Tuberculosis is frequently accompanied in its severer forms with anorexia, nausea, vomiting, and fever, and the question has to be faced how a patient with these symptoms can be got to take the above standard dietary.

Anorexia is a marked feature often met with in early tuberculous cases. This anorexia has developed gradually, and is associated with progressive loss of strength and weight, and the patient may be anaemic or obviously run down. In these early cases there is probably nothing organically wrong with the digestive organs. The best treatment for the condition is to place the patient under good hygienic conditions, with rest, continual supply of fresh air and sunlight, and at the same time give the generous diet above recommended, in spite of the absence of appetite. The result of this is a striking improvement in appetite, the patient soon acquiring the ability to digest and enjoy the food.

A second form of anorexia associated with much constitutional disturbance, e.g., high fever, sweating, is very difficult to feed. In itself, the fever accompanying the anorexia in tuberculosis cannot be regarded as a reason for reducing the amount of food. The patient, however, is often found to be quite unable to take the large bulky meals necessary for his condition, on account of the dyspepsia set up. The meals have then to be presented in a less bulky form, but still containing the necessary increase of protein. The anorexia accompanying a long-standing case of tuberculosis is generally due to impaired digestive power, and has, in addition, symptoms of distension and flatulence after meals, nausea, and vomiting. In these circumstances the increased protein must be supplied, but has to be given in the most easily digested form. In order to do this the food must be presented in smaller bulk, and it is better often to give the greater part in a fluid or cemi-solid form, solid food being diminished.

To effect this, all foodstuffs having a large bulk and small nutritive value must be eliminated from the diet, viz., potatoes, green vegetables, porridge, pulses, bread, suet puddings; and this must be replaced by other foodstuffs of equal value, but smaller bulk. This may be done by increasing the amount of animal foods, giving more raw-meat rissoles, mince, steak, chop, etc.; or the milk may be " fortified " by the addition of soluble casein preparations, such as Plasmon or Protene (see p. 159). As much as 1 to 1 1/2 ounces of these preparations can be given without causing any disturbance to digestion; and as 1 teaspoonful of Plasmon powder is equivalent to the protein value of 2 pints of milk, its value is obvious. Casein preparations are best added to soup or to milk puddings; when added to plain milk it alters the flavour. Plasmon bread and Plasmon biscuits can be bought ready-made.

Eggs may be added to milk (e.g. egg flip, custard) or to soup, thus obtaining extra nourishment with little extra bulk.

Raw Meat

1 lb. of scraped beef can very easily be added to a small cup of beef soup; or 1/2 lb. scraped meat, made into sandwiches with tomatoes, is an exceedingly easy method for some patients to take the extra nourishment. Cream and yolk of egg are the best methods of getting in the necessary fat.

By the use of Benger's, Allenbury's, and other invalid foods, an easily digested starch can be prepared in many ways (p. 183).

A few practical points that may help in the feeding of these difficult cases are here given. Where there is vomiting or a feeling of nausea whenever the stomach is full, it is well to insist on the patient, in addition to resting before and after meals, to take the meal in the recumbent posture; this is sometimes of great value. A great distaste for sweet things is often present with the anorexia. In these circumstances it is well to reduce the sugar contained in the cooking by one-half; the "invalid foods" are just as nice when flavoured with salt, and the puddings, when very slightly sweetened and well flavoured with lemon, will be quite readily taken. Variety is another most important matter when there is fever. A useful aid to improving the appetite is cold sponging of patients with pyrexia in the course of the hour before the meal; the temperature is temporarily improved, and this allows of the food being taken with less difficulty. This is specially useful before the evening meal.

The following dietaries are examples of diets that may be given when the patient's enfeebled digestion is unable to take the ordinary tuberculous diet: -

1. Fluid Dietary: Mainly Milk

This is advisable where the anorexia is persistent and severe. In place of giving the usual three large meals and two snack meals in the twenty-four hours, it is advisable to feed oftener and in smaller amounts; also, if the patient is wakeful, to give nourishment in the course of the night.

7 A.M. - Milk, 1/2 pint.

8.30 A.M. - Milk, 1/2 pint; with casein, 1/2 oz., flavoured with coffee or cocoa. Gruel made with milk, and eaten with cream.

I! A.M. - Soup, thickened with 1/4 lb. raw beef, scraped; or Soup, thickened with egg and cream; or Milk, with egg.

I P.M. - Chicken essence, or veal jelly, strengthened with casein, 1/2 oz., and milk, 1/2 pint; or Raw-meat mince, 1/4 lb., with milk; or Raw-meat rissoles, with milk; or Raw-meat sandwiches, with milk.

3 P.M. - Milk, with egg, or thin custard.

5 P.M. - Milk tea, 1/2 pint, with cream.

7 P.M. - A meat juice, e.g., Wyeth's, Leube Rosenthal's meat solutions, mixed with port or Burgundy; or Soup, with raw meat; or Beef extract, with egg and milk, forming a custard; or Beef extract, made with milk and casein, 1/2 pint; or Milk and arrowroot, with casein and cream, 1/2 pint. (Brandy may be added).

8 P.M. - An invalid food, made with milk and casein, 1/2 pint (see p. 183).

11 P.M. - Milk and egg, or chicken tea with egg.

In very severe cases the milk may have to be peptonised or pancreatised; or fermented milk (koumiss or Kephir) is sometimes tolerated when ordinary milk causes digestive disturbance; whey, also, flavoured with sherry and fortified with casein and cream.

2. A Largely Meat Dietary

This is often of great assistance for a time in cases where dyspeptic symptoms follow the large mixed meals.

6 A.M. - Milk, 1/2 pint. 8 a.m. - Milk, 1 pint, fortified with casein, 1/2 oz., flavoured with coffee or cocoa (peptonised).

Slice of toast, with butter.

Bacon, ham, eggs, fish, meat rissoles, or steak (taking two things). 11 A.M. - Glass of hot milk, with eggs, or raw-meat soup. I P.M.: Lunch and Dinner - Soup from strong stock, or fish soup, or helping of fish.

Mince lightly grilled, tender steak or chop; or slice of underdone sirloin of beef; or roast leg of mutton.

Stewed fruit and custard, or jelly with cream.

Toast; glass of milk.

4 p.m. - Cup of milk-tea, toast and butter, or biscuit and butter. Dinner - Much the same as Lunch. A little wine.

Intermediate Diets

It is advisable occasionally to stop this largely meat dietary for a day or so, and give other foods, e.g, fish, a little farinaceous food, and vegetables, just for a change. This gives the kidneys a rest, and diminishes the risk of the development of albuminuria, or other urinary troubles arising out of the large protein diet.

Two further dietaries may be given that are not so specialised as the mainly fluid and the mainly meat diet. They are both more concentrated than the ordinary standard dietary, and are useful steps in the process of getting a patient up to the standard diet.

(A) 7 a.m. - Milk, 1/2 pint.

Breakfast

Coffee or cocoa (pancreatised), made with milk, and 1/2 oz. casein. Well-boiled gruel, made with milk, eaten with cream, or bread and milk. I egg, lightly cooked, and a small piece of toast and butler.

11 A.M.- Soup, with raw beef; or three raw eggs (p. 424).

Dinner

Milk, 1/2 pint ; toast, or rusks, and butter.

Fish souffle, or cream, or quenelle ; or Pounded chicken, or cream, or souffle ; or Omelet, with chicken or fish.

Mince from scraped beef, or meat rissoles; or Raw-meat sandwiches.

Small helping of pudding. 4 P.M.-Tea made with milk. 6.30 P.M. - Milk, 1/2 pint.

Choice of one light meat, solid, as under Lunch.

Custard, cream, or light souffle.

Glass of wine. 9 P.M. - Invalid food, with casein.

During night

Milk, with egg.

(B) Breakfast

Tea or coffee, with milk, two large cups, with casein.

Bacon, eggs, fish, sausages, rissoles (two courses).

Toast ; roll with butter. 11 A.M. - Milk, 1/2 pint, with two raw eggs ; or Soup, with raw beef.

I P.M - Soup from meat stock.

Fish, or entree.

Meat, fowl, or game, with one vegetable.

Milk pudding with casein, or stewed fruit, custards, creams, or jelly.

Milk, 1/2 pint, with bread or toast and butter.

4 P.M. - Tea made with milk. Bread, biscuits, and butter.

Dinner

Milk, 1/2 pint.

Soup and meat, and a vegetable; or Fish, entree, and a vegetable.

Pudding, or a savoury containing casein or cream.

10 p.m. - Milk, with egg; or Soup, with raw beef.

Tuberculosis of the various organs require special modifications of the standard dietaries.