The general principles to be followed in the dietetic treatment of tuberculosis have been admirably summed up by Kardswell and Chapman 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in the physiological diet should be increased by 30 per cent., and this increase should be maintained until the disease is obsolete.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 carbohydrates, or partly in each. This increase should be maintained until the weight becomes stationary at 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 A decrease of 15 per cent, may then be made, and the diet, thus altered, should be continued until the disease is obsolete.

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 foodstuffs.

4. The meals should be well cooked, varied, and given as far as possible at considerable intervals, and reliance should be placed upon plain foodstuffs whenever possible; proprietary invalid foods should only be used when ordinary foods cannot be taken.

The Diet

From the outset the patient must be impressed with the fact that the diet is of primary importance in the treatment of the disease, and must be kept up so long as the condition is present. Whenever the patient tends to grow careless, the injunctions concerning the diet must be repeated. Directions should not be given in a general way, but should be detailed, special mention being made of the food to be eaten and the food to be avoided. The hours for taking food and the amount to be taken should be carefully outlined. It is generally better to give written instructions concerning the diet, as the patient is apt to be forgetful, more especially if he has certain likes and dislikes.

The diet should be restricted to three good meals a day, with two snacks at suitably separated intervals. Thus if breakfast be at 9 A.M., lunch at 1 P.M., dinner at 7 P.M., a light snack may be allowed at 7 A.M. and at 4 P.M. It is unwise in such cases to allow further extras of any kind between meals. If the patient sleep well, it is better not to give anything by night If wakeful, a cup of beef-tea or diluted warm milk may be allowed through the night. The food must be nicely prepared, daintily served, and varied as much as possible. It is not as a rule advisable to give much fluid at meal-times. Where the extra nourishment required riven in the form of milk, not more than one tumblerful should be given with meals. The quantity of food should be increased as appetite advances ; it is noteworthy that a patient in the most favourable conditions of fresh air and sunlight may be able to digest and assimilate an extra diet of six to eight raw eggs daily, whereas under less favourable conditions in a town, not more than one or two eggs daily could be assimilated without deranging the digestion.

Amongst The Well-To-Do Class

The extra nourishment required can be given either in the form of 3 pints of milk extra daily, or two to three eggs and 2 pints of milk, or as underdone red meat, 6 to 8 ounces. More commonly it is supplied by a judicious combination of these foods. The eggs may be taken raw (p. 47), or added to milk or soup, or 1/2 lb. raw meat or meat juice may be added to the daily dietary.

A typical dietary, framed for an average case of fair digestive capacity and free from complications, is here given. A choice is given for the chief courses in the menu. It will be observed that the diet contains a restricted amount of bread, breadstuffs, suet puddings, and the like, which predispose to fermentative changes.

8 A.M. : Breakfast - Coffee, or cocoa, or tea, made mainly with milk-two breakfast cups.

One of the following:

Egg - plain boiled, scrambled, or poached-one or two. Bacon, ham, tongue, herring or fish, meat rissoles.

Toast, two to three half-slices ; roll or oatcake ; plentiful supply of butter. 11 a.m. - Milk, 1/2 pint, to which may be added one or two raw eggs. 1 30 p.m. : Lunch - Fish or entree, an ordinary helping.

Meat - roast, grilled steak, or chop (rather underdone), and vegetable.

Custard, curds, stewed fruit and cream, souffles, or omelets.

Milk, 1/2 pint. 4 P.M. - Cup of tea with cream, bread and butter, slice of cake. 7 P.M. : Dinner - Soup, about 8 ounces of clear consomme^

Fish or entree.

Meat and vegetable.

Pudding. Savoury, or biscuits and cheese. Milk, 1/2 pint.

With any tendency to sleeplessness, a cup of clear soup is of special value, or a glass of hot milk taken at bedtime.

If the custom of the patient is to take the chief meal of the day at midday, and a late meat tea, the evening meal may be as follows: - Fish or egg.

Meat, ham, sausage, or brawn.

Cold sweet - such as cornflour shape, custard, or stewed fruit Milk, 1/2 pint, flavoured with cocoa or coffee. Biscuits, butter, and cheese.

Amongst The Working-Classes

Here the extra protein required may be got from the cheaper meats and fish, from skimmed milk, and from the pulses. The extra fat may be obtained in the form of margarine. The cost of the following dietary works out at about is. the day: -

Breakfast

Bowl of well-boiled porridge, made with half milk and half water; milk, 1/2 pint. Bacon, egg, or fish. Bread and butter. Cocoa or coffee, made with milk - breakfast cup.

Dinner

Meat, potatoes, and green vegetable.

Suet pudding, with jam, treacle, or stewed fruit.

Milk, 1/2 pint (skimmed).

Tea

Tea made with skimmed milk. Bread and butter.

Supper

Soup, made from pulses (lentil, pea, bean); or porridge and milk; or sausage, ham, or cold meat. Bread and butter. Milk, 1/2 pint.

A still cheaper dietary may be necessary, and may be framed by using skimmed milk in place of sweet milk, margarine instead of butter, also by using the cheaper meats at 5d. to 8d. per pound, and making more use of lentils and the cheaper varieties of cheese.

The following directions will be found useful for the dietetic treatment of tuberculous patients of the poorer classes living under home conditions. These are taken from Bardswell's admirable work on this subject.

Directions for economical home feeding for patients living at home - for instance, those attending out-patient departments at hospitals, etc. - It is by no means easy to direct efficiently the dietetic treatment of tuberculous people belonging to the working-classes, unless they are immediately under supervision, eg. in an institution. In our experience, the prescription of a definite diet to consumptive patients among the poorer classes is not satisfactory, as, for the most part, they have not the means at home of carrying out the instructions at all accurately.

We have obtained more satisfactory results in such cases after giving general directions, as under: -