Dietetics for Nurses

by Fairfax T. Proudfit

PTOMAINE POISONING, ACIDOSIS AND PELLAGRA

PTOMAINE POISONING

The poisoning due to ptomaine is very similar to that brought about by overeating and other dietetic errors. However, it is not so easy to avoid being poisoned by ptomaines as it is to observe moderation in the quantity of food eaten.

Origin.—These substances are believed to be of an infective bacterial origin and may be present in foods which are otherwise seemingly fresh and good. The fact that they cannot be detected in food without an analysis makes them more of a menace than they would otherwise be, for any substance which is not discernible to our senses, the taste, sight, or smell, and which exerts a baleful influence, such as ptomaine, cannot be anything but a menace to humanity.

Infected Food Materials.—We may congratulate ourselves in the knowledge that these substances are not present in many foods, and if we avoid eating nitrogenous materials, which may have become polluted, either through imperfect canning or by standing in unclean vessels, we may avoid much of the poisoning which may otherwise be due to the action of ptomaines.

Chicken Salad and Ice Cream Poisoning.—Certain violent attacks of so-called ptomaine poisoning may be traced to chicken salad which has been allowed to stand overnight in tin receptacles or to ice cream which has melted and been re-frozen. In any case the treatment remains the same.

Treatment.—The patient is put to bed and the intestinal tract cleansed by means of enemas and in many cases purgatives (salts, castor oil, etc.) as directed by physician.

The symptoms usually present in those suffering from ptomaine poisoning are nausea, vomiting, dizziness, pain more or less violent in character, and prostration which is at times alarming.

Dietetic Treatment.—The treatment instituted under the circumstances is very much the same as that used in other forms of acute poisoning. All food is withheld for a period; the duration of this starvation must necessarily depend upon the condition of the patient, the violence of the poison and the extent of the prostration.

Rectal Feeding.—When the prostration is great, it is sometimes necessary to give saline enemas and even rectal alimentation to prevent collapse.

Fluid Diet.—After the violent attack subsides, the patient is placed upon a fluid diet similar to that used in auto-intoxication and practically the same as the diet for acute infectious diseases. The diet must be gradually increased until it becomes normal and the nurse must remember that the patient is in a condition to suffer a relapse with the least indiscretion. It is advisable to have a thorough investigation made to ascertain the source of the original attack, that the patient may be able to avoid future trouble from partaking of the same food.

Personal Idiosyncrasies.—It may be that there is a personal idiosyncrasy against one particular food, and in this case it becomes more or less of a simple matter to prevent future attacks. Certain individuals are, for example, invariably poisoned by eating shellfish, others manifest a similar idiosyncrasy against strawberries. Thus is the old proverb demonstrated: “What is one man’s meat is another man’s poison.” And he who wantonly flies in the face of the danger signals Nature provides for his guidance must necessarily suffer the consequences of his folly.

It has been proved with certain individuals that the foods that at one time cause an attack of poison at another time may be eaten with impunity. Thus it would seem to remain a question not so much of the type of poison, ptomaines, etc., as the amount of resistance manifested at the time by the individual partaking of the infected food.

ACIDOSIS

Metabolism of Fats.—Acidosis is a condition believed to be due primarily to some impairment in the metabolism of fat in the body, in consequence of which there is an accumulation of substances more or less irritating and at times toxic in character in the blood. These substances, known as acetone bodies, are especially apt to appear in the urine of individuals suffering from diabetes, likewise in those undergoing starvation, whether as a result of treatment to overcome a definite pathological condition, as in diabetes, or as the result of disease itself.

Malnutrition as a Source.—Certain individuals, children especially, develop symptoms of acidosis under many different circumstances; for example, in many cases of malnutrition the evidences of acidosis are almost invariable. The treatment in these cases must be, of course, prompt in order that the condition may not assume a serious aspect.

Dietetic Treatment.—The diet is adjusted in order to neutralize the effect of the acid in the blood. This is done in two ways: first, by reducing the fat, and second, by increasing the amount of base-forming foods in the diet.

The following table[164] illustrates the foods in which the acid-forming elements and base-forming elements predominate:

Foods in Which Acid-Forming Elements Predominate

Estimated Excess Acid-forming Elements Equivalent to C.C. Normal Acid per 100 Calories

Beef, free from visible fat	10.0
Eggs	.9
Round steak	6.7
Oatmeal	3.2
Wheat flour	2.7
Wheat, entire grain	2.6
Rice	2.4
Bacon	1.0
Corn, entire grain (high protein)	.1

Foods in Which Base-Forming Elements Predominate

Estimated Excess Base-forming Elements Equivalent to C.C. Normal Alkali per 100 Calories

Celery	40.0
Cabbage	10-13.6
Potatoes	9-12.0
Prunes	7.9
Turnips	6.6-12.5
Apples	5.0
Milk	3.3
Beans	2.9-6.8
Peas	1.9
Corn, entire grain (low protein)	.8

The fruits likewise show a predominance of base-forming elements over acid-forming elements and for this reason may be used to balance the diet.

Diabetic Acidosis.—The acidosis during diabetes has been already discussed in the chapter devoted to that disease.

It has been found advisable in the majority of cases of acidosis to restrict the fat in the diet of all patients who, during the course of a disease, have given evidence of this condition; at the same time it is well to remember that fat is one of the essential food constituents and absolutely necessary to the welfare of the individual, consequently it is impossible to eliminate it from the diet entirely. The only feasible method, then, to pursue under the circumstances is to restrict the fats in the diet so long as there are symptoms of acidosis and to add them gradually and in very small amounts until the individual’s tolerance for fats is determined.

Balancing the Diet.—In many cases of acidosis due to starvation, no matter what the cause, the diet must be necessarily regulated and properly balanced. It would be decidedly unwise to attempt to build up the body by giving building foods alone, without due consideration to the foods containing the agents provided by Nature to neutralize the acid formed during the process of their metabolism. It is readily seen in the table just given that meat and eggs show a marked excess of acid-forming elements, whereas vegetables and fruits yield an excess of base-forming elements. With these data, it becomes more simple to balance the diet and to avoid the acidosis which may arise from impairment of the fat metabolism of the body.

PELLAGRA

The enormous increase in the number of cases of pellagra in America during the last twenty years makes it necessary for something to be done to arrest its progress. The cause of this disease is still under discussion, but much has been done to find out definitely the reason for the tremendous increase in the number of cases, especially in the Southern States, where the increase has been most noticeable.

Cause.—This disease has been the subject of much study and discussion in this country in recent years. Voegtlin, in an article published in a Report of the United States Public Health Service (Reprint 597 of Public Health Report), summarizes the current findings on pellagra as follows:

“1. The hypothesis that there is a causal relation between pellagra and a restricted vegetable diet has been substantiated by direct proof to this effect and has led to results of considerable practical and scientific value.

“2. The metabolism in pellagra shows certain definite changes from the normal, which point to decreased gastric secretion and increased intestinal putrefaction.

“3. In the treatment and prevention of pellagra, diet is the essential factor. The disease can be prevented by an appropriate change in the diet without changing other sanitary conditions.

“4. A diet of the composition used by the pellagrins prior to their attack by the disease leads to malnutrition and certain pathological changes in animals, resembling those found in pellagra. A typical pellagrous dermatitis has not been observed in animals. Pellagrous symptoms have been produced in man by the continued consumption of a restricted vegetable diet.

“5. The nature of the dietary effect has not been discovered, although certain observations point to a combined deficiency in some of the recognized dietary factors as the cause of the pellagrous syndrome.”

Dietetic Treatment.—The diet in pellagra is one which is well balanced in all its particulars, and one in which the proteins are carefully adjusted as to type. The best results have been observed on diets in which the complete proteins (milk, meat and eggs) have a prominent place. As a rule, in the diet of an adult suffering from pellagra, at least forty grams (about 60 per cent) of the necessary proteins should be in this form. The diet for pellagra must necessarily be such as to overcome as far as possible the progressive emaciation which is an important symptom. However, it must be kept in mind that gastro-intestinal disturbances are likewise prominent and that diarrhea is often most difficult to overcome. For these reasons it is essential to formulate a diet which will not interfere with the treatment for the disease, and which will be at the same time one on which the patient can gradually be built up, and in this way benefit, as far as possible, under the circumstances. The diet used in the treatment of anemia seems to be the one best suited to meet the requirements of the patient suffering with pellagra; changes may be made in this diet, however, by the physician, who will be able to judge the need of the individual under his care. Whether pellagra can be cured by dietetic treatment is very uncertain, but the condition of the patient can undoubtedly be materially improved, provided the treatment is begun sufficiently early; that is, before the disease has progressed to such an extent that neither diet nor anything else can bring about a cure.

The above dietetic treatment is not claimed to be infallible. It is merely given as a suggestion to be used at the discretion of the physician.

In all probability the treatment of pellagra will undergo a definite change in the near future, but at present our best results accrue from the giving of an adequate, well-balanced diet. The extent of the relief of such dietetic measures depends, as has already been stated, upon taking the disease in its early stage.