Facultative Carnivore

[This is the second half of the paper.]

In accustoming the patient to the more strict form of diet, care should be exercised not to permit the stomach to be overloaded. The beneficial effects of temperate eating in glycosuria were very prominently illustrated during the siege of Paris, as Bouchard observed that sugar entirely disappeared from the urine of diabetics in whom up to that time it had persisted, even though they had been living on a carefully regulated diet. The diminution in the quantity of food, occasioned by its great scarcity during the siege, effected that which alteration in quality had failed to accomplish.

The more slowly food is submitted to the digestive forces, the more completely is it likely to become assimilated. Tight meals frequently repeated is the better rule to follow, at least until the patient becomes accustomed to the change. It is important also that the diet be varied as greatly from day to day as the range of food in the list will permit.

I have repeatedly placed diabetic patients that were considerably under 20 years of age upon the strict lines of diet herein indicated, with the result of completely eliminating the sugar from the urine for weeks and months together, and without resort to medication. Thus it may be seen how much may be expected from proper dieting, even in cases that we are forced to consider as ultimately hopeless ones.

By way of illustration—a year ago this month a lad of 18 years came to me from a distant State with a history of diabetes of over a year’s standing. His symptoms, as is usual in such cases, were great thirst, morbid appetite, polyuria, and advancing emaciation, with a very considerable amount of sugar in his urine. His physician at home had put him upon a diet scarcely so limited as the ‘ ‘ first step ’ ’ laid down in this paper, and but a slight check was put upon the disease. I gradually restricted his food allowance until it conformed to the strict diabetic diet already laid down. His thirst gradually subsided, the quantity of urine diminished, and at the end of six weeks no trace of sugar was to be found in his urine, and he began to regain his lost weight. •Under a continuance of this course the urine remained normal in quantity and free from sugar for about three months, when he returned to his home with directions to follow as closely as possible the course that had so greatly benefited him. This case may be fairly ranked among the most unpromising ones, chiefly on account of the patient’s age; for it is a rare exception to meet with a case under 20 years of age in which the disease does not rapidly prove fatal unless the patient be very strictly dieted.

It may be said of glycosuria in general that its severity is usually in inverse ratio to the age of the patient. The youngest diabetic I have seen came under my care a short time since, in the person of a little boy 3 years and 2 months old. In this case the polyuria was so pronounced that a nurse had to be provided to attend him at night, as he “ wet the bed’’ from six to eight or more times each night. It may be of interest to note that he was put upon an animal diet, including milk, which soon lessened his polyuria so that the patient did not urinate during the whole night. I believe milk is more easily assimilated by children than by adults ; at any rate it seems to agree better with them in these cases ; and this is very fortunate, since we are almost driven to its use in diabetics of tender age. As a rule, in patients under middle age, we shall be obliged to bring to bear against glycosuria all our resources of dieting in the more strict form. I have met with an exception to this rule in the case of a Jewess, 29 years of age, in whom moderate restrictions of diet have kept the urine practically free from sugar for the past year and a half, only exceptional traces having appeared occasionally. It has been remarked by several observers that diabetes is frequent among Hebrews, and that in them the disease is always of. mild form. My own experience tends to confirm the latter statement. I have, indeed, at the present time, three cases in Hebrew women under treatment, and they are all of mild form.

For the most part the milder forms of glycosuria are met with in people that have passed the age of 40 or 50 years. In this class of cases our resources against the disease are always more effective ; indeed, one or two years careful dieting not infrequently leads to permanent cure.

It remains, to speak of the medicinal treatment of glycosuria, and I may as well state frankly at the beginning that I have little faith in the curative power of medication over the disease, while on the contrary I am satisfied that the use of drugs in these cases is often productive of harm. My conclusions upon this point have been reached through separating the dietetic from the medicinal treatment, and then comparing the results of each. When a system of diet and medication are employed together from the beginning, the benefits accruing from diet may be attributed to the medicines, while the unfavorable influence of medication may be attributed to the disease. Our faith has become so supreme in the efficiency of medication in these days, that we are apt both to permit ourselves to be misled in its favor, and to overlook its possible injurious effects.

Of the various drugs that have been recommended in glycosuria, opium, perhaps, maintains its reputation best and has become the most popular. Opium undoubtedly tends to restrain the excretion of sugar in these cases, but the doses necessary to accomplish this result are so large that the drug is likely to induce constipation and impaired digestion, and thus any good accomplished through its use is more than counterbalanced by resulting evil. I have recently gone over this ground very carefully in a series of trials systematically conducted. Three cases were selected, in each of which the sugar excretion had been reduced by strict diet to about i per cent. They were all typical cases of true diabetes of central origin; and no little pains had been expended in reducing the sugar to so small a percentage, and maintaining a good general condition with excellent digestion and assimilation. Under gradually increasing doses of opium the sugar excretion was reduced Somewhat in all the cases, but sooner or later constipation, loss of appetite, or nervous disturbances compelled the dis- continuence of the drug without exception. This has always been my experience in the use of opium in glycosuria ; nor have I found any material advantage in the use of morphia, its bimeconate, or the use of codeine. They all comport themselves much the same as does opium when used in equal physiological doses.

Ergot is probably the next most popular drug employed in the treatment of glycosuria. In the necessarily large doses required to effect the disease it is unsuitable for lengthy periods of administration. Its controlling power over glycosuria is very feeble and uncertain, and on the whole it may be regarded as unworthy of much confidence.

Bromide of arsenic and syzygium jambolanum have recently been highly lauded in the treatment of glycosuria. I have known the former to be administered in the largest doses (25 drops Gilliford’s solution), during which time the patient continued to excrete urine that contained 30 grains of sugar to the ounce. Upon withdrawing the bromide of arsenic and placing the patient upon a restricted diet, I had the satisfaction of seeing the sugar speedily reduced to 2]/i grains to the ounce. I have administered jambul to a number of my patients, but without noticing any favorable change that I could fairly ascribe to its use. A number of other drugs have been more or less highly extolled for their alleged specific influence over glycosuria. Among these may be mentioned iodoform, bromide of potassium, iodide of potassium, arsenic, sodium phosphate, nitrate of uranium, salicylic acid, picric acid and Calabar bean. There does not, however, appear to be sufficient evidence in favor of any one of these to entitle it to any degree of confidence. Carefully discriminated from the benefits derivable from dieting, these drugs are probably nearly inert so far as their influence over glycosuria is concerned.

The legitimate field of therapeutics in glycosuria becomes practically narrowed down to the treatment of its accompanying symptoms, and upon this point but few words will be here added. It has already been stated that disordered digestion is so frequent in glycosuria as to constitute it an accompanying rule. Indeed, many of the milder cases owe their origin without doubt to this cause. The digestive and assimilative functions should therefore receive especial support through such agents as experience has taught us prove the most efficient. Among these may be mentioned, pepsin and the vegetable bitters— and especially strychnia. The latter I have come to regard with increasing favor.

Constipation, so frequent an accompaniment of glycosuria, should be especially guarded against, as this condition reacts very markedly in enfeebling the digestive and assimilative powers. I have an especial preference for the natural alkaline purgative waters to meet such requirements, since they relieve the over-acid condition of the intestinal canal so common to the disease. Fried- richshall or Sprudel—or the salt made by the evaporation of the latter—given before breakfast,

in hot water, seem especially appropriate. In middle-aged people inclined to stoutness and overeating, a course of purgation by either of these agents often proves highly beneficial.

The various nervous disturbances accompatiy- ing glycosuria are, on the whole, perhaps best met by the use of bromides—especially that of sodium or lithium. It is not uncommon to meet cases of glycosuria complicated by anaemia. When pronounced, this condition is frequently attended by oedema of the extremities, and under such circumstances the liberal use of iron and arsenic is attended by excellent results. The appearance of multiple boils is not uncommon in glycosuric patients; a complication generally considered ominous of approaching danger. I have seen a disappearance of this complication in two weeks under the use of quinine—8 to io grs. daily— after having resisted other measures for nearly three months.

The most dangerous, and certainly the most rapidly fatal, of all the complications of glycosuria is that of Kussmaul’s coma—sometimes called acetonaemia. Since the treatment of this complication has thus far proved so unsatisfactory, a knowledge of the conditions commonly leading thereto should be borne in mind, in order to guard the patient against it. Constipation, mental emotion, and fatigue seem especially to predispose to this complication, while a highly acid state of the urine often precedes it. I have repeatedly, in these cases, observed sudden death by coma to constitute the penalty of a hunting expedition, or long railway journey entailing unusual fatigue. If the early indications of approaching coma are observed, stimulants and hot baths should l>e resorted to without delay. It is believed that diabetic coma is brought about by some toxic agent in the blood, perhaps derived from alcoholic fermentation of glucose. Whether this be acetone, or some other agent, we are warranted by certain f facts in believing that it is of an acid nature and, therefore, large doses of alkalies seem the most appropriate remedies to employ. An ounce of tartrate or citrate of soda dissolved in a pint of water may be given three or four times a day. The intravenous injection of sodium carbonate, with chloride of sodium, is strongly advised if coma has already become established. Under the latter circumstances, however, recovery is extremely rare under any form of treatment. On the whole, then, promising results are only to be expected by attempts at warding off the attack through such measures as have already been suggested.

In concluding what has been intended as a practical review of the management of glycosuria, it seems desirable to emphasize the immense importance of careful dieting as greatly outweighing all our other resources combined. This fact should be strongly impressed upon the patient from the beginning. He should be taught to rely little upon medication, and the most effective means of doing this is to show him how much can be accomplished by careful dieting alone. When he has once learned through experience that the amount of sugar in his urine always bears a direct ratio to the prohibited foods indulged in, he is less likely to overstep the proper limits imposed. With his thirst, polyuria, and other discomforts relieved—a sure sequence of careful conformance to the rules—unless he be greatly lacking in intelligence and gratitude, he will cheerfully submit to the conditions imposed, since he will see and feel how greatly he is indebted to them.

163 State St., Chicago.

In the treatment of diabetes the diet plays tho most important part. We cannot attack the real cause of the disease because we do not know it. Our task, then, is to prevent, so far as is possible, sugar-production. This can bo done only in the mild form of diabetes. The diet should be regulated as follows: 

There should be absolute avoidance of carbohydrates, and accordingly a diet composed exclusively of fat and meat. Cantani and other physicians have wished to embody this principle in its entirety in their practice, and Cantani believes that he has seen a cure following a long-continued diet composed exclusively of meat. The reader has never seen so fortunate a result. Absolute meat diet, if it be long continued, has undoubtedly the advantage that it permits a certain tolerance for starch; but this tolerance is a very limited one, and a diabetic who, after a long-continued life of meat diet, allowed himself to live like a healthy person, would pay heavily for it. 

Aside from its great difficulty of accomplishment, a diet composed entirely of meat has this great drawback: cases so treated quickly acquire a catarrhal gastritis and enteritis. Besides this, the less-determined patients generally break through their diet regulations and eat injurious food without stint, because the treatment is so very unpleasant and of such long duration. 

The theory that diabetes can be cured has another great disadvantage connected with it. Patients from whose urine the sugar has all disappeared except a trace, consider themselves cured, and think their diet may be varied. In this way relapses occur. 

The idea which Seegen follows out in treating his diabetes cases is as follows: there should be ordered for the patient such a diet as can be continued throughout a life-time, with the aid of a strong determination. A diet of meat and fat should prevail. Seegen warns you that the patient must not be allowed to eat meat and eggs in too great quantities for the purpose of building himself up. A diabetic patient does not need more meat than any healthy person who lives chiefly on a meat diet. But with this diet the patient should be ordered green vegetables in any quantity desired, and sour (not sweet) fruit in moderate amount. Bread is indispensable for a time, and Seegen orders 40-60 grs. per diem, but speaks most decidedly against fresh bread, because this always contains starch, and if allowed, the control of the diet (over the disease) will be lost. An exclusive meat diet is strenuously to be recommended :

 (1.) If it is necessary to decide whether the disease is of the first or second form. 

(2.) When wounds do not heal and when gangrene sets in, or a surgical operation is necessary. 

Sour (not sweet) red or white wine is allowed in any quantity, and yet it is an error to allow a diabetic patient to drink large quantities of wine with the idea of strengthening him. Beer may be allowed in moderate quantity, (that is, about half a litre). In diabetes of the severe form abstinence from carbohydrates is important only because, as a result of such abstinence, the excretion of sugar is markedly lessened. To restrict cases of this kind to a meat diet is not indicated, for it makes little difference whether 20-30 grs. (sugar), more or less, are excreted ; and the advantage gained is not equivalent to the privation endured.

The three classes of proximate principles that are neces- sary to be understood in the intelligent study of the food- stuffs, and in the selection of the most efficacious diet in disease are best divided into three distinct divisions ; the inorganic, the CHO, and the CHNOS compounds, or a first, second, and third class. 

First. The inorganic substances, such as water, the phosphates, chlorides, carbonates, sulphates, etc., etc. These chemical compounds all enter the body under their own form, either alone or in combination with the other two classes. They are not oxidized or split up within the system to enter into the chemical formation of other com- pounds, but are united mechanically with the proteid group, in fact, their whole action is, as it were, mechanical. After having served their purpose to the body they pass out of the system with the excretions absolutely unchanged in their composition. All medicinal compounds of a corresponding compo- sition and nature probably act in a similar mechanical manner. 

Second. The CHO substances which have for their chemical composition the elements carbon, hydrogen, and oxygen only as fat, sugar, and starch. These substances are all oxidized or split up within the system, yielding heat, energy, lubrication, and rotundity only, and are finally eliminated from the body as carbon dioxide and water. The medicinal agents of like chemical construction probably are oxidized and broken up to yield their effects by a similar cycle of changes. 

Third. The CHNOS substances or those which have for their chemical composition the elements carbon, hydrogen, nitrogen, oxygen, and sulphur. The common representatives of this group are called proteids, or the albuminous parts of milk, eggs, meats of all kinds, which chemically and histologically include fish, lobsters, crabs, turtles, oysters, clams, etc., also poultry and game. The nitrogenous or albuminous parts of all plant life, which is now commonly called vegetable proteid, is included in this class. 

All these nitrogenous substances, irrespective of specific names, are somewhat slowly oxidized or split up within the system and are absolutely essential to form the different constituents of all the fluids, tissues, glands, and ferments of the body, being united mechanically in varying proportions with water and the mineral salts. 

When these proteid bodies are normally transformed, their excrementitious products are urea, uric acid, kreatinine, carbon dioxide, and water in certain and definite proportions. If for any reason there is an abnormal transformation along this line of proteid metabolism, the relative quantity of urea falls and the uric acid rises. By closely studying these urinary changes and intelligently interpreting them, there is furnished an almost exact key to the perfection or imperfection of the oxidization processes and the nutritive condition of the body. By this method of study it is positively known whether the food-stuffs are absorbed and properly utilized by the system or not. 

Another important phenomena to be remembered in connection with the oxidization of the proteid substances is the fact that a disturbance in their anabolism not only changes the relative proportions between the urea and the uric acid, but tends to develop an almost unlimited number of katabolins, some of which are perfectly inert, while others are as toxic and dangerous to life as the well-known cyanide compound prussic acid. 

The action of the CHNO medicinal agents can he explained largely upon the same principles and chemical laws that govern the usefulness of the proteid bodies. 

With an intelligent conception of these three classes of proximate principles and what results are obtained for the system by their perfect and what by their imperfect oxidization, a comparative table of the common substances rated as food-stuffs is instructive. This table subdivides each kind of food product into its three distinct classes of principles. The inorganic compounds, however, are subdivided into water and the inorganic salts, so that their true position may be more clearly elucidated and the whole subject made plainer. 

[[Table 1]] 

Having in this brief manner outlined the composition of the food-stuffs and intimated at the same time the absolute necessity of understanding thoroughly the chemical and physiological laws that control their usefulness within the system, it becomes possible to advance a step further and state the quantities necessary for the most perfect nutritive condition. 

It also shows clearly how, by indulging too freely in any kind of food or by an unwise selection of the various kinds of proximate principles, the digestive system is constantly overtaxed, assimilation imperfectly effected and a host of diseased conditions developed. These abnormalties are brought about in the most insidious and often almost inappreciable manner, until, in some instances, well-defined symptoms are established by which a distinct name can be applied to the condition before attention is attracted to the malady. In a much larger percentage of the cases, however, the symptoms presented are so vague and changeable that the most learned specialist cannot possibly name the condition and sharply define the abnormalty so that it can be differentiated from many other states of a similar nature. Yet it is perfectly clear to every one, patient and practitioner, that something is decidedly wrong with the physiological mechanism of the system. 

Briefly stated, it may be assumed that the following table, No. II., gives a pretty close and satisfactory basis how the first and second classes of proximate principles should be arranged as to the relative proportions needed of each, from bare subsistence up to the largest amount of mental and physical work. 

[[Table 2]]

Before advancing any further in this physiological problem of food and nutrition, it must be admitted that the oxygenating capacity of the system is a limited one — but, fortunately for the human race, it has a moderately wide margin. There frequently comes a time, however, when this margin is exceeded, which is usually brought about by eating too large quantities of all kinds of food or too freely of the CHO classes of food-stuffs — as fat, sugar, and starches — or of both. As a natural sequence one of three things of necessity follows. 

First. The respirations and circulation must be increased to supply more oxygen or the food-stuffs will be imperfectly oxidized. But Nature has set a limit upon the actions of the heart and lungs so that complete relief cannot be granted in this manner. 

Second. The red blood corpuscles must be increased in number or empowered to carry more oxygen, or the absorbed food-stuffs will be imperfectly oxidized. But here again Nature has set a limit upon the number and carrying capacity of these anatomical bodies so that relief in this direction is wanting. 

Third. The super-abundance of food-stuffs absorbed must be incompletely oxidized because the system has no means by which the extra amount of oxygen required can be furnished. This statement applies with special force to che proteid bodies on account of well-established chemical laws, which show that the CHO elements are quickly and completely transformed under all circumstances while the CHNOS are only perfectly transformed when everything is most favorable. The CHO compounds, as fat, sugar, and starch, are rapidly and easily oxidized, consequently they are the first elements to be changed, and they are also completely transformed into their final products ; this tends to leave a deficient quantity of oxygen to act upon and accomplish the more difficult task of carrying the nitrogenous com- pounds through their cycle of change and finally into perfect excrementitious substances. This defective supply of oxygen disturbs the perfect metabolism of the proteid bodies and produces an unlimited number of katabolins and furnishes a rational explanation for many, if not all, of the pathological conditions and symptoms that have to be treated. At least it is fair to assume that so long as the anabolic processes of the body are perfectly effected, no pathological lesion or abnormal symptom can be developed. Keeping constantly in mind the table indicating the relative proportions existing between the proteids and the CHO compounds, or the fats, sugars, and starches, and studying a little more closely the composition and comparative merits of the various food products, much valuable information is brought to light. 

First. It is found almost impossible to arrange a mixed or vegetable diet so as to obtain the requisite amount of proteid elements without at the same time taking more than the needed quantity of the CHO compounds, that is, without introducing more than can be safely utilized or oxidized. 

Second. It is found that with an exclusive meat diet composed of the ordinary average meat almost the exact quantities of both the CHNOS and CHO compounds can be obtained from bare subsistence up to that for forced work. Taking four ounces of pure proteid matter as the standard amount required in twenty-four hours to perfectly maintain the constructive forces of the system, the following tables are quite instructive, viz. :

 [[Tables 3-7]] 

Examples of this kind might be multiplied almost ad infinitum. With all of the tables, however, excepting Table No. VI., there is clearly shown a larger quantity of the CHO compounds than is found of proteid elements. This shows that with almost all kinds of food-stuffs and especially when taken in excessive quantities the system is liable to receive a superabundance of the CHO substances. The ease with which the requisite amounts of proteid matter can be rightly adjusted to meet the demands of the system is clearly demonstrated. These tables just as clearly illustrate that it is almost impossible to arrange any form of the mixed food-stuffs in such a manner that the system will not be constantly super- charged with the stimulating and non-nutritious compounds of CHO construction. 

TABLE VIII. 

This comprehensive comparative diet table, compiled and used by Prof. William H. Porter, of the New York Post-Graduate Medical School, has been worked out upon the atomic basis of the proximate principles, which enter into the construction of the ordinary food-stuffs. 

It proves quite conclusively that Professor Porter's animal diet yields all that can be obtained by the use of a mixed diet containing the three elements — proteid, fat, and carbohydrate. 

In fact, in the proportions as here given, it calls for the use of a little more oxygen than the mixed diet based upon the proportions given by Moleschott ; it also yields a little more carbon dioxide and water. 

When it is remembered, however, that in the egg and the ordinary run of good meat, the proteid element is always a little more abundant than the fat, this excess of oxygen used — when taking an ordinary animal diet — will not be required, and the increased amount of carbon dioxide and water will not be produced, but the total results in excrementitious products cast off and the amount of heat and so-called energy evolved will come so very close to the amounts obtained by using Moleschott's mixed diet, that the two are practically the same. 

The conclusion, therefore, is that the relative proportions of these two elements, proteid and fat, as commonly found in eggs, meat, and fish, come so nearly to the required physiological demands of the system that, in this class of food-stuffs, there is found an almost perfect standard for diet. By adding a very small allowance of bread and butter, it becomes absolutely perfect. 

These chemical facts, based upon the atomicity of the Sood elements, explain the higher nutritive vitality developed in the carnivora as compared with the herbivora and vegetable feeding classes. 

Again, in diseased conditions where the nutritive powers are severely overtaxed, the proteid and fat diet is especially serviceable, for by its use the expenditure of vital force in transforming the food-stuffs is kept at the lowest possible standard. Because, in the use of animal fat to the exclusion of the carbohydrates, the system is spared the necessity of laying out force and oxygen to convert the starch and various sugar elements into a diffusible glucose, and then into an alcoholic-like compound before they can be utilized by the animal economy for the production of heat and the so-called energy, which is finally computed in foot pounds of work accomplished. 

This great saving in vital force by the exclusive use of fat — to supply the CHO elements necessary to produce the heat and energy required — is unquestionably the exact factor that enables the system to effect the cure in all the pathological conditions, which otherwise could not be carried on to a complete recovery. 

These same laws make Kumysgen one of the most valuable food products ever produced, because it has been found, that only about one-half of the fat contained in milk is capable of being absorbed, and with the lactose converted into an alcoholic compound there is developed in Kumyss or Kumysgen, particularly in the latter, a partially predigested food-stuff which contains about equal quantities of proteid and fat in a state to be readily absorbed. This then corresponds exactly with the requirements found in Professor Porter's table, which consists of only proteid and fat. 

Practical experience has long since taught that this form of dieting was the only kind available in connection with the successful treatment of the acute diseases. 

This table is further a demonstration and confirma- tion from a chemical and physiological standpoint, of what has been so often repeated in a clinical way, that upon this purely proteid and fat diet, together with the administration of suitable medicinal agents, the most aggravated forms of digestive disturbances can be quickly removed, nutrition improved, and a healthy standard permanently re-established. They show conclusively that this form of animal diet yields the largest working power to the system for a given amount of food taken, and a similar amount of oxygen used to carry the food substances through their anabolic cycle of changes, and finally form and discharge from the body the resulting excrementitious products.

At this point, however, it may be well to mention that the standard amount of proteid matter taken, in the construction of all these tables, was 130 grammes — 4.5 ounces. Moleschott's original diet-table contained only 120 grammes or (4.2 ounces), but as almost all observers agree quite closely as to the amount of proteid material necessary to be used, and also as to the results obtained from its oxidization, the same quantity was used in all instances that a more exact comparison might be established. The chief difference of dispute, however, is in relation to the relative value of the fats and carbohydrates, and particularly in reference to the latter compounds. 

In trying to develop out of a purely vegetable diet, anything like the same amount of working power for the system that is obtainable by the use of Porter's or Moleschott's diet, almost double the amount of proteid had to be taken with the proportionate rise in the fat and starch as is contained in the vegetable chosen. 

To produce the same amount of work by using a vegetable diet necessitates the outlay of a much larger amount of oxygen, and the production and handling by the glandular structures of the body of an excessive amount of the nitrogenous excrementitious elements. These facts illustrate quite conclusively the manner in which the damage to the system is brought about by indulging too freely, or living exclusively upon a cereal or vegetable compound. 

The vegetable proteid in these tables is further given an undue advantage, to which it is not justly entitled, by crediting it with the same atomic formula as that possessed by an animal proteid ; since the nitrogenous element found in plant-life contains a much larger number of nitrogen atoms, and consequently requires more vital force and oxygen to digest and assimilate it. This naturally decreases rather than improves the nutritive value of the proteid compound of vegetable origin. 

An average of a compound fat molecule is taken as the working standard in all these tables. 

Attention is also directed to a probable error in the rating of the heat-producing power of the carbohydrate. It is & commonly stated, that the comparative oxygenating capacity of a carbohydrate and fat is as one to two and one-half, but by their chemical atomicities, it is as one to thirteen, or thirteen and one-half in favor of the fat. 

That such an error exists in the computations in Moleschott's standard is sustained by a comparative study of the atomicities of the food-stuffs used in both Porter's and Moleschott's diet tables, and of the amount of oxygen required for complete oxidization in both instances. In the former, or Porter's proteid and fat diet table, a little more oxygen is needed than is necessary in Moleschott's mixed diet* yet it is claimed that in the latter instance 393,170 kilogramme-metres or 54,358 more foot pounds of work is produced. This, however, is directly opposed by the smaller quantity of oxygen used in the oxidization processes. When this error in work, produced out of the carbohydrates in Moleschott's diet, is corrected in accordance with the difference in atomicity and the amount of oxygen used between the fat molecule and the carbohydrate molecule represented as glucose, and a computation is made in accord with the correction, a slight difference in work produced when living on a Moleschott's or Porter's diet, is found to exist. The increase in work produced, however, is now found to exist in connection with Porter's diet and is in accord with the larger amount of oxygen used, which makes atomicity, oxygen used, and work produced correspond, while the reverse was stated in the calculations formerly made in connection with Moleschott's diet. 

If this error be true, as it appears to be, the profession have been sadly misguided in all their attempts in the construction of diet tables starting with Moleschott as their standard. 

On the other side, if these chemical and physiological laws be true, as based upon the atomicity of the proximate principles, by carefully considering the percentage composition of each food product to be used, exact results can be obtained. Another point to which attention is called by Dr. Porter is this, that the factors 1.812 and 3.841, which are used in computing the kilogramme-metres in Table VIII., are taken from Frankland — Philosophical Magazine XXXII., and are those which are generally quoted in all scientific works upon physiological chemistry and upon diet. 

In studying the proximate principles, however, by the atomicities, and considering the amount of oxygen required to completely transform a fat molecule into its final products of excretion water and carbon dioxide and a proteid molecule into its final products of excretion — urea, uric acid, kreatinine, carbon dioxide, water, etc. — it is found that only eighteen (18) more oxygen elements are used in the complete oxidization of the fat than in that of the proteid molecule. The computed amount of work performed by the oxidization of the fat molecule is found to be 530 foot pounds as compared to 250 foot pounds for the complete oxidization of the proteid molecule. This makes the eighteen (18) more elements of oxygen used in transforming the fat molecule result in the production of 280 more foot pounds of work than is obtained from the eighteen less used in the proteid. 

From this a decided discrepancy is quite evident between the results obtainable by former calculations and those based upon our modern chemical atomicities. 

However, for an illustrative and comparative study of the working power obtainable from the use of the various food-stuffs, this table is still of great value, as the same figures are used in each and all the calculations. 

As these same factors, 1.812 and 3.841, appear in all the modern scientific works, they were retained in the arrangement of this table, but not without appreciating and calling attention to this discrepancy when the computation is based upon the atomicities of the food elements used, the amount of oxygen required, and the results obtained. 

Again, it must be remembered that the proteids are not directly transformed into their final products, but undergo a series of intermediate changes, all of which require the use of oxygen and must of necessity yield more or less heat and energy, so that all our estimates are approximate. 

When upon Moleschott's diet with the proteid substances raised to the common standard of 130 grammes and the carbohydrates rated in accord with the correction previously noted, it requires 36,115 oxygen elements to produce 678,270 kilogramme-metres or 93,773 foot pounds of work. 

When upon Porter's diet of proteid and fat, it requires 38,415 oxygen elements to produce 734,890 kilogrammemetres or 101,602 foot pounds of work. When upon a purely vegetable diet that will yield anything like the requisite amount of work that can be obtained by using Moleschott's or Porter's diet, it requires 47,191 oxygen elements to produce 742,018 kilogramme-metres or 102,587 foot pounds of work. 

To obtain the 63,748 more kilogramme-metres or 8,814 foot pounds of work out of the vegetable diet as compared with Moleschott's diet, it requires the expenditure of 11,076 more oxygen elements. 

To obtain the 7,128 more kilogramme-metres or 985 foot pounds of work out of the vegetable diet as compared with Porter's diet, it requires the expenditure of 8,776 more oxygen elements. The vegetable diet in both instances yielding an excessive amount of nitrogenous excretory matter, carbon dioxide, and water. 

A careful study of Table II. and VII., and Porter's diet in Table VIII., proves beyond a question of doubt that upon an exclusive diet of our ordinary average meat alone very nearly the required proportions of the proteids or CHNOS compounds and of the fat or CHO element can be established. 

The only defect in the perfection of Table VII. and VIII. is found in the saline column, which contains much more mineral matter than perfect physiological laws indicate are required. This excess in saline or inorganic compounds, however, appears to be true in all kinds of food products — that is, if the proportion of salts in the milk is taken as the guide for a working basis. The reason for looking upon the amount of salts in the milk as the guide to the maximum quantity required is based upon the fact that during the infant period of life, where milk forms the only source of food supply, bone formation is most rapidly progressing, and the amount of mineral matter needed by the system is at its height and much larger than at any other period of life. The bones continue to grow and become fully and perfectly developed with the ordinary quantity of mineral matter contained in the milk. 

Physiology also teaches that a little less than one ounce of mineral salts are required daily by the system, but in all the tables given, except the one containing milk alone, the amount of salts is fully up to or more than an ounce. 

The only great objection that can be raised to an exclusive meat diet is the lack of variety, but that is quite easily adjusted by varying the kinds of meat used. The perfection of the proportionate composition of the proximate principles when using a meat diet, the smaller liability to imbibe an excessive quantity of any one kind and the little danger that there is of taking an excess of the CHO or stimulating and non-nutritious compounds, clearly establishes the fact that in meat we approach the nearest to an ideal food. 

If attention is turned for a single moment to the lower orders of the animal kingdom, it is quite apparent that the most supple and intensely powerful organisms are found among the carnivora only. This tends to substantiate the high utility of the meat diet. Another interesting point is the almost universal absence of tuberculosis among meat-eating animals, while the vegetable-feeding class are specially prone to suffer from this fatal malady. 

Again, the milk which is so generally considered as being fully equal to all the demands of the system, and especially so during the first few months of infant life, might be brought forward as proof positive and clearly illustrating the fact that nature calls for an excess of the CHO elements, because in the composition of the milk it is found that the CHO substances are about twice as abundant as the proteid or CHNOS elements. When these facts are examined a little more closely and scientifically, it is found that the pancreatic gland and its ferment-forming bodies are imperfecty developed at this period of life. Consequently, the fat, if emulsified and rendered capable of being absorbed by the lacteals of the villi, must have this transformation effected almost exclusively by the biliary fluid alone. It is further taught that the biliary secretion acts but little, if at all, upon vegetable fats and that it has the power to effectually emulsify only about one-half of the total quantity of animal fat introduced into the alimentary canal. This being true, fifty per cent, of the fat contained in the milk, together with the bile constantly flowing into the alimentary tract, is unquestionably utilized by the system as a natural laxative principle, and is undoubtedly the chief method by which nature effectually maintains the regular movements of the bowels and produces the daily evacuations so characteristic of a perfectly healthy infant. 

The proportionately larger size of the liver in a child as compared with an adult also points to the fundamental importance of the hepatic gland and its secretion as a necessary agent of prime importance in the infant; the large size of the liver compared with other organs also indicates its great importance during adult life. 

How much of the lactose — which is the form of sugar introduced in the milk — is inverted into glucose and rendered capable of being absorbed and utilized is an open question. In fact, there is no very reliable data upon this important point, but what is to be found upon the subject indicates quite positively that a considerable quantity of the lactose is not changed so as to be utilized by the system, but passes off with the faeces. Therefore, when the scientific truth is clearly appreciated, it is found that the relative proportion between the CHO and the CHNOS elements contained in the milk and that which can gain access to the vascular channels and be of service to the system is not far from equal in amount the major quantity, perhaps a little on the side of the CHO substances or in favor of the fat and sugar. Then, again, the infant requires a little more of the heat-producing compounds during the first few weeks or months than is needed a little later on or in adult life, because the proportionate amount of energy expended is greater in the infant and child than is the case during the adult period of life. Very early in the infant life there is comparatively little muscular action by which heat and energy can be evolved, while a large amount of heat is needed to maintain a perfect physiological condition, and for a time warmth must be artificially supplied. These conditions will admit of a little excess of the CHO elements during this period of life , but when the stage of infant muscular activity commences its never-ceasing motion, then the proportionate amount of the proteid substances must be raised and the CHO, or fat and sugar lowered, if the most perfect type of physiological development is to be effected. 

Observing clinical phenomena a little more closely, it is quite apparent, as life advances, that milk is not equal to the demands of the system, and a more strongly proteid diet is urgently called for by nature. Eggs and lean meat must next be added to furnish this much-needed proteid pabulum for the constructive purposes of the animal economy, and out of which alone the most perfect muscles, glands, ferment bodies, and brain tissue can be formed. 

By this process of reasoning, it is clearly and well established that even with the commonly supposed typical food-stuff, milk, it is not sufficiently perfect in its composition to thoroughly sustain the nutritive economy under all circumstances, but must have added to it a more liberal proteid pabulum. It is also clearly demonstrated that a portion of this excessive amount of fat is not taken up by the circulatory or lymphatic system but is used largely by nature as a laxative agent.

Proceeding a step further in the investigation of the clinical facts bearing upon this most interesting subject and there is found quite a common tendency among people at large to add to the nutritive supply of the infant not the most serviceable kind of food-stuffs in the way of an animal proteid of some kind, but on the contrary the more general practice is that of adding a cereal or vegetable compound, — one in which the CHO elements are very greatly in excess of the demands of nature. Another important point to be remembered in this connection is the well established fact that, although the proteid of vegetable origin, while in quite sufficient quantities, is a much higher nitrogenous compound and, as a rule, is far more difficult of digestion than a proteid body derived from the animal kingdom. 

By this method of infant feeding in which an excess of the fat, sugar, and starch or CHO compounds are used, a natural taste and habit of eating food derived largely from ficially supplied. These conditions will admit of a little excess of the CHO elements during this period of life , but when the stage of infant muscular activity commences its never-ceasing motion, then the proportionate amount of the proteid substances must be raised and the CHO, or fat and sugar lowered, if the most perfect type of physiological development is to be effected. Observing clinical phenomena a little more closely, it is quite apparent, as life advances, that milk is not equal to the demands of the system, and a more strongly proteid diet is urgently called for by nature. Eggs and lean meat must next be added to furnish this much-needed proteid pabulum for the constructive purposes of the animal economy, and out of which alone the most perfect muscles, glands, ferment bodies, and brain tissue can be formed. By this process of reasoning, it is clearly and well established that even with the commonly supposed typical food-stuff, milk, it is not sufficiently perfect in its composition to thoroughly sustain the nutritive economy under all circumstances, but must have added to it a more liberal proteid pabulum. It is also clearly demonstrated that a portion of this excessive amount of fat is not taken up by the circulatory or lymphatic system but is used largely by nature as a laxative agent. Proceeding a step further in the investigation of the clinical facts bearing upon this most interesting subject and there is found quite a common tendency among people at large to add to the nutritive supply of the infant not the most serviceable kind of food-stuffs in the way of an animal proteid of some kind, but on the contrary the more general practice is that of adding a cereal or vegetable compound, — one in which the CHO elements are very greatly in excess of the demands of nature. Another important point to be remembered in this connection is the well established fact that, although the proteid of vegetable origin, while in quite sufficient quantities, is a much higher nitrogenous compound and, as a rule, is far more difficult of digestion than a proteid body derived from the animal kingdom. By this method of infant feeding in which an excess of the fat, sugar, and starch or CHO compounds are used, a natural taste and habit of eating food derived largely from the vegetable kingdom is engendered. The natural sequence is, that on through life the individual is apt to continue eating excessively of all kinds of food-stuffs and particularly those of the CHO and vegetable class. This poorly nourishes the body; adipose tissue in abundance is often acquired from the imperfectly transformed foodproducts. The appetite increases because the system is not properly sustained. The individual continues eating more and more until finally the marginal capacity of the system for supplying oxygen is reached and passed, digestion is imperfectly effected, and the oxidization powers of the body exceeded.