Gout is a constitutional disease characterized by an inflammatory condition of the joints. It is caused by or associated with a retention of uric acid in the blood. Gout is also characterized by the deposit of uric acid or sodium salts which occurs in different parts of the body, the joints, the lobe of the ear, the knee and the elbow being common points where the deposit of these salts ordinarily occurs. The amount of uric acid is lessened in the urine in cases of true gout, except in acute attacks, and in this way it is distinguished from the so-called goutiness in which a urinalysis shows an excess of uric acid. According to Strouse, this excess of uric acid in the urine “means a physical-chemical change in the urine and is quite different from the small amount usually excreted.”[156]

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

Elimination of Uric Acid.—In gout such is not the case, the body loses to a certain extent the ability to eliminate the uric acid, hence it is retained within the body, causing an excess in the blood stream, and it is this excess uric acid in the blood which causes the acute attacks and general pain and discomfort which inevitably occur in chronic gout.

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

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

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

Alcohol in Gout.—If the patient is accustomed to alcoholic stimulants and has been in the habit of taking them constantly for years, the amount of alcohol consumed daily must be radically reduced and only the amount prescribed by the physician taken. Alcohol without a doubt assists in the retention and increases the difficulty of uric acid elimination by the body. In view of the present knowledge of the cause and effect of uric acid in the body, the treatment of gout is directed with the object of relieving the condition (1) by facilitating the elimination of uric acid from the body, and (2) by so regulating the diet as to exclude as far as possible those purin-bearing foods which, by reason of their chemical composition, augment the general amount of uric acid formed within the organism.

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

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

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

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

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

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

Exercise and Massage.—The patient should be recommended to take a certain amount of mild exercise in the open air, or massage if he is accustomed to living an indoor life or is confined to office work. He must be warned against overindulgences of all kinds, especially of overeating and drinking. A glass or two of hot water before breakfast is recommended.

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

Allowable Foods.—The following foods are practically purin-free and may be used in the diet of gout:[157] Milk, cheese, butter, eggs, nuts, gelatin, fruits, sugar, breads made with white flour, cereals, cream of wheat, farina, rice, hominy, tapioca, cornstarch, potatoes and other root vegetables, green vegetables, except asparagus, spinach, and all fats.

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

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

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

Daily Dietaries:

OBESITY

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

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

Obesity Cures.—A great number of the “cures” are undertaken not from a health standpoint but from the esthetic point entirely. It makes no difference what reason is brought forward for instituting the treatment, it is the results which count. Of the cures undertaken which are in themselves good, but which are too strenuous for the average “fat person” to stick to may be mentioned some of the early cures instituted and recommended by Banting, Oertel, and Ebstein. Obesity, then, may be said to be due to (1) heredity, (2) overeating and drinking, (3) lack of exercise (sedentary life), (4) a combination of the above causes. Whether the obesity is due to the lack of exercise or the lack of exercise is due to the accumulation of fat which causes a disinclination to move on the part of the individual, can only be judged when a thorough examination into the life and habits of the patient is made.

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

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

Water as a Fat Maker.—That water is in itself fattening is of course untrue. A chemical analysis of this fluid shows that it is inorganic in character and cannot alone either produce energy or build tissue. However, this food constituent plays a most important part in all the functions of the body. In the first place the body cannot utilize food unless it is in solution; water is also one of the best known stimuli to the flow of gastric juice, and for this reason is an important factor in the preparation of the food for its absorption and utilization; since water forms the bulk of the blood, it acts as a distributor or carrier of food to the different parts of the body.

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

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

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

OBESITY DIETS AND CURES

Banting Method.—This method is said to be unsuited to those with weak digestions. Following its use such individuals have been known to develop renal colic or gallstones; constipation may be present and the entire system may become so deranged as to render the patient liable to disease.[158]

Banting Diet for Obesity.—Breakfast at 9 A.M., consisting of 5-6 ounces of animal food, meat or boiled fish (except pork or veal), 1 small biscuit or 1 ounce dry toast. Total solids, 5-6 ounces. Coffee or tea (without milk or sugar), 9 ounces.

2 P.M.—Dinner: Fish or meat (salmon, eels, herring, pork, and veal excepted), poultry or game; any vegetable except potatoes, parsnips, carrots, turnips, or beet roots; dry toast, 1 ounce; fruit cooked and unsweetened; good claret, sherry, or Madeira, 10 ounces. Total solids, 10-12 ounces.

6 P.M.—Tea: 2-3 ounces cooked fruit; 1-2 ounces rusks; 2-4 ounces solids; 9 ounces tea, without milk or sugar.

7 P.M.—Supper: Meat or fish as at dinner; claret or sherry and water, 7 ounces.

Total daily solids, 21-27 ounces.

Total fluids, 35 ounces.

Oertel pointed out the great benefits which might be derived by those individuals suffering from certain types of heart disease which are accompanied by obesity. He made it distinctly understood that while the treatment in no way affected the heart lesion,—that is, in so far as altering the character of the disease,—it greatly reduced the work imposed upon the circulatory organ and permitted a more complete oxidation of the blood.[159]

Oertel’s Method.—Oertel bases his dietetic treatment of obesity upon the heart changes and those which naturally follow in the circulation. He makes the following suggestions, taking always into consideration the condition of the patient, whether he is anemic or plethoric. “(a) Where there is an abnormally increased amount of fat in plethoric patients with unimpaired or only beginning changes in the heart action, the diet should aim at:

(1) An increased supply of protein.

(2) A decrease in the fat-forming substances.

(3) Little or no diminution in the supply of liquids below the physiologic amount (1500 c.c.—3 pt.)

(b) Where there is obesity in anemic patients, viz. serious plethora, the diet should aim at:

(1) An increase in the quantity of proteins.

(2) A diminution in amount of fat-forming substances and eventually

(3) a decrease in the amount of fluid.

(c) Where there is obesity in adults with anemic symptoms in whom not only the amount of protein but also the abnormally increased amount of fat is slowly wasting away, they require:

(1) An increase in the amount of protein taken.

(2) A sufficient amount of fat and carbohydrates or even an increase of same to prevent the falling off of fat.

(3) A diminution in the amount of fluid taken.”

Oertel claims that the simplest method of reducing the fat-forming elements in a diet is to decrease the amount of fat and allow a certain amount of carbohydrates, regulating the diet according to the individual. The following table is given by him as showing the minimum and maximum amount of the different food constituents constituting the obesity diet:

In instituting a treatment for obesity Oertel insists upon a certain amount of exercise daily in the open air, the amount to be regulated by the physician according to the individual case. He suggests that five or six small meals a day be given rather than a few large meals. He eliminates soups, tea, and coffee while the cure is being given.

Ebstein suggests a diet in which the carbohydrates and fluids are reduced but in which the fats are allowed to a considerable extent. The diet consists of meat, eggs, fish, vegetables (green) and fruits. The following menu demonstrates his dietary rÉgime:

Breakfast: Large cup of tea (no milk or sugar); 2 oz. bread with plenty of butter.

Dinner: Soup 4½ to 5½ oz.; meat with fat sauce; green vegetables; fresh fruit; 2-3 glasses light wine.

Afternoon: Tea as at breakfast.

Supper: Tea, 1 egg, fat roast meat or ham, smoked fish; about 1 oz. bread with plenty of butter; a little cheese and fresh fruit; potatoes, sweets and sugars forbidden.

Dietetic Treatment.—The following menus are suggested by the author: The carbohydrates and fats are restricted and the fluids reduced to a minimum. The meals as far as possible are kept “dry”; soups, milk, cocoa are avoided; water is not permitted at meals; alcoholic beverages, white bread, butter, potatoes, sugar, candy, pastry, cakes, puddings, gravies, sauces, bread dressings, griddle cakes, sirups, molasses, honey, ice cream, cereals, pork of all sorts, ham, bacon pork chops, etc., olive oil, spaghetti, macaroni, and noodles are prohibited.

Allowable Foods.—The following foods are allowed: Black coffee or tea, small cup twice daily without milk, cream, or sugar—saccharin may be used to sweeten if desired; fresh or stewed fruit with the exception of bananas, raisins, and dates, served without sugar; all green vegetables cooked or served without butter or fat of any description; salads, except potato or banana, served with a special dressing (no oil or sugar); water ices; watermelon and other melons served without sugar; 1 egg a day; gluten toast, no butter; brown bread or muffins made with gluten flour and prepared bran.

The following menus may be used as guides in the treatment of obesity:

Amount of Food.—The amount of food is limited to a certain extent. Green vegetables may be eaten in abundance, but the protein foods such as meat, fish and eggs must be limited.[161] The bread (even gluten and bran breads) must be limited to 1-2 slices at each meal. All meals are eaten without fluids except breakfast, when one small cup of coffee or tea without milk, cream, or sugar is allowed. If fruit juice is to be served instead of fruit, it must be prepared with little if any water and no sugar. The juice may be poured over cracked ice, if desired.

The following reducing diet is suggested by Dr. Rose for the use of over-fat women:

Reducing Diet for Obese Women[162]

Fuel value 1052 calories—ordinary requirements 2200 calories

Author’s Reducing Diet

Approximate fuel value 965.5 calories

Approximate fuel value 930.5 calories

Rules and Regulations.—The following directions and menus are given to be used when a reduction in weight is necessary. Care must be taken not to allow large amounts of even the non-fat-forming foods in the dietary, since under certain conditions the body will manufacture adipose tissue of any surplus organic material ingested. Breakfast must be limited as demonstrated in the tabulated diet sheet.

Keeping the Weight Down.—After the individual has been reduced to approximately the desired weight the diet may be made a trifle more liberal, keeping in mind, however, that moderation is the keynote in the obesity rÉgime and will have to be practised to a certain extent always. It is wise to continue the dry meals and to limit the amount of butter, cream, and other “fatty foods,” to a certain extent. Pork, with the exception of crisp bacon several times a week at breakfast, had best be avoided, and alcoholic beverages should be omitted entirely except when prescribed by the physician. The outdoor exercise should be continued and only the amount of sleep requisite to health indulged in. If the individual will faithfully carry out these directions, there is no reason why the weight should continue to be a burden. It must be remembered that it is never safe to diet indiscriminately and without the advice of a physician, since much harm may come of so doing.

Value of Massage.—Massage is an advisable accompaniment to an obesity diet and will help to prevent a sagging of the tissues which have been deprived of the supporting fat. The tissues of the face, neck, and breast are especially apt to wrinkle unless given the exercise and stimulation from massage. Cold baths are likewise advisable, since they stimulate the body to burn up the fat.

OBESITY MENUS

EMACIATION

Emaciation as a rule is a symptom of an abnormal condition rather than a disease in itself. Certain individuals are said to be “constitutionally thin” and upon investigation it is often found that this thinness extends back in many cases for generations, many members of a family being thin no matter what measures are taken to overcome the condition. However, constitutional emaciation is not so prevalent as constitutional obesity and, as has already been stated, is more often a symptom of some metabolic disturbance or pathological condition.

Causes of Emaciation.—Errors in diet—insufficient or improper food—are accountable for most of the cases seen in infants and children. Over-exercise, that is, when the amount of exercise taken is not commensurate with the intake of food, is accountable for other cases. This type of emaciation is found especially in growing children.

Disease as a Cause.—Wasting diseases, such as tuberculosis and anemia, bring about a loss of weight, while in fevers in general and typhoid fever especially not only the febrile condition hastens the metabolic processes but also the activities of the bacteria act together and break down the tissues of the body, causing a falling off from the normal body weight. Loss of sleep, unhygienic or unsanitary surroundings, and capricious appetites probably cause some of the cases of excessive thinness.

Thinness in Children.—Parents are to blame for much of the thinness seen in children, especially the nervous high-strung children whose energies outweigh their desire for food or, as is more often the case, their willingness to eat the proper foods. It is a mistaken kindness to cater to the whims and fancies of a child’s appetite, and much harm is wrought by allowing the “trash” to overbalance the necessary building or repair food in the dietary. Not that sugar is not necessary, for it is particularly so at the age when the metabolic processes are faster than later in life, but it must be remembered that the body is being built up both in height and breadth.

The Need for Building Foods.—The skeleton and the muscular tissues cannot be constructed from sugar, hence the diet which consists chiefly of this food constituent is unbalanced and will sooner or later bring about disturbances which are very apt to result in emaciation. The causes of emaciation may be summarized as follows:

(1) Those cases which are due to pathological conditions such as tuberculosis, anemia, typhoid fever, etc.;

(2) Those induced by errors in diet and bad habits such as insufficient or improper food, loss of sleep, over-exercise, lack of ventilation in the sleeping apartment, which destroys the appetite;

(3) Malformation or deformities of mouth, throat, or stomach which make it impossible for the individual to partake of sufficient food to cover the needs of the body;

(4) Heredity (“constitutional thinness”).

Regulating the Diet.—As has been stated in a former chapter, any persistent loss of weight or failure to gain on the part of an infant whose chief business in life should be to grow, should be given immediate and careful attention. As a rule the diet is to blame; it is either improperly balanced, insufficient in amount, or poorly prepared, any of which might readily cause a disturbance to the delicate apparatus of the child.

Diet and Habits.—In adults, the diet and habits of life are in many cases to blame for the excessive thinness seen in many individuals. If the trouble can be traced to some abnormal condition, it can only be removed by relieving or checking the disease which induced it. The older methods of treating typhoid fever, for example, did nothing to prevent the progressive emaciation which was the result not only of the accelerated metabolism from the fever but also from the invasion of the intestinal tract by the specific bacteria which brought about a like result. In tuberculosis a similar breaking down of the tissues occurs, as is likewise the case in anemia and other diseases in which the functions of the blood-making organs are interfered with. Any of the above diseases may cause emaciation, and the treatment in most of the cases resolves itself in removing the cause as far as possible and in adjusting the diet.

Selection of Food.—The dietetic treatment for emaciation is practically the only one which will materially change the weight of the individual, since by food alone is the body built. Certain foods are more capable of being readily converted into adipose tissue than others, and these must have a prominent place in the dietary.

Rules and Regulations.—In obesity it was found that it was necessary to curtail the sleep and rest, increase the amount of exercise and decrease the amount of food. In emaciation practically an opposite rÉgime is adopted. The patient is urged to eat plenteously, drink copiously of water and nutrient beverages, soup, etc., avoid worry and excitement, over-exertion and indigestion, to take one or two naps every day, to retire early, to avoid hot baths and take a warm cleansing bath followed by a cold shower or sponge bath. Exercise must be of a mild character; the patient must be warned against becoming exhausted, since this condition precludes a gain in weight.

Dietetic Treatment.—The meals must be carefully selected, well prepared and daintily served, that all of the psychical benefits from such efforts may be attained. A nutrient beverage such as cream, egg, and vichy, reËnforced fruit beverages, malted milk, with egg and chocolate, cereal and milk gruels, etc., may be given between breakfast and lunch, lunch and dinner and before retiring. The meals must consist of the simplest foods that the digestion may not be overtaxed by the quantity ingested. Allowable Foods.—The following foods may be used in the treatment of emaciation: All dairy products, milk, cream, butter and cheese, eggs cooked in various ways, soups of all kinds, meats in moderation, vegetables, especially potatoes, olive oil, and the various salad oils, cereals, tapioca, macaroni, spaghetti, noodles, rice, bread of every description, fruit including bananas, grapes, dates, raisins, prunes, etc., ice creams, farinaceous puddings, sauces, except those containing vinegar, grape juice and other fruit juices sweetened with sugar, cocoa and chocolate, malted milk and proprietary infant foods, honey, molasses and sirups, cakes, cookies and pastry in moderation. It is advisable to make milk the chief fluid food; to this is added cream, malted milk, lactose, eggs, and other reËnforcing agents.

Milk Cure.—Certain physicians advise milk alone, giving from one to two gallons a day for three weeks or longer. Many individuals complain that “milk makes them bilious” but, as a rule, this is because the amount taken is small and the solids insufficient to lend the necessary bulk to the feces, consequently the peristaltic action becomes sluggish and the passage of the food mass delayed in the intestinal tract, furnishing a medium for bacterial growth and activity. When larger quantities are ingested such is not the case and the fluid so high in nutrient qualities is utilized by the body for the building up of the depleted tissues. When the emaciation is the result of disease the diet is necessarily adjusted to meet the condition. At times it is most difficult to overcome the anemia and accompanying emaciation on account of the disease precluding the giving of the foods especially designed by nature to produce flesh. This is especially the case in the progressive emaciation in diabetes. However, in this case the Allen starvation treatment, with the reËducation of the organs to a toleration for carbohydrates, has gone far toward overcoming this distressing condition.

Readjusting the Habits.—When the loss of weight is found to be the result of close application to work, lack of fresh air and sleep, or from errors in diet, a change of climate and occupation should be made, together with a readjustment of the daily habits, such as substituting a cool bath for the regular hot one, and sleeping out of doors or on a sleeping porch instead of in a poorly ventilated bedroom.

The patient must be urged to eat, regardless of appetite, for in this way only can the body weight be increased. The dietary must be made up largely of the fat-forming foods, but not to such an extent as to upset the nitrogen equilibrium.

The following diet sheet is given to be used as a guide in the treatment of emaciation. Other foods of a similar composition and fuel value may be substituted for those given here, to vary the diet.

Emaciation Diet Sheet

Approximately 5106 calories

Methods of Increasing the Diet.—The above diet furnishes three times as much food as is needed to maintain the body living a sedentary life, or about as much as would be needed to maintain a lumberman at hard outdoor labor in the Maine woods. It would be impossible for an ordinary individual to handle such an abundant diet without making the increase in the diet gradually. This is best done by adding the milk and cream at the end of each meal and a glass of milk between meals and at bedtime, then gradually adding the fattening foods already mentioned until the diet approximates the diet sheet here computed.

SUMMARY

GOUT

Gout is a constitutional disease characterized by an inflammatory condition of the joints.

The Joints are the seat of chalky deposits of uric acid or sodium salts.

Metabolism in gout is disturbed, with a consequent retention instead of elimination of uric acid by the body.

The Blood contains an excess of uric acid which increases greatly during an acute attack.

The Urine in true gout does not contain an excess of uric acid except during an acute attack, whereas in the so-called goutiness there is a constant excess of this acid.

Uric Acid is produced as the result of the metabolism in the human body of the nucleoproteins and in food of the purin bodies.

Alcohol undoubtedly assists in the retention and increases the difficulty of uric acid elimination by the body.

Chief Causes of Gout.—Overeating, excessive alcoholism, and too little exercise, especially in the open air.

Treatment consists in regulating the diet both as to the quantity and type of food eaten; reducing or eliminating the alcohol in the dietary, and increasing the amount of outdoor exercise.

Dietetic Treatment.—The best results are obtained by reducing the size of the meals and avoiding the purin-bearing foods as far as possible. Eggs are purin-free and may be substituted for much of the meat in the diet. In chronic gout it is impossible to eliminate meat entirely from the diet, but the quantity can be materially reduced and that which is eaten may be rendered less harmful if it is boiled instead of roasted or broiled, as in this way much of the purin is dissolved out. Highly spiced and seasoned foods, rich gravies, etc., are apt to cause an acute attack and should be omitted. Excesses of all kinds must be avoided to enable the patient to live a fairly comfortable life, free from frequent painful attacks of gout.

OBESITY

Causes.—Heredity, overeating, unbalanced diet, chronic alcoholism, and disturbed metabolism, as manifested in gout and other pathological conditions.

Cures are more or less of a risk, except when undertaken upon the advice and under the care of a competent physician. As a rule they are too strenuous to be carried out alone and are of no good unless persisted in. Among the best known obesity cures may be mentioned those formulated by Banting, Oertel and Ebstein.

Most physicians have their own methods of treating obesity, but all are based primarily on diet and exercise.

Food is the chief cause of obesity and since some foods are more readily converted into adipose tissue than others, it is necessary to understand the behavior and functions of the various food combinations in the body before it is possible to say which are the offending articles of diet.

Water has no fattening properties of its own. This is proved by a glance at its chemical composition, but as it acts as a distributor and carrier of food to the various parts of the body and since the bulk of all the secretions is composed of water and every tissue in the body stores this fluid, thus adding to the weight, a consideration of the intake of water for obesity patients is most essential.

Appetite requires attention. The majority of obese patients eat more than their energy output calls for, consequently it is necessary to curb the appetite and increase the energy output in order to utilize the material on hand in the form of adipose tissue.

Exercise is absolutely essential in order to force the body to burn up its surplus fat as fuel. The best form of exercise is that which is taken out of doors. The well-worked muscle is heavier than one which is unaccustomed to exercise. The latter is infiltrated with fat and weighs less than muscular tissue, but a muscular body can endure more than one which is covered with adipose tissue.

The Heart of obese patients becomes more or less affected as obesity advances and it becomes absolutely necessary in many cases to get rid of some of the surplus fat in order that the patient may live. This is best accomplished by dietetic treatment.

Circulatory Changes likewise occur as the heart becomes affected, making it necessary to institute some dietary measures at once.

Glycosuria in obese patients suffering from gout is not at all unusual and to relieve this condition the carbohydrates in the diet must be at once reduced.

Dietetic Treatment is most important. It constitutes the only rational method of ridding the body of its surplus fat. To do this it is necessary to regulate the diet both as to quantity and type. Fat-forming foods are those which the body utilizes most easily for the production and storage of fat. Any food, no matter whether it is fat-forming or not, if taken greatly in excess of the needs of the body, will be stored as adipose tissue.

Chief Points to be remembered in formulating a diet and instituting an obesity treatment are the necessity for small meals and dry meals, no fluid given at all during the meal except perhaps one or two small cups of coffee per day, without sugar or cream, the avoidance of fat-forming foods, sugars and starches in all forms, milk, cream, butter and oil, potatoes, bananas, fat meats of all descriptions, especially pork, soups of every description and alcoholic or malted beverages. It is necessary to limit the amount of sleep, prohibiting naps during the day, and to increase the amount of outdoor exercise.

Massage is advisable, especially in those patients who are unable, on account of their excessive weight or heart symptoms, to take the requisite amount of exercise necessary for their future welfare. Massage likewise makes the muscles firmer, often preventing the disfiguring sagging of the skin caused by depriving it of its padding of fat.

EMACIATION

Causes.—Errors in diet, overwork, over-exercise, heredity, nervousness, worry, malformation of the mouth, throat, or stomach, heredity and certain pathological conditions, such as typhoid fever, tuberculosis, anemia, dysentery, etc., in which the breaking down of the tissues occurs more rapidly than they can be rebuilt.

Children are often emaciated on account of their unbalanced diet. They receive an insufficient amount of building food to cover their growth and development requirements. Parents are often to blame for allowing the child to overeat of some of the food constituents at the expense of others. Sugar, for example, is very necessary in the diet of a growing active child, but all sugar and very little milk and eggs will lead to an unbalanced diet which may bring about a condition of extreme thinness later on.

In Adults the constant eating of the wrong foods, overworking and persistent worrying, all contribute to the breaking down of the tissues which ends in emaciation.

Weight is an index to health. Any persistent loss of weight on the part of an adult or loss or even failure to gain in a growing child, are indications that all is not right and immediate measures must be taken to locate and relieve the trouble.

Loss of Weight due to pathological conditions can only be relieved by removing the cause, after which the diet may be adjusted to suit the condition.

Dietetic Treatment is practically the only means of combating and overcoming emaciation, since it is by food alone that the body is built.

Fat-forming foods, which in obesity were prohibited, have a prominent place in the diet for emaciation. Padding the nerves and organs with a layer or covering of fat protects them from the jars and shocks incidental to daily life, besides lending grace and contour to the body.

Foods Which Produce Fat are nutrient beverages of all sorts; milk, malted milk and cream are especially valuable; water, because of its particular properties and functions in the body; and fruit beverages, which are made chiefly of water and sugar, are always included in the dietary. Milk and cream, soups and milk gruels, as well as all dishes made with milk or cream, add materially to the fat-forming quality of the diet. Butter, olive and other salad oils, as well as cereals, potatoes, bread and simple desserts are advised. The diet must be bountiful, the meals frequent, and lunches consisting of milk or cream with crackers will hasten the gain in weight.

Rest, preferably lying down, is absolutely essential. A period of relaxation covering from fifteen to thirty minutes should be taken before or after each meal. The body derives the use of the food for the storage of fat which would otherwise be required to cover its energy expenditures.

Sleep is essential to gain, consequently the patient should retire early and take one or two naps during the day.

Baths should be warm, not hot, followed by a cold shower or sponge.

Exercise must be mild in character; over-exertion precludes a gain in weight and exhaustion undermines the forces which make it possible for the body to store fat as adipose tissue.

Nervous Excitement and Worry must be avoided.

Gastro-intestinal Disturbances should be guarded against, since all the pounds gained through months of treatment may be quickly lost during one acute attack of diarrhea or auto-intoxication.

Massage is advised. The kneading and gentle manipulation of the muscles stimulates them to utilize more food material, besides enabling the patient to eat more by reason of an increased appetite.

The Milk Cure has been used extensively in overcoming extreme emaciation. It consists in the taking of large quantities, ranging from one to two gallons per day. It is given every hour or oftener for a period of one month to six weeks.

ReËnforcing the Diet with eggs and lactose is often found of great value in increasing the weight quickly, as is the giving of one-third of a glass of cream and two-thirds of a glass of milk after each meal and at bedtime. The whole scheme of putting on pounds resolves itself into the giving of proper food in larger quantities than are ordinarily given, but dividing it up into frequent meals in order not to upset the digestion and do away with the good already accomplished.

PROBLEMS

(a) Formulate a diet order for a patient with gout in which the purin foods are eliminated.

(b) Formulate a diet order for an obese patient whose heart is more or less affected.

(c) List the foods of special value in the diet for emaciation. Write a diet order for day suitable for a patient (woman) weighing 110 pounds, whose normal weight is 135 pounds.