The maintenance of a high level of nutrition is of essential importance for the efficient, treatment of tuberculosis, and inability on the part of a patient suffering from this disease to take a fairly generous diet, such as one of our standard dietaries, materially prejudices his chances of recovery. Anorexia is a very common symptom in tubercular patients. In some cases it is of small importance and requires no special treatment. Not infrequently, on the other hand, it requires the most careful dieting.

Anorexia of a very marked character is often met with in patients suffering from early tuberculosis; this anorexia has usually been of gradual onset and associated with progressive loss of strength and weight. The patient is anaemic and obviously run down, and on inquiry is found to be taking a diet altogether inadequate for a person in ordinary health, much less for a person suffering from tuberculosis.

Consumptives suffering from the earlier stages of the disease, especially those living under unfavourable hygienic conditions (for instance a clerk working in a badly ventilated city office), very commonly have this anorexia of early tuberculosis. A certain amount of dyspepsia is sometimes associated with loss of appetite, but examination of the alimentary track shows that the digestive organs are perfectly normal.

The treatment of this type of anorexia consists in placing the patient under good hygienic conditions and giving him a generous diet which he should be strongly encouraged to take, in spite of the absence of appetite. There are few things more striking than the immediate improvement in appetite which follows the removal of a patient suffering from early pulmonary tuberculosis from unfavourable conditions to a sanatorium. If the patient takes the generous diet, as advised, it is seldom that this course of treatment is not completely successful.

Within a week of his arrival the patient usually has entirely regained his normal appetite, and indeed, if urged to do so, will eat enormously, an experience which many a sanatorium patient has unfortunately suffered from.

A much more serious type of anorexia is that very often met with in patients suffering from active tuberculosis associated with pronounced constitutional disturbance, such as high fever, etc. A patient with a considerable amount of fever, whatever be its cause, rarely retains a normal appetite. In a large number of febrile diseases, especially in those running a short course, comparatively speaking, the normal diet of health can be appreciably reduced without disadvantage to the patient. In the case of tuberculosis this cannot be done; at all costs, the patient's diet must be kept up to a high standard of nutritive value. The same principle holds good for another type of anorexia, commonly met with in tubercular patients, viz., the chronic loss of appetite associated with slowly progressive disease of long duration. Patients who suffer from long standing progressive tuberculosis usually have their constitutions permanently damaged; vascular and muscular tone are poor, and the alimentary track is generally impaired. This impairment, in our experience, is very largely atonic in character, the most pronounced symptoms being persistent loss of appetite, fulness and abdominal discomfort after meals with nausea and vomiting if large meals are taken. We have been interested to observe that stomach analyses and metabolic investigations in these cases show that digestion and absorption are almost invariably normal.

The dietetic treatment of the anorexia of acute constitutional disturbance, and of the digestive impairment of disease of long standing are very similar. In the case of patients with acute symptoms, such as high fever, etc., it is a good practice to encourage the patient to make an effort to take an ordinary diet, such as one of our standard diets, and to remind him that his illness is likely to be a protracted one and that he must take a good supply of food daily if he wishes to get better.

We have found that many patients with high fever, especially those in whom the infection is of a recent date, and in whom the constitution has not been impaired, take an ordinary diet quite well and with most satisfactory clinical results. Our experience inclines us to think that the patients who manage to take an ordinary diet, for the most part, make more rapid progress. An ordinary diet, however, should not be continued if it gives rise to much dyspepsia, or if the patient, after some ten days' trial of it, takes an inordinate time over his meals. In a similar way, patients suffering from long standing chronic disease and who have marked anorexia and dyspepsia, can sometimes be persuaded to take an ordinary diet and do remarkably well; general health improves, and with this improvement the dyspepsia gradually disappears and appetite returns. Such a happy result is most likely to follow this treatment in the case of such patients who have just given up work and exchanged life in a town for the favourable conditions afforded by residence in a sanatorium. To prescribe generous diets to the same class of patients who are still at work in a city, or who have already enjoyed the advantages of a sanatorium for some time, is much less likely to prove a success. Considerable judgment must be exercised in determining how long to urge the taking of ordinary diets despite the existence of loss of appetite and dyspepsia, both in the case of patients with acute and chronic disease; gradually increasing anorexia and dyspepsia, and especially onset of nausea and vomiting, however, certainly indicate that the diet should be modified by way of concentrating it.

In constructing what we term, for convenience, concentrated diets, we aim at two things.

(1) To give the necessary nutritive value in an appreciably smaller bulk than that of our ordinary diets.

(2) To give the diet generally in a more easily taken form, for which purpose the amount of solid food is diminished.

Method Of Concentration

The first thing to do is to diminish, or even to eliminate, the amount of food-stuffs which have little or no nutritive value, for instance, soups, potatoes, green vegetables, also the amounts of those food-stuffs which are somewhat bulky, for instance, porridge, pulses, bread and suet puddings. The nutritive value of the food-stuffs thus eliminated must be replaced by the inclusion of other food-stuffs which give the same nutritive value in a smaller bulk. To keep up the protein intake to the requisite standard, the milk should be "fortified," i.e. its nutritive value should be increased by the addition to it of a soluble casein preparation such as casu-men, plasmon and similar food-stuffs. This is easily done. It is also a very good thing to fortify milk puddings and soups in the same way.

We find that as much as an ounce and a half of such a casein preparation, which represents some 32 grammes of protein, may be taken daily without giving rise to the slightest disturbance of the alimentary tract. The advantage of being able to increase the protein value of a diet by 30 grammes with so little trouble is obvious.

Milk is altered in taste by the addition to it of a casein preparation so that patients usually prefer to take this foodstuff disguised in puddings, etc. Bread and biscuits fortified in the same way are also very useful, and can be bought ready prepared, for instance, as plasmon bread and plasmon biscuits.

Another good method of keeping up the protein intake is by increasing the eggs in the diet, as egg-flip, for example, which can replace some of the plain milk. Protein also can be taken by some patients very well as raw meat given either in sandwiches or in milk.

The calorie value of the diet can be conveniently maintained at the requisite level by the use of various food-stuffs. Cream, for instance, is very useful, and 5 oz. of cream can be readily given partly in the milk and partly with the puddings. Benger's food and similar starchy food preparations are also very useful.

Dislike Of Sugar

A practical point to bear in mind is that patients with anorexia are mostly intolerant of sweet foods, and it is a good practice to reduce the amount of sugar contained in their food-stuffs by one-half. More or less unsweetened puddings will be well taken by febrile patients much longer than sweet puddings.

Variety

Variety is always essential when diets of considerable nutritive value have to be taken for a very long period. Plenty of variety is especially important in the dietetic treatment of patients with fever. Free use should be made of all the ordinary roast joints and meats, of poultry, game, etc., varied by made up dishes such as mince, hashes, stews, etc.; sweetbreads and sausages also make a change. Puddings may be readily varied, so long as their ingredients are of a high nutritive value, such as egg, milk, cereals, bread, flour, etc. Blancmanges, cream, gelatine, junket, custards, etc., are very useful puddings with which to vary the diet.

It is perhaps not out of place for us to say that the controlling of fever by the use of sponging or various antipyretic drugs, is often a very great aid in the dieting of patients with febrile anorexia. The reduction of temperature by some such methods in the course of the hour before meal, often sufficiently improves the condition of the patient, if only temporarily, to allow of his taking his food with much less difficulty. The prescription, also, of an ordinary bitter tonic half an hour before meals is often of considerable service in all types of anorexia.