f If, however, as seems possible, the pancreatic ex- tracts could be administered in capsules composed * Philadelphia Medical News, Feb. 16, 1889. f Prof. Chittenden on "Digestive Ferments," Philadelphia Medical News, Feb. 16, 1889. 54 FOOD IN DISEASE. [Pan n. of a substance insoluble in dilute acid, but soluble in alkaline fluids, and be so conveyed through the stomach harmless to the duodenum, the difficulty would be overcome. (Keratin appears to be a sub- stance of this kind.) Trypsin acts best in an alkaline medium, and pancreatic extracts are usually mixed with an alkali ; but it is also active in a neutral medium. Peptonised foods, strictly speaking, are artificially digested albuminates, and might be made with pepsin and hydrochloric acid, as Avell as with pancreatic extract ; but the latter is generally used, and when applied to foods containing carboli yd rates, or fats, as well as albuminates, its amylolytic and emulsifying properties also come into operation, and we obtain a very completely pre-digested food. Pancreatin and the pancreatic peptones decom- pose very readily, and for this reason it is important in using them to be careful that no poisonous fer- ments are thereby introduced into the organism. Meat peptones are, no doubt, highly nutritious, but they are often of an unpleasant taste and odour : the smell of pure muscle peptone is stated by Zuntz to be very objectionable, and the more agreeably flavoured preparations were said by Dujardin-Beau- metz to contain much comparatively useless gelatin- peptone. The unpleasant odour and taste detract un- doubtedly from the administration of meat peptones by the mouth, but it does not interfere with their employment in rectal alimentation, for which they are, as we shall presently see, very valuable. Benger's peptonised beef -jelly (partially digested and solidified beef-tea), and chicken jelly are, however, pleasantly flavoured foods, and agreeable to patients generally. Savory and Moore's beef peptone is also said to be of not unpleasant flavour. There are many meat peptones in the market, the best known being Koch's, Kemmerich's, Catillon's, and Carnick's. Chap, xii.] PEPTONISED FOODS. 541 There are also many pancreatised foods, containing other pre digested substances besides peptones ; these are very useful in states of depressed nutrition with loss of digestive power. " Benger's Food " is one of the best of these ; it is prepared with cooked wheat- meal and pancreatic extract ; mixed with warm milk or milk and water, it acts on starches like malt diastase, and renders the casein more digestible. In the same manner pancreatised oat flour and lentil flour are prepared by Benger. " Carnick's Soluble Infant's Food " is made with partially peptonised milk, by means of pancreatin, together with wheat flour and some added lactose. Concentrated peptonised milk, cocoa and milk, and coflee and milk are prepared by Savory and Moore, and are agreeable and valuable preparations. Loeflund's peptonised kindermilch is also a good food. But many peptonised foods can be conveniently made for the sick-room, as required, by means of pan- creatic extracts now readily obtainable. The best of these are Benger's liquor pancreaticus, Benger's peptonising powders, and Fairchild's zymine, a very convenient and active pancreatic extract, in- troduced by Messrs. Burroughs and Wellcome, and supplied in air-tight glass tubes, each containing the exact quantity of pancreatic extract (5 grains), and sodium bicarbonate (15 grains) required to pepLonise one pint of milk. These pancreatin powders are very hygroscopic, and it is important that they should be kept in air-tight glass tubes such as these. Milk can readily be peptonised by these pancreatic extracts, the casein is converted into soluble peptones, and it thus becomes a most valuable food for delicate infants and others who cannot digest the coagulated casein of cow's milk. If, however, the milk be com- pletely peptonised, it acquires a bitter taste which readers it unpleasant, and children will object to take it; but if, as we shall describe, the process of pepton- isation be arrested at the proper time, and the milk 542 FOOD IN DISEASE. [Part n. be only partially peptonised (which, for other reasons, is an advantage), no disagreeable bitter taste is de- veloped. The method of peptonising milk by means of Fair- child's peptonising powders is very simple. Into a clean quart bottle pour a pint of milk, add a quarter of a pint of water, and a tube of Fairchild's powder ; shake them together. Put the bottle into water as hot as the hand can bear (about 150 F.), and let it stand for half an hour ; then boil for two or three minutes. It is then ready for use. It should be kept in ice, or freshly made for each feeding. Boiling is for the purpose of permanently arresting the action of the ferment ; cold will arrest it temporarily, and if kept covered with ice it is not necessary to boil it If the milk be allowed to stand longer than half an hour, peptonisation will proceed too far, and un- desirable bitter products will be generated. We can regulate the peptonisation to any degree required, and we should be guided by the readiness with which the food is assimilated by the patient. For young bottle-fed infants a very slight degree of peptonisation is often all that is required. A teaspoonful or two of Benger's liquor pancre- aticus and 15 grains of bicaibonate of soda will answer equally well. The more completely we desire the food to be peptonised, the more, proportionately, of the digestive agent should be employed, and the longer should the process be allowed to continue. Peptonised milk gruel is also an excellent and valuable pre-digested food, highly commended by Sir W. Roberts. It can be made as follows : A good thick gruel made with oatmeal or other meal, while still boiling hot, is added to an equal quantity of cold milk. The temperature of the mixture will then be about 140 F. To a pint of this mixture two or three teaspoonfuls of liquor pancreaticus and twenty grains of bicarbonate of soda are added. It is kept at the same temperature for about two hours, and then boiled for a few minutes and strained. Chap, xii.] PEPTONISED FOODS. 543 In this mixture not only is the casein of the milk peptonised, but the starch of the meal is converted into sugar, and its albuminates are peptonised. The bitterness of the pre-digested milk is scarcely perceptible in this gruel. Lean meat can also be readily peptonised by means of Fail-child's pancreatic extract, or Benger's liquor pancreaticus. If 4 oz. of finely-minced lean meat be added to half a pint of water, and then gradually brought to a boil, then half a pint of cold water be added so as to reduce the temperature to about 140 F., and then thirty grains of Fairchild's zymine and twenty grains of sodium bicarbonate be added, and the mixture kept warm for about three hours, the meat will be peptonised. Peptonised beef-tea can be made in the following manner : Take half a pound of finely-minced lean beef, add to it a pint of cold water, and cook over a gentle tire till it boils. Decant the beef-tea into a jar or bottle, rub the meat into a paste, add it to the beef-tea, and mix in another pint of water to reduce the temperature to about 140 F. Add a table- spoonful of liquor pancreaticus, or sixty grains of Fairchild's pancreatic extract, and twenty grains of sodium bicarbonate. Stand in a warm place for three hours, shaking occasionally; then boil quickly for two or three minutes and strain. This is a weak beef-tea, but it can be made of any strength required. Following this method various foods can be pre- digested or peptonised according to the wants and tastes of the invalids. Bauer praises very highly Leube's meat solution, as it contains, besides peptones, some unaltered albu- men. It is made by exposing meat and dilute hydro- chloric acid to a high temperature in air-tight vessels. 1,000 grammes of lean meat minced fine are placed in a porcelain vessel with 1,000 centimetres of water, and 20 centimetres of pure hydrochloric 544 FOOD IN DISEASE. [Partii. acid. This is placed in a closed Papin's digester and boiled for 10 to 15 hours. The mass is then taken out and rubbed in a mortar to a paste. It is again boiled in the closed digester for another 16 to 20 hours ; after this it is neutralised with pure sodium carbonate, and evaporated to a syrupy consistence.* In rectal alimentation the unpleasant flavour of meat peptones is no bar to their employment, and they have been found very useful in this method of artificial feeding. But it is necessary to inquire here to what extent the nutrition of the body can be maintained by the administration of food solely in the form of rectal enemata ? It has been ascertained experimentally that soluble albumen, such as is contained in expressed meat juice, is absorbed in the rectum to nearly the same extent as complete peptones ; also that starch is converted into sugar and absorbed in considerable quantity ; egg albumen, when mixed with a small quantity of common salt, is also absorbed ; but the mixture is too irritating to be suitable for enemata. Fat in emulsion also appears to be absorbed in the rectum. Solutions of peptones appear to be absorbed readily, but they must not be too concentrated or they prove irritating to the mucous membrane of the rectum, and they are then not retained. Expressed meat juice and peptones seem, then, the most suitable foods for rectal alimentation. According to Bauer's observations, under no circumstances can more than a fourth part of the amount of nourishment necessary for subsistence be absorbed in the rectum from nutrient enemata, as its capacity is limited, and the absorption of nutrient matters therein exceedingly slow. Leube has pointed out the importance, if nutrient enemata are to be used for any length of time, of only employing substances that cannot cause the least irritation of the mucous membrane of the rectum, * Bauer, " Dietary of the Sick," p. 88. Chap, xii.] RECTAL ALIMENTATION. 545 and that can be prepared without any great difficulty ; and he has suggested enemata of meat and pancreas made in the following manner: Mince fine 150 to 300 grammes of meat, and mix with 50 to 100 grammes of finely-chopped pancreas, free from fat. Beat the mixture into a paste with a pestle or spoon, adding a little lukewarm water to make it of a suitable consistence for injection through the enema- tube. Use warm ; if cold it may excite the rectum and cause expulsion. If thought desirable, from 25 to 50 grammes of fat may be mixed intimately with the mass by the help of a warmed pestle. A syringe with a wide nozzle must be used. ~ Such enemata cause no irritation of the mucous membrane of the rectum, and can be retained from 12 to 36 hours. Evidence was also obtained by Leubo that a con- siderable portion of the albumen and fat of such enemata was absorbed. Dujardin-Beaumetz particu- larly recommended the following formula : To a cup of milk add two or three tablespoonfuls of liquid, or two or three teaspoonfuls of dry peptone, the yolk of an egg, five drops of laudanum and seven grains of bicarbonate of soda if the peptone is acid, as the contents of the large intestine are alkaline or neutral, and never acid. Owing to the difficulty of keeping pancreatic extracts sweet, Wood* has advised the preparation of a glycerine extract made by rubbing down bullock's pancreas with glycerine, and adding some of this to finely-divided meat for each injection ; but the known aperient action of glycerine when injected into the rectum would surely lead to the speedy rejection of such enemata. Peptonised milk - gruel or peptonised beef - tea, mixed with some soluble carbohydrate, such as maltine, or a mixture of one of the malted foods and peptonised milk, is a useful preparation for rectal alimentation. Small quantities of wine or brandy may beuddod lo'iiich onemata when stimulation is indicated. * "Therapeutics." J .1 546 FOOD IN DISEASE. It is advisably to wash out the rectum with pure water an hour before administering a nutrient enema. Only a small quantity should be injected at a time, from 1 oz. to 3 oz. ; a larger quantity is liable to be rejected. The tube should be well oiled to avoid setting up soreness or irritation at the anus, and it is well to use a long one so as to inject the fluid as high up as possible in order that it may come in contact with a more extensive absorbing surface. The enemata must not be given too frequently, or irritation of the rectum and intolerance will be provoked about every 3 to 4 hours according to circumstances. A suitable temperature is from 90 to 95 F. The addition of opium to the injection may insure retention, but it may also retard absorption. Re- tention is favoured by placing the patient on the left side with the hips well raised. Peptonised suppositories are also prepared con- taining peptonised concentrated milk, or meat, to- gether with digested oil. These are said to have sustained life for weeks without exciting any rectal irritation. But we know instances in which the rectum and lower part of the colon have been found, post-mortem,) full of such suppositories quite undi- gested. We have seen that it is impossible to maintain life for any length of time simply by rectal alimen- tation. If we have to trust to this alone, we can only avert death from starvation for a brief time, probably for two or three weeks. Not only is the amount of nutriment that can be absorbed by the rectum insufficient for the maintenance of life, but diarrhoea is extremely liable to set in after a time, so that the rectal injections are no longer retained. As a temporary expedient rectal alimentation is exceedingly useful in all those cases in which there exists a mechanical impediment to the reception of food in the natural way ; if this is not permanent it may afford time for its removal, but if it is perma- nent it can only prolong life for a few weeks. Chap. xii.] RECTAL A/.IMENTATION. 547 Rectal feeding is also a useful resource in certain states of the digestive organs ir, which they are in- tolerant of the presence of fond, and in which it is desirable they should for a. time be kept at rest, or when they cannot, from feebleness of function, digest sufficient food ; in cases of obstinate vomiting, of gastric ulcer, of acute gastritis, of diphtheritic paralysis, of spasmodic or other stricture of the oesophagus, as well as in the exhaustion of fevers, in delirium, and in other conditions which it is not necessary here to enumerate. Attempts have been made to administer food by subcutaneous injection of oils, milk, eggs, and other substances, but not with any markedly good results ; indeed, the very small amount of nourishment which could under any circumstances be thus administered renders the attempt of little practical utility. Jl-5 APPENDIX I. HOSPITAL DIETAEIES. No precise scientific data arc available for estimating the quantity of food appropriate and sufficient for the various classes of invalids ; and when it is considered how different are the conditions, as affecting the nutritive needs and digestive capacities presented by different individuals suffering not only from different but even from the same maladies, it would seem almost impossible that such precise and accurate data should ever be obtainable. Under these circumstances our only reliable guidn is that furnished by the prolonged and observant experience of those who have had the direction and care of institutions adapted for the reception of the sick. It will, therefore, bo of some practical value to collect together and compare a certain number of these dietaries which the ex- perience of such institutions has shown to be suitable and sufficient. In most of these dietaries wide scope is usually given for the introduction of " extras," which is an acknowledgment of the necessity for permitting grout latitude in estimating the quantity of food requisite for individual cases. In the estimate made by Bauer, from the tables accessible to him, of the relative quantities of albumen, fat, and carbo- hydrates (in grammes) contained in the dietaries of some of the principal English hospitals, the variations, especially in the quantity of 1'uts, appear to be considerable. It is probable, however, that these calculations were made from tables that, in some instances, are no longer in use. Albumen. Fat. Carbo- hydrates. Total. Middlesex Hospital 85 28 297 410 St. Bartholomew's Hospital 83 50 291 424 Consumption 83 32 254 369 St. George's 100 65 308 473 Westminster 125 43 388 556 German 97 68 309 474 Margate Sea Bathing Intirmary 123 55 43S 616 In those Hospitals in which the diets are classified mainly into "Full," '"Middle," and " Milk " diets, it may be instructive to compare these together. Meat is " cooked " in all cases, unless the contrary is stated. 550 APPENDIX I. FULL DIETS. Guy's. King's College. London. Bread, 14 oz. Bread, 12 oz. Bread, 12 oz. Butter, 1 oz. Meat, 6 oz. Meat, 6 oz. ; females, Meat, 6 oz. Potatoes, \ Ib. 4 oz. Mte ~) Mu^on broth, Potatoes, J Ib. Potatoes, $ Ib. 'nate ( . p , illt> . or Gruel, 1 pint days. J pudding, 1 Ib. Porter, males, 1 pint ; Porter, males, 1 pint ; Porter, 1 pint; or milk, females, \ pint. females, I pint. 1 pint. (Or milk, instead of Milk, \ pint. porter. ) Tea and sugar. Bartholomew's. St. Thomas's. University College. Bread, 14 oz. Bread, 12 oz. Bread, 12 oz. Butter, 1 oz. Butter, J oz. Meat, 6 oz. Meat, 8 oz. Meat, 4 oz. Potatoes, \ Ib. Potatoes, | Ib. (or Potatoes, i Ib. fresh vegetables). Broth, or pea soup, { pint (on alternate days). Rice pudding, made Beer, men, 2 pints ; Porter, if ordered. with milk, 4 oz. women, 1 pint. Milk, * pint. Beer, 1 pint, when or- Tea, 2 pints. Tea, 1J pint; with dered. milk and sugar. Milk, 1 pint. Westminster. Great Northern. Edinburgh Infirmary. Women's. Bread, 14 oz. Bread, 12 oz. Bread, 14 oz., or Bread, 10 oz. Butter, j oz. Butter, i oz. Potatoes, 2 Ib., Butter, j oz. Meat, 5 oz. Meat, males, 6 oz. ; in place of 11 oz.|Meat, 5 oz. Potatoes, i Ib. females, 4 oz. of bread. Potatoes, $ Ib Milk gruel, 1 pint. Potatoes, 8 oz. Meat, 6 oz. (Other vegetables Broth, 2 pints. Broth: on 3 days.) Milk, | pint. Milk, i pint. Meat, 2 oz. Beef-tea, 1 pint. Tea, t oz. Tea or coffee, 1J Barley, 1 oz. (Obtained from Sugar, 1 oz. pint. Vegets., j oz. 1 Ib. rump Porridge : steak.) (Oatmeal, 4$ Milk, 1 pint. oz.), 1J pint. Buttermilk, 20 oz. Milk (new), 10 oz. It is certainly somewhat remarkable to find such wide variations as are apparent in the above tables of '' Full Diets '' in some of our principal hospitals, especially as those are the diets usually allotted to convalescents or to surgical cases, and they are diets with which it is not usual to order " extras." The quantity of cooked meat varies from 4 oz. at St. HOSPITAL DIETARIES. 55' Thomas's to 8 oz. at St. Bartholomew's ! In four no butter is provided, and in the other the quantity allowed varies from ^ oz. to 1 oz. In such essential articles of diet as these more uniformity might surely be expected. MIDDLE DIETS. Guy's. King's College. London. Bartholomew's. Bread, ] 2 oz. Bread, 12 oz. Bread, 12 oz. Jread, 12 oz. Butter, 1 oz. Juttcr, 3 oz. Meat, 4 oz. Meat, men, 4 oz. ; Meat, 4 oz. tleat, 4 oz. women, 3 oz. Potatoes, \ Ib. Potatoes, i Ib. Potatoes, } Ib. Potatoes, J Ib. On alternate ilays : Mutton broth, Gruel, 1 i>liit. i pint, or milky rice pudding, J Ib. Porter, J pint ; or Porter, J pint. Porter, 4 pint; or Beer, 1 pint. milk. Milk, \ pint. milk, \ pint. Tea and sugar. Tea, 2 pints. University College. Westminster. Great Northern. St. Thomas's. Bread, 12 oz. Bread, 10 oz. Bread, 12 oz. Bread, 12 oz. Butter, } oz. Butter, i oz. Butter, J oz. Meat, 4 oz. ; or Meat, 3 oz. Meat, 4 oz. Meat, men, 4 oz. ; fish, 8 oz. women, 3 oz. Potatoes, \ Ib. Potatoes, \ Ib. Potatoes, 8 oz. Potatoes, i Ib. ot Soup (with bar- Milk gruel, 1 pint. Broth, ij pint. fresh vegetables. ley), 1-J- oz. ; 01 Tea, J oz. Rice or brea^l beef-tea, 1 pint Sugar, 1 oz. pudding, 8 oz. or rice pudding with milk. Milk, 1 pint. Milk, J pint. Milk, J pint. BiTr (if ordered) Tea or coffee, I 1 pint. pint. MILK DIETS. Bartholomew's. Kwy's College. St. Thomas . Bread, 12 oz. Butter, 3 oz. Milk, li pint; or milk with arrowroot, rice, or sago, 1 pint. Tea, 2 pints. Gruel. Bread , 8 oz. Milk, | pint. Ri<:e-milk, A pint ; or rice, or bread pud- ding, i Ib. Bread, 1 2 oz. Butter, J or. Milk, 1} p:nt. Rice, or biead pudding, ilb. Tea, 1J pi-it, with milk and siiar. 552 APPENDIX I. MILK DIKTS (continued] . University. Great Northern. fJuy's. Bread, 12 oz. Bread, 12 oz. Bread, 12 oz. Butter, 1 oz. Milk, 2 pints. Milk, 3 pints. i Milk, 2 pints; or milk, n.'irf-frea, 1 pint. Ilice pudding, i lb., if 1 pint, with rice, sago, Arrowroot, 2j Ma ,, c jn . ordered. Barley water, ad lib. or arrowroot. Beef-tea, pint, if or- Sugar, 1 oz. J ^ dered. Gruel and barley water, ad lib. Glasgow Infirmary. Women s. Bread, 8 oz. Milk, 3 pints. Hice, 2J oz. Bread, ad lib. Butter, i} oz. Milk, 2 pints. Beef-tea, 1 pint. Light pudding, J pint. In these diets we may also notice considerable discrepancies as to quantity. The bread varies from 8 to 12 oz. ; the total amount of milk from 1| pint to 3 pints. Two allow a large quantity of tea, six allow no tea. Four allow butter, and four allow no butter. Some other hospitals classify their diets difrVrently ; we will compare the so-called " Ordinary Diets " of these Institutions : St. Mary's. St. George's. Middlesex. Bread, 12 oz. Bread, 12 oz. Bread, 10 oz. B'ltter, 1 oz. Butter, 1 oz. Meat, 4 oz. Meat, 3 oz. Meat (uncooked, and with bone), oz. Potatoes, } lb. ; or other Potatoes, i lb. Potatoes, { lb. vegetables. Milk', i pint. Milk, i pint. Milk, ; pint. Milk or beef-tea, 1 pint. Porter, \ pint. Beef-tea, strong, i pint. Gruel, 1 pint. Tea, coffee, or cocoa, 2 Tea, 2 oz. weekly. pints, with sugar. Sugar, \ lb. weekly. HOSPITAL DIETARIES. 553 Urompton. Bread, 13 oz. Butter, 1 oz. Meat, 4 oz. Egg, or bacon. 1'otutues, 5^ oz. ; and other vege- tables. Milk, gruel, or soup, \ pint. Pudding, S oz. Tea, coH'ee, or cocoa, 1 pint. Treacle. Royal Chest. Bread, 12 oz. Meat, 4 to 6 oz. Potatoes, \ Ib. Milk, f pint. Milk or cocoa, j pint Light pudding (wnli milk and eggs), (3 oz. It is certainly regrettable that more uniformity in the estimation of the quantities of food necessary for invalids is not observable in these tables. Jn some hospitals the diets are not specially named, but simply numbered ; as in the following : Charing Cross Hospital. No. 1 Diet. Milk, 4 pints ; beef-tea, I pint. ,, 2 Bread, 9 oz. ; butler, 1 oz. ; broth or beef-tea, 1 pint; milk, 2 pints; milk pudding. ,i 3 ,, Bread, 12 oz. ; butter, 1 oz. ; meat, 4 oz. ; pota- toes, i Ib. ; milk, 1 pint; milk pudding. 4 Bread, 12 oz. ; butter, 1 oz. ; meat, 6 oz. ; pota- toes, Ib. ; milk, 1 pint ; milk pudding. Royal Free Hospital. No. 1 Diet. Bread, 8 oz. ; beef-tea, ^ pint ; gruel, 1 pint ; coffee, jj pint; milk, \ pint. 2 Bread, 12 oz. ; soup, 1 pint (with boiled rice, 3 oz.) ; gruel, 1 pint ; coffee, Is- pint ; milk, \ pint. ,, 3 ,, Bread, 12 oz. ; meat (Kir.cooked), 8 oz. (males) ; 6 oz. (females) ; potatoes, ^ Ib. ; gruel, 1 pint ; coffee, 1| pint; milk, pint. The following hospitals provide a " Fish " diet : Middlesex. Bread, 10 oz. ; milk, 1 pint; fish, 8 oz. (whiting, cod, plaice, or brill) ; potatoes, \ Ib. St. Georges. Bread, 12 oz. ; butter, 1 oz. ; milk, J pint; gruel, 1 pint; fish, plain boiled, 4 oz. (whiting, plaice, flounders, or haddock). Womeii's. Bread, 10 oz. ; butter, oz. ; milk, l.j pint; beef- tea, 1 pint ; fish, 6 oz. ; potatoes, \ Ib. London Fiver. Bread, 10 oz ; fish (sole, haddock, cod, or brill, uncooked), 8 07,. ; potatoes, 8 oz. ; cocoa, 1 oz. ; sugar, J oz. ; milk, J pint. 554 APPENDIX I. We give as examples the full diet tables of the following three hospitals : London Hospital. Admission Diet. (For all patients on admission, unless other- wise ordered.) Bread, 12 oz. ; milk, 2 pints; beef-tea, 1 pint. For Children. Bread, 8 oz. ; milk, 1 pint ; beef-tea, J pint. I till Diet. Bread, 12 oz. ; potatoes, 8 oz. ; meat, 6 oz. ; porter or milk, 1 pint. Middle Diet. Bread, 1 2 oz. ; potatoes, 8 oz. ; meat, 4 oz. ; porter or milk, \ pint. Fi-rer Diet. Milk, 2 pints; beef-tea, 1 pint. Children' 's Diet. Bread, 8 oz. ; potatoes, 6 oz. : meat, 2 oz. ; milk, 1 pint. Hydrocarbon Diet. Bread, 12 o/. ; fat bacon, 4 oz. ; milk, 1 pint ; pudding (arrowroot, 1 oz. ; yolks of 2 eggs ; milk, 1 pint). Diabetic Diet. Gluten bread, 6 oz. ; meat, 6 oz. ; watercress ; gluten bread pudding (soak 1 oz. gluten bread in \ pint milk for an hour, beat up with an egg, and 1 oz. gluten flour, then put mixture into a mould, and bake). Special Diet. Mutton chop, or beef steak (8 oz. uncooked) ; or fish (10 oz. uncooked), with, in each case, bread, 12 oz. ; potatoes, 8 oz. ; and milk or porter, 1 pint, as ordered. Ordinary beef-tea is made with 8 oz. meat to the pint. Children's Hospital. Milk Diet. Bread, 6 oz. (with butter) ; milk, 2 pints ; rice, or other milk pudding. Broth Diet. Bread, 7f oz. (with butter or dripping) ; milk, 1 pint ; mutton broth, made with vegetables, \ pint. 3ecf-tea Diet. Bread, 5 oz. (with butter) ; milk, l pint ; beef -tea, 13 oz. Fish Diet. Bread, 8 oz. (with butter, dripping, or treacle) ; milk, 1 pint (or milk, * pint, and cocoa, ^ pint) ; sole, boiled, 2ij oz. ; potatoes, mashed. 3 oz. Meat Diet. Bread, 6 oz. (with butter, dripping, or treacle) ; milk, 1 pint (or milk, \ pint, and cocoa, | pint) ; meat, 2^ oz. ; potatoes, mashed, 4 oz. London Fever Hospital. Low Diet. Bread, 6 oz. ; milk, ^ pint ; gruel, 1 pint j sugar, | oz. Beef -tea Diet. Bread, 4 oz. ; milk, 1 pint ; beef -tea, 1 pint. Middle Diet. Males: bread, 10 oz. ; milk, 1 pint; broth, 1 pint ; rice, or bread (for pudding), 2 oz. ; egg (for pudding), 1 ; sugar (for pudding), oz. Females : 2 oz. less bread. Fish Diet. Males: bread, 12 oz. ; fish (sole, haddock, cod, or brill, uncooked), 8 oz. ; potatoes, 8 oz. ; cocoa, 1 oz. ; sugar, ^ oz. ; milk, \ pint. Females, 2 oz. less bread. HOSPITAL DIETARIES. 555 Full Diet. Males, bread, 16 oz. ; meat, 12 oz. (uncooked, and without bone) ; potatoes, 12 oz. ; cocoa, 1 oz. ; sugar, i oz. ; milk, \ pint ; beer, 1 pint. Females : 4 oz. less bread, 2 oz. less meat ; beer, ^ pint. The following extras may be prescribed : Beef-tea, strong beef-tea, and eggs, as ordered. Arrowroot, J oz. ; custard pudding 1 egg, | pint milk ; oz. sugar ; tea, oz. per day ; sugar, 1 oz. per day ; butter, 1 oz. per day. Extras which are largely ordered by the physicians and surgeons in London hospitals are thus very fully enumerated in the diet tables of the Middlesex Hospital : Chops (mutton or pork), J Ih. when trimmed ; steak, rump, Ib. ; chicken, a quarter ; sausages, % Ib. ; rabbit, a quarter; tripe, ^ Ib. ; bacon, 3 oz. ; strong beef-tea (12 oz. beef to pint) ; jelly beef-tea (24 oz. to pint) ; broth (neck of mutton, with bone, Ib. to pint), without meat; chicken broth (^ chicken to pint) ; oysters, greens, suet pudding (beef suet, 1 oz. ; flour, 2 oz.) ; custard pudding, arrowroot, sago, oatmeal gruel (3 oz. to pint) ; eggs, jellies, porter, ale, stout, wine, spirits, oranges, lemons, meat essences. The hours and apportionment of food are exemplified in the following extract from the diet tables of St. Mary's Hospital: Ordinary Diet. Breakfast, 6 a.m. Tea, coffee, or cocoa, with sugar, 1 pint ; milk, pint ; bread and butter. Dinner, 12 noon. Meat, 4 oz. ; potatoes, or other vegetables, \ Ib. ; bread. Tea, 4 p.m. Tea, coffee, or cocoa, with sujar, 1 pint ; milk, pint ; bread and butter. Supper, 1 p.m. Beef -tea, milk, oj cocoa, 1 pint; bread and butter. New York Hospital. Daily House Diet (furnished to all patients unless otherwise specially directed by the attending physician or turgeon only). Bi-f alt fast. Oatmeal or hominy ; tea or coffee, with milk and sugar ; bread and butter. Dinner. Potatoes; bread and butter; one or more of the following vegetables : turnips, sweet potatoes, beets, spinach, squash. Supper. Tea, with milk and sugar ; bread and butter ; stewed or fresh fruit. 556 APPENDIX I. Tn addition, on Sunday, at breakfast, eggs ; at dinner, roast beef, and corn-starch pudding. Monday : Brcakfasf, baited potatoes; dinner, stock sonp, stewed beef or mutton, rice pudding. Tuesday : Breakfast, mutton chop ; dinner, pea- soup, roast mutton, bread pudding. Wednesday : Breakfust, fried or stewed potatoes ; dinner, roast beef, coru-starch pudding. Thursday : Breakfast, eggs ; dinner, stock soup, stewed beef or mutton, tapioca pudding. Friday : Breakfast, salt mackerel or cod-fish ; dinner, bean soup, baked fish, rice pudding. Saturday: Breakfast, beef -steak; dinner, corned beef, cabbage, bread pudding. Restricted Diet. Breakfast. Tea or coffee, with milk atd sugar ; farinaceous food, with milk ; eggs. Dinner. Soup ; either of the following : raw oysters, roast beef, steak, chicken with vegetables; pudding (bread, rice, tapioca, or corn-starch). Supper. Tea, with milk and sugar ; bread, with butter ; fruit, fresh or dried. Milk Diet. Six pints of milk daily. The above two diets may not be ordered in addition to the regular house diet, but only as a substitute for it ; but the attending physicians and surgeons may order items of special diet in particular cases. Articles of Special Diet. Milk, eggs, beef -tea, oysters, corn- starch, chops, steak, chicken, chicken soup, rice, broth, farina, ice-cream, salt fish, jellies, custards, gruels. APPENDIX H. THE STERILISATION AND PASTEURISATION OF MILK. IT is well known that milk is a fluid which changes rapidly on exposure to the air. Germs enter it from the atmosphere, and warmth favours their development. Milk may also become contaminated by dilution with impure water, or by its recep- tion into vessels that are not perfectly clean. The object of sterilisation and pasteurisation is to destroy any morbific germs that may have gained access to this fluid. Besides the lactic acid ferment, the following pathogenic microbes may get into milk : the bacillus of the green diarrhoea of infants ; the bacterium coll commune (this, if abundant and especially virulent, sets up infectious diarrhoea) ; the filamentous germs of infantile cholera ; the bacillus of tubercle (for this to happen the bovine disease must be greatly advanced, and the udder itself the seat of tubercle) ; the bacillus of typhoid fever, from dilution with impure water, and others. The complete sterilisation of milk is by no means an easy matter. It is true that the typhoid bacillus, the bacillus of preen diarrhoea in infants, and the bacillus of tubercle, are all killed at a temperature of 70 C., and the raising of milk to this temperature for a time is capable, therefore, of destroying them ; but a few living spores remain which require a heat of 107 to 108 C. to destroy; but these develop slowly, and for most practical purposes a heat of 80 C. applied to the 24 or 48 hours' supply ought to annihilate the injurious microbes. Perfect sterilisation can only be effected by submitting the milk to the action of continuous steaming for two hours at a temperature of 248 F. , or for 30 minutes at a temperature of 266 F., but this produces changes in the milk which are not desirable. There is, however, a method of intermittent sterilisation which, on theoretical grounds, should be preferable to all others, but it is so inconvenient in practice, and requires so much time, that it is little suited for cxtejided application, and cannot be carried out on a large scale. For intermittent sterilisation the milk should be heated for 2 hours to 158- 167 F., then kept at a temperature* favourable for germ development i.e. about 101 F. in order to permit of the undestroyed spores developing into ndult bacteria. It should then agsiin be submitted fur 2 hours to a similar temperature, 558 APPENDIX 11. and then again allowed to stand for several days ot 104 F. These consecutive changes of temperature are repeated four or five times, and at last the milk is brought to a temperature of 212 F. It will he seen that this is far too trouhlesome a process to he of practical value. We must, therefore, he content with partial sterilisation, which is easily carried out. The most dangerous pathogenic germs can be certainly destroyed by heating for an hour at 154 to 167 F., or heating for three-quarters of an hour by steam at 212 F. What is termed pasteurisation is the exposure of milk to heat at comparatively low temperatures 140 to 147 F. This gives the milk a slight flavour of having been cooked, which disappears on cooling; but if heated to 158 F., it suffers permanent change in taste. It is, therefore, more agreeable to the taste than sterilised milk, and this heat is sufficient, according to some authorities, to destroy all bacteria likely to be present. It does not, however, keep so well as sterilised milk. It must, of course, be understood that Pas- teurisation does not kill all the bacterial spores, and that it only temporarily checks fermentation, that it does not destroy the tubercle bacillus, and it is better to boil the milk when the presence of this microbe is suspected. The pasteurisation of milk has been found to do much to reduce the spread of disease among infants whose sole food is milk. The introduction of the use of pasteurised milk amongst the poor people in New York has greatly reduced the infant mortality during the hot summer months. With regard to the relative digestibility and nutritious qualities of pasteurised and sterilised milk, there has been much debate. With regard to pasteurisation, it is probable that this does not impair these qualities to any extent. In this connection the following account of the changes induced in milk by boiling, by J. L. Kerr, of Aberdeen, is very interesting : " Milk consists of a multitude of cells suspended in serum. The cells are fat cells which form the cream ; the remaining cells are nucleated, and of the nature of white blood corpuscles. The serum consists of water, in which are dissolved milk sugar and serum albumin, with various salts, and, chief of all, casein. The cells, with the exception of the fat corpuscles, are all living cells, and they retain their vitality for a considerable time after the milk is drawn from the mammary gland. "Milk kept a few days may be perfectly sweet that is, unsoured, but it has a different taste and appearance, and shows a tendency to separate into serum and the more solid portions, which tend to sink to the bottom of the vessel. This change in taste and emulsification is due to the death of the white blood corpuscle-like bodies contained in the milk. " There is reason for supposing that when fresh milk is STERILISATION Of MILK. 559 ingested the living cells are at once absorbed without any process of digestion, and enter the blood stream and are utilised in building up the tissues. The casein of the milk is digested in the usual way of other albuminoids by the gastric juice, and absorbed as peptone. Thar 3 is also absorp- tion of serum albumin by osmosis. " The chemical result of boiling milk is to kill all the living cells and to coagulate all the albuminoid constituents. Milk after boiling is thicker than it was before. " The physiological results are that all the constituents of the milk must be digested before it can be absorbed into the system ; therefore there is a distinct loss of utility in the milk, because the living cells of fresh milk do not enter into the circulation direct as living protoplasm, and build up the tissues direct, as they would do in fresh unboiled milk. " In practice it will have been noticed by most medical practitioners that there is a very distinctly appreciable lowered vitality in infants that are fed on boiled milk. The process of absorption is more delayed, and the quantity of milk re- quired is distinctly larger for the same amount of growth and nourishment of the child than is the case when fresh milk is used." For nutritive value, no doubt, as Dr. Thomson of New York observes, that milk is the best which is " drawn by clean hands from the (healthy) cow into bottles that have been sterilised by boiling water," for this is " germ-free and need not be further treated." Milk in the uncooked condition is no doubt more speedily digested than after it has been boiled. However, in Heubner's polyclinic in Leipzig, in the case of sick children suffering for the most part fiom gastro-intestiniil disorders, the nutritive value of sterilised milk was practically tested, and the result was altogether satisfactory. The milk was sterilised according to Soxhlet's method, and 30 grammes of sugar of milk were added to each litre, so as to make it more like human milk in composition. Several methods have been suggested for carrying out in practice the sterilisation of milk ; one of the simplest and least troublesome seems to us that designed by Mr. C. W. Cathcart, of Edinburgh. It is by its cheapness* and simplicity particu- larly well adapted to the use of the poorer classes, whose infants are precisely those most exposed to the risks of a contaminated milk supply. Mr. Cathcart's apparatus fulfils the following conditions : 1st, it has a capacity of 50 to 60 oz., i.e. enough milk for the 24 hours' feeding ; 2nd, it is easily heated in a pot of a size to be found in workmen's houses ; 3rd, it is provided with a means of stirring the mixture so as prevent the cream from accumulating at the top ; 4th, it * The apparatus costs 5s. 6d., and is supplied by Archibald Gilchrist, 22, Nicolson Street, Edinburgh. 560 APPENDIX II. permits the quantity required for each feeding to be withdrawn without risk of contaminating the remainder; 5th, every part is easily accessible for cleaning. The apparatus (Fig. 1) consists of a tin can 6 in. deep, 6 in. broad at top, 5 in. broad at bottom, and it fits easily into a pot in common use amongst the poorer classes in Scotland. The can is raised on three low studs to allow water to pass below it when it stands in the pot. It is provided with a nickel-plated tap, soldored in just above the bottom, and it has Fig. 1. CATHCAUT'S MILK STERILISER. two stout tinned wire handles at the top for lifting it out of the pot. The lid fits on to an inner rim so as to ensure that the outer surfaces of the lid and can are flush ; over this juncture an indiarubber band, R, is slipped to ensure against entry of air. In the centre of the lid is a funnel-shaped aperture \ in. in diamoter. The "stirrer" is a rectangular piece of tin bent into the form of a ship's screw, with a long tinned wire handle, which rests below in a depression in lho bottom of the can and projects above through the aperture. It is used in the following manner : The quantity of food required for 24 hours is poured into it, the stirrer is placed in position and tho lid pressed on, with the handle of the stirrer projecting through the aperture. The steriliser is then put STERILISATION OF MILK. 561 into the pot, which has previously been about a quarter filled with water brought to the boil. It is kept in this pot of boil- ing water for about twenty minutes, and the mixture agitated occasionally by rotating the stirrer. The can is then taken out of the pot, the broad rubber band supplied with the apparatus is slipped over "the junction of lid and can, and some clean absorbent cotton-wool packed round the projecting end of the stirrer in the funnel-shaped aperture in the lid. The steriliser is then put in a cool place. Before each feeding the mixture is agitated by the stirrer and the quantity required drawn off into the feeding-bottle, in which it is warmed by placing it in hot water. The air which replaces the milk withdrawn through the tap must pass through the cotton-wool in the aperture in the lid and is thus deprived of germs. As to the temperature to which the milk is raised in this way, Mr. Cathcart states that he found that if 40 oz. of Roche's cream mixture were placed in the can at 66 F., a thermometer suspended in the mixture registered, five minutes after the can had been placed in the pot of boiling water, 175 F. In ten minutes it reached 203 F., and in fifteen minutes 206 F., at which point it remained stationary. Mr. Cathcart doubts if the nutritive qualities and the digesti- bility of the milk are interfered with to any serious degree by this mode of sterilisation. He states he has used this milk for delicate infants in his own family, and has known of its use in a great number of similar cases in private practice and with the best results. It has never failed to nourish, but existing diarrhoea has ceased and the infants have put on flesh. Soxhlet's method for sterilising milk sufficiently for practical purposes is thus described by Budin* : In a wide- necked bottle of special shape the quantity of milk necessary for one feeding is placed, and this is heated in a water-bath for from 30 to 4o minutes (Fig. 3). To prevent germs entering the bottles after they have been withdrawn from the bath, where they have been kept for half an hour in boiling water, a special arrangement is adopted to keep the bottles constantly air-tight. This consists in a disc of caoutchouc of sufficient thickness which is placed over the mouth of the bottle and kept in place by a metal capsule. This caoutchouc disc allows the vapour of water to raise it whilst in this water bath, but when the bottle cools the steam inside it condenses and a relative vacuum is thus produced ; then the caoutchouc disc becomes depressed into the neck of the bottle by atmospheric pressure (Fig. 2). So long as this disc is seen to be firmly depressed we can bo assured that no air has penetrated into the bottle. The milk which has simply been heated in a water-bath and not boiled in contact with the air has not a cooked taste but preserves a pleasant flavour. When the infant has to be fed, the bottle is * Conference sur 1'Hygienc de 1'Eufance : Allaitment. Paris, 1892. K K 562 II. Fig. 2. To the left is the upper part of a wide-mouthed bottle on which is placed a caoutchouc disc. In the middle is the metal capsule used to keep the disc in place. To the right is shown the caoutchouc disc depressed into the neck of the bottle by atmospheric pressure. opened and emptied into a feeding-bottle which has been just washed out with boiling water. As each bottl- 7 * only contains enough for one feeding, there is never any leit behind to become contamina to J. Fig. 3. Section of the saucepan for heating the milk In boiling water. It contains a metallic support for the bottles, which are capsuled in Uie manner described in the text and illustrated in Fig. 2. STERILISATION OF MILK. 563 To prevent any contamination of the milk after sterilisa- tion is, of course, most important, and to ensure this so far as possible, M. Budin discards all long tubes and uses a feeding- bottle of the following description. To an ordinary bottle is fitted a special stopper, which he terms a " galactophore " (Fig. 4). This consists of an indiarubber cork through which pass two tubes side by side, the larger one to allow the outflow of milk, the smaller ono the entrance of air. An indiarubber Milk Pig. 4. GALAOTOFHCKB, A, Two tubes aide by side for the purpose of allowing milk to flow out and air to pass in. B, Small indiiirubber stopper through which the instrument is passed. 0, Bottle tilled with milk on which the galactophore has been fitted, furnished with a nipple and a Hat ring of bone. nipple and a flat ring of bone complete the apparatus. The bottle is filled with milk, and corked. It is then inverted and the nipple placed between the lips of the infant. As soon as it makes a sucking movement the milk flows into the mouth. The tube for the admission of air must be very small, so that the milk car.not escape by it and the air does not eater too rapidly. K K 2 APPENDIX III. INVALIDS' DIETARY.- SELECT RECIPES. 1. Almond Cakes for Diabetics (Seegen's), page 383. 2. ALMOND BISCUITS (for Diabetics). To every ounce of almond flour add two whites of eggs, and a little salt to taste. Beat the whites to a stiff froth, add the almond flour, and beat well together. Put in buttered patty -pans, and bake in a moderately quick oven from fifteen to twenty minutes. The whole has to be done quickly, and baked directly the ingredients are mixed. (Hart.) 3. ALMOND PUDDING (for Diabetics). Take two eggs, a quarter of a pound of almond flour, a quarter of a pound of butter, and three tabloids of saccharin. Dissolve in a tablespoonful of brandy. Warm the butter, beat in the almond flour and the yolks of the eggs, adding the dis- solved saccharin. Whisk the whites into a stiff froth ; beat all together. Put into dariole moulds and bake in a quick oven, and serve with a little hot sauce made with dry sherry and saccharin. (Hart.) 4. AL.UM WHEY (an astringent drink). To a pint of boiling milk add oz. of powdered alum previously mixed with three or four tablespoonfuls of hot water. Strain. 6. ARROWROOT. Mix two teaspoonf uls of arrowroot with three tablespoonfuls of cold water ; add half a pint of boiling water, constantly stirring. Milk may be used instead of water. Flavour with sugar, nutmeg, lemon-peel, or other spice. Add port wine or brandy, if required. (Some advise boiling for three minutes in an enamelled saucepan.) 6. Artificial Human Milk (Frankland's), page 255. 7. Barley Jelly (Eustace Smith), page 259. 8. BARLEY WATER. On a tablespoonful of pearl barley (washed in cold water), the rind df a lemon peeled thin, and two or three lumps of sugar, pour a quart of boiling water. Let it stand for seven or eight hours, and strain. More or less of the juice of the lemon may be added, according to taste. 9. BARLEY WATER (Bartholow). Wash 2 oz. of pearl barley with cold water. Then boil it for five minutes in some fresh water, and throw both waters away. Then pour on two quarts of boiling water, and boil it down to a quart. Flavour with thinly-cut lemon-rind, and sugar to the taste ; but do not strain unless at the patient's request. SELECT RECIPES. 565 10. Beef Essence, page 331. 11. Another. Chop up very fine a pound of gravy-beef free from fat and skin ; add a little salt, and put it into an earthen jar with a lid ; fasten up the edges with a thick paste, such as is used for roasting venison in, and place the jar in the oven for three or four hours. Strain through a coarse sieve, and give the patient .two or three tablespoonfuls at a time. 1?. BEEP JUICE (Bartholow). Broil quickly some pieces of round or sirloin, of a size to fit in the cavity of a lemon- squeezer. Both sides of the beef should be quickly scorched to prevent the escape of the juices, but the interior should not be fully cooked. As soon as ready, the pieces should be pressed in the lemon-squeezer, pre- viously heated by being dipped in hot water. The juice, as it flows away, should be received into a hot wine-glass, and after being seasoned to the taste with salt and a little cayenne pepper, taken while hot. 13. BEEF-TEA (Bartholow). Chop fine a pound of lean beef, free from fat, tendons, etc., and digest with a pint of cold water for two hours. Let it simmer on the stove for three hours at a temperature never over 160 Fahr. Make up the water lost by evaporation by adding cold water, so that a pint of beef- tea shall represent a pound of beef. Strain, and cai'efully express all fluid from the beef. 14. BEEF-TEA (Pavy). Put a pound of finely-minced beef into a suitable vessel with a pint of cold water. Let it stand for an hour, stirring occasionally. Place the vessel con- taining the besf into a saucepan of water, place it over the fire, and allow the water to boil gently for an hour (or the vessel containing the beef-tea may be put into an ordinary oven for an hour). Pass the beef-tea through a strainer. It contains a quantity of fine sediment, which should be drunk with the liquid. Flavour with salt. In this process the beef extract should not be exposed to a temperature of more than 170 Fahr. 15. Beef-Tea (Germain See), page 311. 16. BEEF-TEA. Cut up a pound of lean beef into pieces the size of dice ; put it into a covered jar with two pints of cold water and a pinch or two of salt. Let it warm gradually and simmer for a couple of hours, care being taken that it does not reach the boiling point. 17. BEEF-TEA, FLAVOURED. Beef -tea may be agreeably flavoured by boiling in it a pinch of mixed herbs, a bay- leaf, or a little onion, carrot, turnip, or celery and a few peppercorns. The roots should either be chopped small or be scraped to pulp before being put into the broth. 566 APPENDIX III. 18. BEEF-TEA WITH OATMEAL. Mix thoroughly one table- spoonful of grouts with two cf cold water, add to this a pint of boiling beef-tea. Boil for ten minutes, stirring all the time, and strain through a coarse sieve. 19. Biedert's Cream Mixture, page 262. 20. BOUILLON, AMERICAN (American Broth). Place in a tin vessel that can be hermetically closed, alternate layers of finely-minced meat and vegetables. Seal it up and keep it heated in a water-bath (bain-marie) for six or seven hours, and then press out the broth. 21. BOUILLON (Broth) as used in the hospitals of Paris. Raw ment, without bone 1 kilogramme (about 2J Ib.) Fresh vegetables - - 400 grammes (about 1 Ib.) Salt - - - 10 (about 150 grs.) Should be boiled very slowly over a very gentle fire. 22. Bran Cakes (Camplin's), page 381. 23. Brandy and Egg Mixture, page 311. 24. BREAD-JELLY (for the preparation of an artificial food for infants). Take 4 oz. of crumb of bread two or three days old, soak in cold water for six or eight hours ; then squeeze all the water out of it (lactic acid and other peccant matters are thus removed). Place the pulp in fresh water, and boil gently for an hour and a half, so as to break up the granules of starch, and promote its con- version into dextrin and glucose. Rub this semi-fluid gruel through a fine hair-sieve; when cold, it forms a smooth jelly. It will not keep long, and must be prepared twice daily. For children who can digest no milk, this jelly may be simply mixed with enough warm water (one table- spoonful to 8 oz. of water) so as to have the consistence of thin cream, and a little refined sugar added. To make it, however, a suitable food for more than mere temporary purposes, it would need the addition of some albuminate and some fat. Its percentage com- position, mixed in the proportions stated, is proteids 0'74, fat 0-13, carbohydrate 4-15. If the addition of milk can be tolerated, then a mixture of 3 oz. of bread-jelly to 4 oz. of milk (or peptonised milk) and 4 oz. of water will make a fairly good food ; or the necessary amount of proteid and fat may be obtained by the addition of raw-meat juice and cream (the raw- meat juice being prepared by expression from a mixture of four parts meat and one part water). Dr. Cheadle * recommends as a highly nutritious food for children a mixture of four parts of the above bread- * "Artificial Feeding of Infants." SELECT RECIPES. 567 jelly mixture (with water only), three parts of raw-meat juice, half a pint of cream, and one-fifth part of sugar. The raw-meat juice must be quite fresh, and made twice a d;iy. 2.*). Broth, Cold (Parke's), page 158. 26. CAUDLE. Beat up an egg to a froth ; add a glass of sherry and half a pint of gruel. Flavour with lemon peel, nut- meg, and sugar. 27. Celery stewed, for Rheumatism, page 87. 28. CHEESE-CAKES (for Diabetics). Take a pint of milk, half a tablespoonful of rennet, 1 oz. of butter, two eggs, one tablespoonful of brandy, \ oz. of almonds and sacchaun. Turn the milk to a curd ; let it stand in a warm place till thoroughly set, tie a piece of muslin over a bowl, break up this curd and pour it on to the muslin ; leave it till all the whey has run off. Beat the curd smooth and add the butter and eggs, well beaten with the brandy, almonds, and saccharin. When well mixed together, pour some of the mixture into ench of the patty-pans, and bake for about fifteen or twenty minutes. (Hart.) 29. CHICKEN BUOTH (Bartholow). Skin and chop up small a small chicken, or half a large fowl, and boil it, bones and all, with a blade of mace, a sprig of parsley, and a crust of bread, in a quart of water, for an hour, skimming it from time to time. Strain through a coarse colander. 30. CHICKEN, VEAL, or MUTTON BROTH may be made like beef-tea (No. 11), substituting chicken, veal, or mutton for beef, boiling in a saucepan for two hours, and straining. For chicken broth the bones should be crushed and added. For veal broth the fleshy part of the knuckle should be used. Either may be thickened and their nutritive value increased by 'he addition of pearl barley, rice, vermicelli, or semolina. 31. CHICKEN PANADA. Take thi flesh from the breast of a fresh-roasted chi< kon ; soak the crumb of a French roll or a few rusks in hot milk, and put this in a clean stew- pan, with the meat from the chicken previously reduced to a smooth pulp by chopping it and pounding it ia a mortar; add a little chicken broth or plain water, and stir the panada over the fire for ten minutes. 32. COFFEE JELLY. Soak oz. of gelatine in half a pint of water for an hour, dissolve, and add a breakfastcupful of strong, clear coffee. Sweeten to taste, mould, add a little cognac if like-l, and serve when firm. Tea jelly may be made in the same way. 568 APPENDIX III. 33. EGG CORDIAL. Beat the white of an egg to a froth, add a tablespoonful of cream and a tablespoonful of brand}-. 34. EGG DRINK. Mix a tablespoonful of the best arrowroot to a smooth paste with cold water. Add two table- spoonfuls of white sugar and the whites of two eggs which have been whisked with a little water. Add boiling water to make up the quantity to three pints, boil up once quickly, and stir whilst boiling. 35. EGG LEMONADE. Shake together in a bottle the white of an egg, a tumblerful of cold water, the juice of half a small lemon, and a teaspoonful of white sugar. 36. EGG-NOG (Bartholow) (a nutritive drink in acute disease). Scald some new milk by putting it, contained in a jug, into a saucepan of boiling water, but it must not be allowed to boil. "When quite cold, beat up a fresh egg with a fork in a tumbler with some sugar ; beat quite to a froth ; add a dessertspoonful of brandy, and fill up the tumbler with scalded milk. 37. Enema of Meat and Pancreas (Leube's), page 544. 38. Entire Wheat-meal Cakes (Sir Henry Thompson), page 170. 39. Fruit Soups, page 316. 40. Grog de la Pottdre de Tiande (Dujardin-Beaumetz), page 490. 41. GREEN GOOSEBERRY, GREEN CURRANT, GREEN PLUM, or APRICOT FOOL (for the Diabetic). These unripe fruits, before the sugar is developed in them, may be used by diabetics with advantage. They should be stewed with just sufficient saccharin to give them a pleasant sweet- ness, then pressed througli a sieve and a little cream added. 42. GUM WATER. Put an ounce of best gum arabic and 2 oz. of sugar into an earthen vessel with a pint of water. Stand it in a saucepan of boiling water, occasionally stirring until dissolved ; add tho juice of one lemon. To be sipped hot to relieve cough. 43. Haricot Beans, Directions for Cooking (Sir H. Thompson), page 296. 44. IMPERIAL DRINK (a cooling, diuretic bereraye). Pour u pint of boiling water on a large teaspoonful of cream of tartar, a little sugar, and a few pieces of lemon-peel. Strain when cold. 45. Inulin Biscuits for Diabetics (Kultz's), page-374. 46. JUNKET. Sweeten with white sugar one pint of good milk. Add, if desired, a dessertspoonful of sherry. Heat to the temperature of new milk, pour into a shallow dish, and stir in two teaspoonfuls of essence of rennet. This SELECT RECIPES. 569 will form a slight curd. Grate a little nutmeg over it, and add a pinch of powdered cinnamon. Serve when quite cold. In cold weather the milk should be placed in a warm room to set. A substitute for milk io acute disease. 47. KOUMISS (Home-made). Boil fresh milk, and when nearly cold put into quart bottles, leaving room to shake. Add oz. of crushed lump sugar and a piece of Vienna yeast (20 grains), cork with new corks, tie down, keep cool, lay the bottles horizontal, and shake twice daily. Ready to drink on sixth day, or earlier in hot, later in cold weather. Can be made thinner by using skimmed milk. 48. MILK LEMONADE. Put a tablespoonful of loaf sugar, two tablespoonfuls of lemon juice, and two tablespoonfuls of sherry, into a bowl, and pour on a cupful of boiling water. Stir till the sugar is dissolved, add half a pint of cold milk, and stir again till the milk curdles. Strain for use. 49. LAIT DE POTTLE. Make an emulsion by beating up the yolks of two eggs with hot water, sweeten with sugar, and flavour with a little orange-flower water or tan de vie. 50. LEMONADE (Pavy). Pare the rind from a lemon thinly, and cut the lemon into slices. Put the peel and sliced lemon into a jug, with an ounce of white sugar, and pour over them a pint of boiling water. Cover the jug closely, and when cold strain. 61. LEMONADE. Rub two or three lumps of sugar on the rind of a lemon, express the juice, and add three-quarters of a pint of cold or iced water, or a bottle of soda-water. 52 LEMONADE, EFFERVESCING. To the expressed juice of a large lemon add a lump or two of sugar previously lightly rubbed on the rind. Pour on it half a pint of cold or iced water. To cause it to effervesce, put it into a large tumbler, and add half a small teaspoonful of bicarbonate of soda or potash. 63. LEMOX-PEEL TEA (Pavy). Pare the rind thinly from a lemon which has been previously rubbed with half an ounce of lump sugar. Put the peelings and the sugar into a jug, and pour over them a quart of boiling water. When cold, decant the liquid, and add a tablespoonful of lemon-juice. 54. LETTUCE, STEWED (especially for Diabetics). Select a well- grown lettuce, and first boil it in plenty of water, taking care not to let it drop to pieces. When nearly done take out, drain, and place in a stewpan with a little rich brown gravy, and allow it to simmer for twenty minutes. 570 APPENDIX HI. 56. Liebeg's Infant's Food, pages 243, 251, 537. 56. Lime-water, page 256. 57. LINSEED TEA. To a pint of water add two tablespoonfuls of linseed, half a lemon, J oz. of bruised liquorice root (or a piece of liquorice the size of a filbert), and sugar- candy to taste. Boil for an hour and a half and strain. 58. MACARONI A L'!TALIENNE (Sir Henry Thompson). Place in a quart stewpan a pint and a half of boiling water ; throw in 4 oz. of macaroni ; season with salt and pepper, and boil gently for twenty minutes. Strain completely from the water in the colander, wipe out the stewpan, and put back into it the macaroni, with a quarter of a pint of good stock ; let it simmer gently until all the liquid is absorbed by the macaroni, a process requiring about twenty minutes. Grate and mix together an ounce of Parmesan and an ounce of Gruyere or good English cheese. Half of this quantity is to be put into the stew- pan, stirring the cheese into the macaroni over the fire. When this quantity is dissolved, add the rest of the cheese, together with rather more than half an ounce of butter, and stir until all is melted. Season and serve on a hot deep dish. Milk may bo used instead of stock. 59. MALT (GHOUND) AND RICE PUDDING. Stir an ounce of ground malt into a pint of boiling milk ; strain through a sieve, and add the milk to 2 oz. of well-soaked rice. Mix well, and stand for ten minutes in a warm place ; then bake for an hour. 60. Meat Biscuits (Parke's), page 184. 61. Meat Solution (Lcube's), page 543. 62. MEAT TEA (Bartholow). Put one pound each of beef, mutton, and veal, cut into small pieces, into three pints of cold water. It should simmer for three or four hours, but not boil. When finished, the tea should be carefully strained, and seasoned with salt, and cayenne pepper if preferred. 63. MILK SOUP. Boil a pint of milk with a little shredded onion, celery, parsley, or other flavouring vegetable. Strain and serve with fragments of toasted bread. 64. MILK AND SUET (Pavy). Boil an ounce of finely-chopped suet with a quarter of a pint of water for ten minutes, and press through linen. Then add a dram of bruised cinnamon, an ounce of sugar, and three-quarters of a pint of milk. Boil again for ten minutes, and strain. A wine-glassful or two at a time. Nutritive and fattening. SELECT XECIPES. 571 65. MUTTON BROTH (Bartholow). Boil one pound of lean loin of mutton, exclusive of hone, with three pints of water, till tender, throwing in a little salt and onion according to taste. Pour out the broth into a basin, and when it is cold skim off the fat. It can be warmed up as wanted. 66. MUTTON AND CHICKEN BHOTH. Mince a pound of either chicken or mutton, freed from fat, put into a pint of cold water, and let it stand in a cold jar or ice two to three hoars. Then cook three hours over a slow fire, strain, cool, skim off fat, add salt, and serve hot or cold. 67. MUTTON BROTH. Put 2 or 3 Ibs. of neck of mutton into a stewpan, pour over it two pints of water, add pepper and salt. When it boils, skim carefully. Cover the pan and let it simmer gently for an hour. Strain it, let it get cold, and then remove all the fat. When required for use, add some pearl barley, or potatoes, in the following manner. Boil \ Ib. of potatoes, mash them smoothly, so that no lumps remain. Put the potatoes into a pan, and gradually add the mutton broth, stirring it till it is well mixed and smooth ; let it simmer for five minutes, and serve with fried bread. 68. OATMEAL GRUEL. Mix thoroughly one tablespoonful of groats with two of cold water; add to this a pint of boiling water, stirring constantly. Boil and stir for ten minutes. Sweeten with sugar. 69. OATMEAL GRUEL (Another). Take two tablespoonfuls of oatmeal, one saltspoonful of salt, one small tcaspoonful of sugar, one large cupful of boiling water and one of milk. Mix the oatmeal, salt, and sugar together, and pour on the boiling water. Cook for thirty minutes, then strain with a fine wire strainer to remove the husks, place again on the stove, add the milk, and heat just to the boiling point. Serve hot. 70. OATMEAL PORRIDGE. To a pint of boiling water add half a toaspoonful of salt, and sprinkle slowly in three to four ounces of oatmeal till of sufficient thickness, keeping it stirred with a porridge-stick. Boil gently for fifteen to twenty minutes ; add a little more boiling water, and boil for five minutes more. It may be served with milk, cream, butter, sugar, etc. 71. OATMEAL PORRIDGE WITH MILK. Into an enamel-lined saucepan put a quart of milk. When on the point of boiling, stir in slowly ; \ Ib. of coarse oatmeal, and con- tinue stirring as it thickens. Let it boil for about twenty minutes. It can be mado thicker or thinner as desired, and served with cream, salt, sugar, or other addition. 572 APPENDIX III. 72. OATMEAL SOUP (Bartholow). Put 2 oz. of oatmeal in a basin ; pour over it a pint of cold water, stir it, and let it stand a minute ; then pour over it, quickly stirring all the time, a pint of good broth ; pour through a fine strainer into a saucepan, taking care that none of the coarse part of the meal goes into the soup. Boil the soup for ten minutes, season, and serve. 73. OKGEAT (Pavy). (A demulcent and nutritive drink.} Blanch 2 oz. of sweet almonds and four hitter almond seeds. Pound them into a paste with a little orange -flower water, rub this with a pint of milk diluted with a pint of water until it forms an emulsion. Strain and sweeten with sugar. 74. OYSTER BROTH. Take six or eight fresh oysters, chop them small, put them with their liquor into an enamelled saucepan, pour over them a cupful of cold milk, and bring thn liquid slowly to the point of boiling. Simmer for a minute or two, strain through a fine sieve, season with salt and white pepper, add a teaspoonful of cream, and serve. 75. Peptonised Beef- Tea, page 543. 76. PEPTONISED ENEMA (Ewald). Boil a pinch of flour in half a cupful of a 20 per cent, solution of glucose. Mix in three whipped eggs, a glass of red wine, and a tea- spoonful of peptone. 77. Peptonised Milk, page 464. 78. Peptonised Milk-Gruel, page 542. 79. PORT WINE JELLY. Put one ounce of isinglass into a quarter of a pint of water, and set on the fire till the isinglass is dissolved. Then add 1 oz. of sugar and a pint of port. Strain through muslin into a mould, and let it set. 80. POWDERED MEAT (Dujardin-Beaumetz). Take cold boiled meat, mince it fine, dry it in a water-bath (bain-marie), and reduce to powder in a coffee-mill. 81. POWDERED MEAT PUNCH (Dujardin-Beaumetz). Place in a bowl two tablespoonfuls of powdered meat, three table- spoonfuls of syrup of punch, and sufficient milk to make a very fluid mixture. 82. HAW MEAT (Ringer). Cut into small squares 2 oz. of rump-steak free from fat, without entirely separating the meat ; pound in a mortar for five or ten minutes ; add three or four tablespoon fuls of water, and pound again for a short time; then remove all sinew or fibre of the meat, leaving only the creamy substance ; add salt to taste. SELECT RECIPES. 573 Before using, place the cup or jar containing the powdered meat in hot water until just warm. May be made into sandwiches with thin bread-and- butter. Useful in chronic diarrhoea. 83. RAW MEAT WITH MILK AND SUGAR (Ringer). Scrape with a knife half ;i pound of rump-steak until all the pulp is removed from it ; sweeten with sugar, breaking the lumps of sugar with the meat in a basin with a smriil wooden spoon. Add slowly as much milk as will make it the thickness of arrowroot ; flavour with brandy. Strain through a gravy strainer if there is any fibre of the meat in it, as the mixture should be perfectly smooth. 84. RAW MEAT WITH FKUIT JELLY (Adrian). Mix 2 oz. of pulp of fillet of beef (made by scraping with a knife) and 15 grs. of common salt with 1 Ib. of fruit jelly of any kind. 85. RAW MEAT IN EMULSION (Yvon). Take 2 oz. of pulp of raw meat, oz. of blanched sweet almonds, about half one bitter almond, and ox. white sugar. Pound them together in a marble mortar, and add enough water to make an emulsion. 86. RAW MEAT JUICE (Cheadle). Add to finely-minced rump- steak cold water, in the proportion of one part of water to four of meat. Stir well together, and. allow to stand for half an hour. Forcibly express the juice through muslin by twisting it. This contains, per cent. : Albuminate 5'1, nitrogenous extractive 3-1, salts 0'7. Dr. Cheadle calls this "the most easily-digested and most restorative of all animal foods ; the most valuable of all nitrogenous preparations for children. " It mixes well with milk, and it is highly anti-scorbutic. It does not keep well, and must be made fresh. 87. RAW MEAT SANDWICHES. Take 3 oz. of raw beef or mutton, 1 oz. of very fine bread-crumbs, one teaspoonf ul of sugar ; cut the meat very fine so as to be able to rub it through a hair sieve, then pound it in a mortar into a paste. Mix with it the bre.id-crumbs, sugar, a little salt and pepper; spread it between thin slices of cither brown or white bread and butter. 88. RAW MEAT AND TAI'IOCA Soui> (Dujardin-Beaumetz). Take 1 oz. of raw-meat pulp, made by scraping meat (preferably mutton) into a fine pulp with a knife, mix it with half a pint of tapioca soup (No. 101). 8?. Raw Soup (Weir Mitchell's), page 468. 574 APPEND* x 111. 90. RED OR BLACK CURRANT DRINK WITH ARROWROOT. Boil two tablfspoonfuls of red or black currant jam in a quart of water ; let it simmer for half an hour, strain, and re- place 011 fire to keep boiling. Mix a teaspoonf ul of arrow- root in cold water, and pour the boiling fluid on it, and keep stirring until uniformly mixed. May be cooled by standing on ice. 91. BICE CREAM. Cleanse two tablespoonfuls of rice by wash- ing it several times in cold water ; cook it in a double boiler with two large cups of milk until the grains will mash. Three hours will generally be required to do this. Replace by fresh milk that lost by evaporation. When the rice is perfectly soft, press it through a coarse soup strainer or colander into a saucepan, return it to the fire, and while it is heating beat two eggs, two tablespoonfuls of sugar and one saltspoonful of salt together until very light. When the rice boils, pour this mixture in rather Blowly, stirring lightly with a spoon for three or four minutes, or until it coagulates, and the whole is like a thick soft pudding ; then remove from the fire, and pour it into a dish. By omitting the yolks and using the whites of the eggs only, a delicate cream is obtained. 92. RICE MILK.. Soak 1 oz. of rice for twelve hours, wash it quite clean, and drain it. Add the soaked rice to a pint of boiling milk, with half a teaspoonful of salt and of sugar. Stir well, and cook slowly for an hour. Rub through a hair sieve. (Sago or tapioca may be substituted for rice.) 93. RICE PUDDING. Soak 2 oz. of rice in two waters, for six hours each ; add it to a pint of milk, and boil and stir till it thickens. Remove from fire, and mix well in 2 oz. of butter, a little grated nutmeg (or lemon-peel), and sugar. Cool, and then bake in a suitable buttered dish. 94. RICE SOUP. Soak \ oz. of Patna rice for ten hours. Then stir it with boiling water for five minutes. Remove it into cold water, drain it, and stir it into a pint of boiling stock. Simmer in saucepan (not completely covered) for two hours. Season with salt, add the beaten-up yolks of two eggs, and serve hot. 95. RICE WATER (Pavy). (A useful drink in dysentery, diarrhoea, etc.] Wash well 1 oz. of Carolina rice with cold water. Then macerate for three hours in a quart of water kept at a tepid heat, and afterwards boil slowly for an hour, and strain. May be flavoured with lemon-peel, cloves, or other spice. 96. SAGO (Bartholow). Put oz. of sago into an enamelled saucepan, with three-quarters of a pint of cold water, and SELECT RECIPES. 575 boil gently for an hour and a quarter. Skim when it comes to a boil, and stir frequently. Sweeten with a dessertspoonful of sifted loaf sugar. A tablespoonful of wine, or a dessertspoonful of brandy, may be added. 97. Soup (Prison Diets), page 213. 98. Stirabout (Prison Diets), page 214. 09. Succus CARNIS (Meat Juice) RKCENTER EXPRESSUS (Petten- kofer and Voit). Meat is cut up small, arranged in layers separated from one another by coarse linen, and then placed in a powerful press. From each HLogramme of meat about 230 grammes of a blood-red acid juice are obtained. It contains about 6 per cent, of albuminates. It tastes like raw meat ; its flavour may be improved by the addition of salt, and beef-tea not hot enough to coagulate the albumen. 100. TAPIOCA JELLY (Bartholow). Soak a cup of best tapioca with a pint of cold water ; when soft put into a saucepan with some sugar, the rind and juice of one lemon, a little salt, one pint more water ; stir until it boils ; turn into a mould ; set to cool ; add one glass of wine if desired. 101. TAPIOCA SOUP. Boil a pint of meat broth or stock, and while kept constantly stirred, sprinkle in ^ oz. of pre- viously-washed tapioca. Cover the saucepan, and let it simmer till the tapioca is quite soft. Skim and serve. 102. TOAST WATER. Take a slice of stale bread crust is to be preferred and toast it slowly all through without burning it. Let it go cold, and then pour over it a quart of boiling water, and let it stand covered till cold. Strain it through muslin before serving it. 103. TREACLE POSSET. (A diaphoretic drink for a cold.) To two or three tablespoonf uls of treacle add a pint of boiling milk. Boil up well, and strain. 104. VEAL BROTH. Cut a pound of knuckle of veal into small pieces, place these in a stewpan with three pints of water aud two tablespoonfuls of rice. Boil very gently for an hour and a half, or longer. For flavouring, a few parsley leaves, a sprig ol thyme, and a lettuce leaf may be chopped small and simmered with the veal for five or six minutes or a small blade of mace, a sprig or two of parsley, and one of thyme and marjoram, can be used. 105. VEGETAHLE SOUPS FOII THE DIAHETIC. To a weak meat or bone stock add a tine puree of either of the following vegetables : spinach, turnip, tomato, sorrel, lettuce, or asparagus ; and to this a certain amount of cream may be added if the "