Second Stage: The compensation is only moderate and the heart cannot perform its normal functions, hence the diet must be directed toward relieving any pressure upon the organs from other organs and toward lessening the work of the heart itself. Third Stage: In which the compensation is decidedly impaired and for this reason the dietetic treatment undergoes a decided change. ~Digestional Disturbances~ in which there is an evolution of gas in the stomach or intestines may cause a pressure against the heart which is distinctly bad for it. ~Limiting the Fluids~ in the diet in heart disease is necessary when the compensation is only moderate, as they impose an extra burden upon the organ to eliminate them. ~Amount of Food~ must also be limited. The meals must be small and taken without fluid. The latter should be taken between meals. ~Edema~ occurs in a number of cases and must be treated as in nephritic conditions by limiting the fluids and by confining the diet to "salt-poor" foods.[136] ~Karell Cure~ or modification thereof has been used with good results in many cases of heart disease. ~Exercise~ must be limited in amount and confined to types which will not impose a tax upon the weakened heart muscles. Exercise after eating is especially to be discouraged, as this, together with the efforts required for the digestion of food, might readily prove too much for the heart to accomplish. ~Elderly Patients~ must be warned against exercises of all kinds, not only on account of the condition of the heart, but also on account of the condition of the arterial walls. These harden with age and break down under undue pressure. ~The Nurse~ should instruct the patient on the points necessary for the saving of the heart. She should teach the necessity for keeping the meals small and having them more frequently if necessary; of limiting the fluids at meals to a few ounces or leaving them out altogether at this time. She should know how necessary is the reduction of the fluid. She should also warn against the taking of alcoholic beverages except with the permission and advice of a physician. ~Excitement and Worry~ increase the blood pressure, hence must be avoided by individuals suffering with any form of heart disease. PROBLEMS (a) Write a diet order for an elderly patient with severe cardiac disturbance. (b) Outline the method of administering the Karell diet. FOOTNOTES: [134] See Karell Cure, p. 342. [135] "Food for the Sick," p. 150, by Strouse and Perry. [136] See Salt-poor Diets, p. 341. CHAPTER XX DIABETES MELLITUS ~Definition.~--Diabetes is a disease which is characterized by an inability on the part of the body to utilize the carbohydrates, in consequence of which there is abnormal excretion of glucose in the urine.