Every patient on admission was carefully examined and observed for a day or two. This enabled us to estimate the extent and activity of the disease, and to ascertain the amount of fever present, the degree of emaciation, and to some extent the general constitution of the patient, and more especially the condition of his alimentary tract. We next estimated the nutritive value of the diet which was physiological, i.e. adequate for the requirements of the individual patient when in normal health and up to his normal weight. We then constructed a diet for the patient, in which the chief constituents of his physiological diet, viz., protein, fat, and carbo-hydrate, were increased in certain definite amounts. During the course of our observations we varied the amounts of the increase in protein, fat, and carbo-hydrate considerably in different cases, and in many individual cases we observed their progress on diets of varying nutritive value.
As a matter of routine practice we increased the physiological diets of patients in the several chief constituents according to the degree of activity of the disease and the amount of emaciation present in any individual case.
In every instance the physiological diet for the individual patient when up to his normal weight and in normal health was taken as the basis for his sanatorium dietary. The diet as prescribed thus represented the physiological diet, with the addition of certain definite amounts of protein, fat, or carbo-hydrate. The diet prescribed was given to the patients in accurately weighed-out and measured amounts, and after the completion of every meal, any food-stuff that was left was also accurately weighed. By this means we obtained definite data as to the exact amount of the various foods taken by each patient throughout the whole course of treatment.
Careful clinical observations were always made with regard to the progress of the lung disease, alterations in body-weight, improvement in general health, etc.
In many cases, metabolic examinations were also made. Sometimes these observations were made during a four-day period once a month; in other cases, they were made daily for periods varying from a week to three months. The points especially studied were (1) the absorption of fat and nitrogen, (2) the amount of excreted nitrogen, (3) the form in which the nitrogen was excreted, viz., whether simple or in the more highly elaborated form, and their percentage relation. (4) The amount of intestinal putrefaction as evidenced by the ratio between the aromatic and the alkaline sulphates excreted and the amount of indican.
Generally speaking, a person suffering from tuberculosis requires a more generous diet than is physiological for him when in ordinary health. There are, as has been already noted, three chief constituents of a diet, viz., protein, fat, and carbo-hydrate. The question is, in which constituent and to what extent should the increase be made? Some physicians with considerable experience in the treatment of tuberculosis advise that the increase be made in protein sparers, especially fat, while others advocate a very generous increase of all the constituents. Our experience is that the morbid process clears up better and general health improves more rapidly when patients are treated with diets richer in protein than those usually taken in health. We have, for instance, in the case of patients whose progress has been somewhat stationary, noticed distinct improvement immediately follow the addition to their diets of more protein. In similar cases, when a comparable increase has been made in the carbo-hydrate and fat, the protein intake remaining the same, there has not been the same improvement. Theoretically, one might expect equally good results to be associated with the increased use of protein sparers, and an actual increase of protein; in practice we have not found this to be so. It seems possible that the beneficial effects of an increased protein intake may be in part accounted for by the extractives contained in the meat. We have found, however, that when using a diet containing no meat at all, and in which the protein is given chiefly in the form of milk, pulse and oatmeal - in which the amount of extractives is negligible - we obtain results as satisfactory as when prescribing protein chiefly in the form of meat. Protein produces a stimulating effect upon the general body metabolism, and thus has a beneficial influence upon general nutrition; the value of an increased protein intake in the treatment of tuberculosis is probably thus explained.
With regard to the amount of the increase of protein we have observed the course of tubercular disease in a large number of patients treated upon diets containing daily amounts of protein ranging from 150 grammes to 250 grammes, and our experience has been as follows : excellent results both from clinical and metabolic standpoints have been obtained when using diets containing 150 grammes of protein daily. Increasing the intake of protein beyond this point, viz., 150 grammes daily, is not associated with any better clinical or experimental results; on the other hand, we have found that large amounts of protein may do actual harm. Metabolic investigation shows that with a very large protein intake, a very large proportion of the nitrogen ingested is immediately excreted, and throws a considerable strain upon the alimentary and excretory organs, the amount of nitrogen excreted in less completely oxidized form is increased, and there is evidence also of increased intestinal putrefaction. Our experience is, then, that the increase in protein in any individual case should be some 25 to 30 per cent on the amount of protein contained in his physiological diet; this, on an average, works out at some 150 grammes daily.
The necessity for increasing the energy-giving foods of the dietary when treating tuberculosis has frequently been insisted upon, indeed, a good deal more stress has been laid upon this point than upon the desirability of increasing the protein. As a matter of interest, we would point out that the way in which the increase in energy-giving food is usually made, viz., by the addition of milk, means that a considerable increase is at the same time made in the amount of protein.
In a large majority of cases of tuberculosis, it is undoubtedly-desirable to increase the amount of energy-giving foods, especially so in the case of patients who have much fever or who are considerably below their proper body-weight. Fat is a less bulky form of energy-giving food than carbo-hydrate, and for this reason is much more readily taken; a patient with anorexia will take a considerable amount more nourishment in the form of fat than in the form of carbo-hydrate. Fat, then, is rightly recognized as a very valuable item in diets for the tubercular. Fat, also, by experimental observations, we have found to be extremely well absorbed, even by patients with high fever and acute constitutional symptoms; for example, 96.4 per cent was absorbed by a patient who took 231 grammes of fat daily. An increase of energy-giving foods beyond a certain point is prejudicial, just in the same way as an increase of protein beyond a certain point does harm rather than good. The taking of an excessive amount of fat and carbo-hydrate results in the putting on of too much body-weight, largely in the form of fat, a condition which is associated with dyspnoea, flabbiness, poor general muscular tone, and often anorexia and dyspepsia.
It is difficult to state the amount of the increase which should be made in fat and carbo-hydrate, as this depends a great deal upon the amount of physical exercise which the patient is allowed to take, as well as upon the other factors which we have previously referred to. On an average, the tubercular patient at physiological rest, viz., not engaged in actual muscular exertion, appears to do best upon a diet which represents an increase of 30 per cent in total calorie value upon his physiological diet. On diets of such a value, and assuming that the protein value has been increased 150 grammes, our patients have regained lost weight at the rate of from 1-2 lb. a week until they are a few pounds in excess of their normal body-weights, a condition which is usually associated with all-round satisfactory progress. In the case of tubercular patients who have quiescent lesions and are restored in general health, and who may be engaged in actual manual work, a still larger amount of energy-giving food will be required; for example, to patients with arrested pulmonary tuberculosis engaged in heavy gardening work such as digging, we prescribe diets with a calorie value, up to 4,500 grammes, with most satisfactory results. A very fair and "rough and ready" guide, as to whether a patient is taking a proper amount of energy-giving food, is given us by his weight. A steady gain of weight of from 1-2 lb. a week in the case of a patient with active disease who is considerably below his weight is satisfactory. A steady increase of body-weight in the case of a patient already some pounds in excess of what is deemed his normal body-weight, is an indication that he is taking too much energy-giving food, or not taking sufficient exercise. Our practice is to make a reduction of 15 per cent in the energy-giving foods when a patient has reached a body-weight slightly in excess of his normal.
To summarize, then, the general principles for the dieting of the tuberculous are as follows : -
1. The amount of protein in the physiological diet should be increased by 30 per cent, and this increase should be maintained until the disease is obsolete.
2. If the patient is under weight, the physiological diet should also be increased 30 per cent in the purely energy-giving foods, viz., either in fats or carbo-hydrates, or partly in each. This increase should be maintained until the weight becomes stationary at a point a few pounds in excess of the patient's highest known weight before becoming infected with tuberculosis.
A decrease of 15 per cent may then be made, and the diet, thus altered, should be continued until the disease is obsolete.
Individual and class habits will determine the relative amounts of fat and carbo-hydrate prescribed.
(3) Patients with constitutional disturbance associated with anorexia or dyspepsia usually require a somewhat concentrated diet, so as to give the comparatively large amount of nourishment in a but slightly increased bulk of food-stuffs.
(4) The meals should be well cooked, varied, and given as far as possible at considerable intervals, and reliance should be placed upon plain food-stuffs whenever possible; invalid food should only be used when ordinary foods cannot be taken.