With failing compensation there arise various digestive disorders. Loss of appetite, flatulence, constipation, are the subjective indications which result from the congested state of the liver, stomach, and bowels which are now present. In later stages, albuminuria develops from the venous congestion of the kidneys, and the tissues may now become cedematous or water-logged, from the interference to the free return of blood to the heart.

The general directions already given should be closely adhered to. The diet varies according to the degree of severity of the heart failure. The diet appropriate to cases of moderate severity will first be discussed.

The patient, although ill, is not suffering from fever, and there is no necessity to place him upon a fluid diet given at short intervals. It is best to follow his usual habit, and continue having three meals a day. These should be, as before stated, small in amount, simple in character, well-cooked, and nutritive - arranged at sufficient intervals to permit of complete removal of one meal from the stomach before the entrance of the next into it. And, in addition, the meals should be as dry as possible; soup in these cases is better avoided.

Breakfast is generally the best meal, as after the long rest there is more digestive capacity; so with this meal a large cup of tea or coffee may be permitted, and a little carbohydrate foodstuff. China tea, apparently, is much better for a feeble digestion than Indian or Ceylon, and should, where available, be taken.

There is no need to give a tumbler of milk, cup of Bovril, or other food at ii o'clock. It is better to let the patient sip slowly a glass of water about an hour before the next meal is due, at 1 or 2 o'clock. The midday meal should consist of chop or fish or fowl, with some carefully prepared green vegetable (p. 403), cooked with plenty of butter, and rubbed through a sieve. A second course of stewed fruit, sweetened with Saxin, and eaten with cream junket, or custard (baked or boiled) apple cream, lemon sponge, milk blancmange, jelly with cream. Creams flavoured in different ways are allowable. No pudding containing starch is to be allowed. A little cheese, eaten with butter, but no bread or biscuit, should be taken. Half an ounce of brandy or whisky may be allowed with the midday and evening meals.

At 5 o'clock a cup of Chinese tea, unsweetened, or with Saxin, may be drunk, but no breadstuff should be taken with it.

At 7 or 7.30 the evening meal should generally be a repetition of the midday one, but it is best to take chop or other red meat only at one of the meals. The vegetables mentioned above are allowable. A second course may be permitted, and may be followed by cheese, as before, if this agrees.

A glass of whisky or brandy in half a tumbler of hot water, or a small 1/2 pint of beef-tea, chicken tea, or good consomme may be taken after 10.30, but no breadstuff of any kind should be taken along with it. Three small meals will usually be ample for a cardiac sufferer; there is no question that any laxity from this diet will speedily show itself with increased flatulence.

Those patients who have been in the habit of taking dinner and high tea must give up the habit. It is very difficult to make them understand that the midday and evening meal should be very much the same in quality and quantity.

An illustrative diet sheet is here given: -

8 to 8.30: Breakfast - 1 large cup of China tea, with plenty of milk and cream.

Thin crisp toast made from "pan loaf," or Veda bread with butter and a little marmalade. One of the following: -

Bacon (fat, crisply cooked), or fish (steamed or fried or rizzard); egg, plain boiled, scrambled, or poached; tongue, or potted meat.

Midday meal and Evening meal - Choice from:

1. Fish, rabbit, fowl, game, raw-beef mince, steak, chop, slice of roast beef or mutton (hot or cold).

2. Vegetable: One selected from the following:

Greens

e.g., cabbage, lettuce, spinach, sprouts - boiled, rubbed through sieve, and heated in butter. Vegetable marrow or cucumber (stewed). Cauliflower and asparagus (tops only). Celery (stewed). Onions (Portugal) - long stewing.

3. Sweet - Stewed fruit, neutralised with soda bicarbonate, or souffles sweetened with Saxin. Roast apples, apple cream. Custards (boiled or baked), with cream. Junket, jelly creams.

4. Cheese - Eaten with butter or cooked with eggs, if found to be digested. Half a glass of whisky or brandy, with 4 ounces of alkaline water.

Evening a meal

A choice from 1 and 3 in the above midday meal. Two courses only to be taken. White meat in place of red meat should be taken once a day at the midday or evening meal. No cheese.

Diet For Failure Of Compensation - Advanced Degree

The feeding of the patient suffering from severe dilatation of the heart is often a very difficult matter. The liver is in a state of congestion, and unable to do its usual share in the digestive processes; the stomach is in a condition of catarrh, which has induced complete loss of appetite, and often sickness and vomiting. In these circumstances it is sometimes advisable to give the stomach complete rest for forty-eight hours, and feed the patient entirely by the bowel (see p. 221). In most cases the diet must for a time subsequently be entirely a fluid one, and should comprise milk (plain or pep-tonised), koumiss, Kephir, various meat preparations, and invalid foods. The following dietary is given, so as to indicate the amount of food and the variety of foodstuffs that may be recommended in these severe cases. The total nutritive value of this diet is small, but in many cases it is as much as the patient can possibly take for a week or two or more of his illness. In a few cases patients cannot even take as much as is given in this diet sheet, the amount of fluid that can be taken being about one-half of that indicated in this regimen. In all of these cases stimulants are advisable, preferably in the form of best quality whisky or brandy.

6 a.m. - Milk (peptonised), 2 ounces.

8 A.M. - Beef juice, 2 teaspoonfuls in a little aerated water.

10 a.m. - White wine whey, 2 ounces; or koumiss, 2 ounces.

12 A.M. - Allenbury food, 3 ounces.

2 P.M. - Beef juice, 2 teaspoonfuls, either given alone, or in a little brandy and water. 4 P.M. - Milk (peptonised), 2 ounces. 6 P.M. - A few teaspoonfuls of chicken jelly. 8 P.M. - Albumin water and milk, 1 ounce of each; or albumin water and koumiss. 10 P.M. - Allenbury food, 3 ounces, and brandy. 12 P.M. - Beef juice. I A.M. - Milk (peptonised), and brandy. 3.30 A.M. - Chicken jelly, a few teaspoonfuls.

The Senile Heart

In elderly subjects suffering from heart disease, the general rules already given are the best guide in the treatment of such patients as are below their usual weight. A smaller number, however, are over their normal weight, and suffer more from breathlessness than the preceding class, these require careful dieting to reduce the obesity without reducing their strength. And for a third class, where the failure of compensation shows itself in dropsy of the tissues, a special "dry diet" is necessary.

Diet For Heart Disease In Obese Subjects

This dietary is also appropriate to the general run of cases of angina pectoris, where there is no serious organic disease of the kidneys.

Breakfast

Fluid restricted to 4 to 5 ounces - tea, milk, coffee, or cream, and seltzer water. 1 slice of crisp toast with butter. 1 poached or boiled egg, or 1 fillet of fish. 1.30 or 2 P.M.: Midday meal. - The principal meal of the day; should consist of two courses only.

Fish, meat, and 1 vegetable or Fish and a potato. Light pudding.

Or:

Meat and 1 vegetable. Pudding.

(Fluid not to be more than 4 ounces of hot water).

5 P.M - A small cup of China ten, freshly made, with cream and sugar. 7 P.M.: Evening meal (one course). - Fish, with toast; or beef-juice mince. Chicken puree, with to Savoury Bovril custard. Egg in some form.

(Farinaceous foods better avoided.) 10 P.M. - 1/2 tumbler of hot water.

Dry Diet For Dropsy (After Balfour)

Breakfast

I slice of dry toast, no butter. I cup freshly made tea with cream.

Dinner

1/4 lb. of rump-steak; or "eye" of 2 mutton chops; or an equal quantity of mutton (roasted); or beef, chicken, game, or fish; as much dry toast as desired. Brandy or whisky, 1/2 ounce, and 3 ounces water. Supper. - As much dry toast as is desired, along with 1/2 ounce of brandy or whisky in 3 ounces of water; nothing more. (It is not desirable that patients in this condition drink much, but if thirsty, they may be allowed to sip slowly 4 ounces of water an hour before meals).

Aneurism

Rest, a restricted diet with a limited amount of fluid, together with potassium iodide, form the chief points in the treatment of aneurism. The starvation diet recommended by Tufnell is only applicable in a very small proportion of cases. Tufnell's diet is as follows: -

Morning meal

2 ounces of bread and butter, with 2 ounces of milk or cocoa. Midday meal. - 3 or 4 ounces of meat, with 2 to 3 ounces of bread or potato, and 3 to 4 ounces of water. Evening meal. - 2 ounces of bread and butter, with 2 ounces of milk or tea.

This rigid regime is only advisable in well-nourished subjects, especially those with a plethoric tendency. It is quite unsuitable in debilitated subjects. In the latter there is sometimes an enfeebled digestion, and it may be advisable to have recourse at the outset, to a milk or lacto-vege-tarian diet. The important points to attend to in framing the dietary in all cases are the following: -

1. Restriction in the amount of fluids of all kinds. Not more than from 20 to 30 ounces in the twenty-four hours.

2. Meats and meat foods to be given in very sparing amount, the stimulating effects of these foods on the circulation being prejudicial.

3. A light, simple, nutritious diet, given thrice daily, with no food between meals. The meals should be much on the lines of the diet laid down on p. 548.

4. Alcohol in all its forms is inadvisable, excepting in cases of feeble digestion where its use in small doses may prove beneficial.