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rapidly dried, and friction with a rough towel is em ployed. If the temperature is above 102° F. a general bath is indicated. Dr. Baruch cited the case of an infant six months old, temperature of 106, which seemed to be rescued from impending death by a graduated bath of 95° to 80° for fifteen minutes, with friction. Dr. J. L. Smith saw this case with him. He concluded that no case of summer diarrhoea should be regarded as hopeless until some form of hydrotherapy has been judiciously tried. This treatment requires the best judgment and precision in its applicaton. Dr. J. M. Mabbott read a paper on the "Use of Drugs in Diarrhoea." Antiseptic drugs have been much vaunted in recent years, but it must be admitted that they have been tried and found wanting. As Dr. Baruch said here three years ago, it is impossible to administer any known antiseptic drug in sufficient quantity to affect the alimentary canal, without danger to the patient. Bacterial studies have, however, been of great value in teaching us to secure asepsis where we cannot apply antisepsis. Now that we endeavor to promote asepsis and control fermentation by evacuant, dietsry, and hygienic measures, alkalies are of less importance than formerly, and their value in many cases is to be doubted. The indications for the use of acids are uncertain, though they seem, from the researches of Dr. Pfeiffer, to be upon a rational basis. The vegetable astringents have been almost discarded. The same is true of the mineral astringents, except bismuth, which is extensively used and in large doses. Opium for checking peristalsis is valuable, after the bowels have been cleared, but highly dangerous before. It is also indicated for the relief of restlessness, pain, and tenesmus and the control of frequent watery passages. It is contra-indicated when the passages are small and of bad odor, when the number of stools decrease but become more offensive, when fever and toxic symptoms increase.

Dr. Henry Koplik read a paper on "Feeding in Diarrhoea." A considerable proportion of infants fed upon commercial infant foods show sugar in the urine, an element not found in children fed at the breast or upon cow's milk. Numerous theoretical reasons have been advanced against sterilized milk, but clinical experience shows that it is better tolerated by the stomach than by any other artificial food. At the Good Samaritan Dispensary during the past summer milk was sterilized on a large scale. Six bottles containing four or five ounces of milk each were given to each patient. In this way over 40,000 bottles were given to 575 different patients. The results were favorable in the extreme. To obviate certain changes which take place when milk is sterilized at a high temperature, an attempt has been made to destroy the activity of the germs by employing a lower temperature. Milk is a very complex fluid, and every dis

turbance of its elements renders it less desirable as a food. Our aim should be to produce as little change as possible. If, therefore, it can be rendered safe by heating to a less degree it should be done. This process of heating milk to a temperature of 167° F. and cooling quickly is known as Pasteurization. It does not actually sterilize the milk but renders inactive certain ptomain producing germs. Such milk will keep several days, and as it is but little changed in its constituents, it presents an improvement over the older form of sterilized milk.

Dr. Smith asked how long the heat should be applied with the Arnold Sterilizer.

Dr. Koplik replied that the hood could be removed in twenty or thirty minutes.

The Chairman referred to the formulæ recently prepared by Dr. Blackader—a pint of water, a Bunsen burner, fifteen minutes. The hood may be then removed and the cover left ajar.

Dr. A. Jacobi said that of all the remedies referred to this evening, the intestinal irrigations recommended by Dr. Baruch are the most useful. It is an error to suppose that sterilized milk was anything but cow's milk. It required just as much modification as unsterilized milk. Sterilizing produced but one result the destroying of germs. Alkalinity in cow's milk raised the suspicion that it had been tampered with. Pepsin was useful in a few cases, but should always be combined with an acid. Some sugar was required in the food, but milk sugar was so quickly converted into lactic acid that it was not to be advised. Dr. Baruch said he had not prescribed pepsin without acid for ten years, and had not administered it to children at all for five years.

Literary Notes.

The International Medical Annual and Practitioner's Index-a work of reference for medical practitioners, 1892. Tenth year-pp. 644. New York: E. B. Treat, 5 Cooper Union. Price, $2.75.

To the busy practitioner this condensed summary presents the cream of the work done in the various departments of medicine during the past year.

With the exception of a few pages devoted to the presentation of graphic formula of the constitution of the Aldehydes and Methanes, and of the Aromatic Series of Remedies, which the "busy doctor" will surely skip, this book is of the most practical charac

ter.

The article on New Remedies and New Treatment is a valuable summary. is a valuable summary. Indeed, there is scarcely a branch of medicine in which the progressive physician may not find the latest thought reproduced in these pages.

the causes and treatment of summer diarrhoeas. The

Dietetic and Hygienic Gazette; disease, as it occurs in infants, has been recently dis

A Monthly Journal of Physiological Medicine.

SIMON BARUCH, M.D.,
CYRUS EDSON, M.D.,

J. CLARK SLAY, M.D., Manager.

NEW YORK, JULY, 1892.

EDITOR.

cussed in the New York Academy of Medicine. The present number of the GAZETTE contains an excellent resumé of this discussion, which brings out clearly the fact that in the proper sterilization of the foodEditor Dept. Hygiene. i.e., the freeing of the infant's stomach from extraneous filth, be it microbic or otherwise, introduced with the food-lies the promise of the baby's weal. The absence of or the small quantity of hydrochloric acid in the infant's stomach is probably one reason why impurities contained in a simple diet of milk even are not destroyed, but rather multiplied, in the gastrointestinal canal. Strict cleanliness in the preparation of food prevents gastric fermentation, and the absence of the latter precludes its occurrence in the upper intestinal tract, where the chief processes of milk digestion are performed. Freedom from fermentative action keeps the intestines unirritated and diarrhoea does not occur. Hence an effective sterilization of the milk becomes of paramount importance. This is proved clinically in the daily experience of every active practitioner.

Contributions upon subjects legitimately coming within the scope of THE GAZETTE will be always welcome, and if found to contain useful ideas or practical information, will be accepted for publication. Articles of exceptional value or embodying original research are especially desired, and if found suitable for the pages of THE GAZETTE, ample remuneration will be made to the authors.

All remittances, business communications, books for review, matters relating to the editorial department and to advertising should be addressed THE GAZETte Publishing Co., 1218 Broadway, New York.

Entered at the post-office, New York City, as second-class mail matter.

Editorial.

SUMMER DIARRHOEAS.

The approach of summer renders a consideration of the causes and treatment of this distressing and, not infrequently, alarming malady interesting.

This is essentially the era of common sense; the lay mind is no longer content with finely-drawn hypothesis, spun out ad libitum for the purpose of "hedging in the divinity" of the doctor. The latter, if not impelled by his own desire for a broad and reliable basis of treatment, must find these for the purpose of satisfying the just demands of his clientèle. The simple prescription of bismuth and opium, which seems to have usurped the place of the old-fashioned sugar of lead and tannin or camphor and opium, is now coming to be regarded as unscientific and irrational as the former astringent medication. Causa sublata tollitur effectus holds here, as in other conditions, it is true. But when the gastro intestinal canal has become irritated, its vessels continue to pour forth an unwonted quantity of fluid, which is a serious drain to the system. The removal of the cause is not sufficient. The sufferer must have relief from pain and debilitating discharges. "Time," says the therapeutic nihilist, "will be the healer;" "Diarrhoea mixtures will check the bowels," says polypharmacist. Between these upper and nether millstones is the poor sufferer crushed. The application of a little common sense throws much light upon

the

Indeed, so highly is this process now regarded, that some excellent authorities doubt if the actual superiority of mother's milk over cow milk lies not more in the fact that the former is unfailingly sterile at all times, reaching the infant's mouth without the possibility of contamination in transit to its stomach; while the milk of the cow, which is also sterile, while issuing from the teat, must pass through many contaminating influences, beginning in the stable air and ending in the oftentimes still more foul air of the tenement house. Startling as the proposition that it is not so much the difference in chemical composition as the difference in absolute purity which makes the most important distinction between human and cow milk, may be, we have in the experiments of Escherich and Uffelmann, a remarkable basis for it. In the Jahrbuch fuer Kinderheilkunde, October, 1887, Escherich shows what every experienced physician has had occasion to observe that the great hue and cry about the unappropriateness of casein from cow's milk to infantile nutrition actually has no rational basis. Escherich gave to a healthy infant, ten weeks old, one quart pure cow's milk per diem with the result that not only did it not produce any trouble, but a careful chemical analysis of the fæces proved that a large amount of this casein was entirely digested. He was so surprised by this result--being entirely in contradiction to his preconceived ideas--that he did not venture to publish the experiment until he discovered that the same conclusion had been reached in experiments made by Uffelmann and Foster. Escherich felt justified therefore in declaring that "there is no doubt that healthy nurslings are capable

of utilizing in the most complete manner cow casein in quantities far in excess of their requirements of nitrogen." His examinations of the fæces have established this as a fact. If albuminoid bodies approximating casein are found in excess in infants nourished with cow's milk, this is due rather to habitual overfeeding than to inability of the gastro-intestinal canal to appropriate casein from cow's milk. "After these investigations," concludes Escherich, "let not another word be said of the digestion of cow's milk being more difficult in the normally developed infant than the digestion of breast milk." It is surprising that these positive experiments of a most reliable observer have received so little attention in recent discussions. Four years ago this writer said before the Pædiatric Section of the New York Academy of Medicine (Med. News, June 7, 1888), while he would not be willing to go as far as Escherich, he could not escape the conclusion that clinical observations sustained by the chemical investigations here referred to, point to the fact that, practically, cow's milk is not so illy adapted to the nutrition of infants as has been generally accepted. Hence the reason of its being so potent a factor in the production and maintenance of summer diarrhoea must be sought in another direction.

Four years of close observation of the trend of pædiatric opinion would show that the kind of food if it be reasonably constructed with due regard to the physiological functions of the infantile digestive tract, would be of minor importance if we could prevent the access of micro-organisms in its preparation. The reason why cow's milk, prepared in the old-fashioned way, by dilution, warming and sweetening, does not produce serious diarrhea in winter, while it almost invariably does so in summer, lies not so much in its larger amount of casein and smaller amount of fat, etc., but more in the fact that a high atmospheric temperature favors the development and multiplication of bacteria.

A wide recognition of these simple thoughts and facts by medical men and, therefore, by the lay people must lead to a simplification of the infant food problem which will bring order out of chaos, and a great saving of the little household pets, which, during their brief existence, bind themselves to our hearts with cords of steel.

In the treatment of the summer diarrhoea of infants the discussion referred to brings out clearly that common sense is supreme. Cleanliness of the stomach and intestinal canal, brought about, if need be, by artificial yet simple means-by irrigation with tepid water is regarded as far more valuable than drugs, which, however, should not be underrated.

A child attacked with vomiting or purging, or both, requires complete abstention from food and, if need be, drink also, to allow of a spontaneous cleans

ing of the canal. This may be aided by a simple purgative-castor oil if the stomach is not too irritable, calomel if it is irritable. Antiseptics are, as the writer has shown several years ago, opposed to the teachings of common sense, because a solution sufficient to kill the microbes will poison the babe.

one

The application of reason to the management of the summer diarrhea of adults-called usually cholera morbus-is important also. The cause of this malady is usually misunderstood. It is interesting to hear the patients' assignment of causes-sea air, mountain air, fish, flesh or fowl, vegetables, fruits and what not-are definitely charged as causative factors. While one or more of these may become a contributing element, the chief cause may almost invariably be found in the suppression of cutaneous secretions. Just as in winter this cause will produce a nasal catarrh, with its attendant excessive secretions from the nasal mucous membrane. The same cause will in summer produce a gastro-intestinal catarrh, with the same excessive secretions. In the case the organ involved is unimportant; its functions may be in abeyance without interrupting the processes of life. Discomfort is the chief result; the excessive secretion is received into the handkerchief until the disease has run its course. In the other case vital organs are involved. The stomach and bowels resent the presence of large quantities of fluids exuding from this congested mucous membrane. Vomiting and purging ensue without the attendant discomforts. To attempt to check these secretions may give temporary relief; complete abstention from all food and drink, and the removal, if need be, of these secretions by a gentle laxative, is the primary indication; the calming of the irritations by mild anodynes, if abstention from food and drink has not been effective, leads surely to comfort and recovery. Thus does common sense assert itself in the management of these simple affections, which, though alarming and painful, yield to its application tuto, cito and jucundi.

IMPURITIES IN FRUITS.

In our larger cities, and especially at points where "people most do congregate," the wheeled stand of the fruit vender is a familiar object. The innate fondness for fruit of most people is probably the raison d'être of the large number of these offerings that tempt the passer-by to indulgences in the good, bad and indifferent wares presented in a more or less attractive form, according to the locality.

That spoiled fruit is not a fit article of food is well known, even to people who are ignorant of the laws of health. The Boards of Health of our cities make a feeble but praiseworthy effort to protect the people

against the unscrupulous vender. A more energetic warfare would not only redound to the credit of the health authorities but also prevent much of the gastro-intestinal trouble which excessively high temperature followed by cooler night air frequently produces during the summer solstice.

We desire more especially to refer to another more serious objection to the street fruit venders' wares, viz. the fact that investigations made in one of the German University towns have demonstrated that tubercle bacilli find a favorite lodging place on fruits by means of the street dust. It occurred to this investigator to examine some bunches of grapes offered for sale on a fruit stand which was frequently passed by the patients from the University clinic. To his great surprise the washings from these grapes contained numerous tubercle bacilli.

The lesson to be drawn is the same which has been constantly inculcated in these pages-cleanliness in health and disease.

All fruit should be carefully washed before using. This rule is observed in the best households, but members of the latter will not hesitate to purchase fruit temptingly displayed at some busy street corner and eat it while walking from place to place. In a busy thoroughfare numbers of tuberculous patients pass to and fro, mingling their expectoration with the street dust, which, with the addition of other more palpable impurities, lodges upon the moist surfaces of fruits exposed on the corner stands.

The physical welfare of man can only be furthered by attention to minutia. Small things are least open to observation, but the danger arising from them are often enormous. Witness the magnificent results of Semmelweiss' observations in the Vienna lying-in wards that the enormous mortality from puerperal diseases was chargeable to a lack of cleanliness on the part of the students who were there instructed. He ordered them to wash their hands with soap and water and rinse them off in a solution of chloride of soda before entering the wards. The result was the reduction of mortality from 40 per cent. to 7 per cent. in the first year. And to-day millions of suffer

ing women would rise and call him blessed if they would appreciate that to this attention to a small thing is due the almost total abolition of puerperal fever, which formerly sent thousands of women to untimely graves in the most interesting period of their lives. From the observations of Semmelweiss has been evolved the present aseptic management of labor.

Similar illustrations of the value of attention to small things in the preservation of health and cure of disease may be found constantly in the pages of the GAZETTE.

Annotations.

FOOD FOR THE SICK.

WHEN a physician is in attendance upon a patient, he will direct the dietetic treatment. It is, however, essential that the nurse, or those employed in nursing, be familiar with the proper methods of preparing food for the sick, and the manner in which it should be administered. It is necessary to fully realize the fact that in nearly all diseases one of the first symptoms is loss of appetite. There are few duties in the sick room which demand such thoughtfulness, patience, and good judgment as the judicious feeding of invalids. Many are not merely disinclined to take sufficient food, but they are also often so extremely perverse and obstinate in their refusals, that its administration is attended with the greatest difficulty. A simple way of making beef tea is: Mince finely one pound of lean beef, and put it in a preserve jar or other suitable vessel. Add to this one pint of cold water. Stir well, and let the two stand for about an hour; after which set the jar into a kettle of cold water, over a slow fire, and allow it to boil gently for an hour. Or the jar may be placed in a pan of cold water, and introduced into the oven, a method much more convenient. The fluid contents, after being poured through a coarse strainer, duly flavored with salt, and the quantity of sediment is well stirred in, has an agreeable, rich, meaty flavor, and is highly restorative and stimulating. It possesses, however, but little or no nutritive value. It may be rendered nutritious by the addition of the meat remnant, which should be first made into a paste by crushing it in a mortar.

Chicken, veal, or mutton tea is prepared like beef tea, substituting either of these meats. If broths instead of a tea are required, the articles should be boiled in a saucepan for two hours, and then strained. For chicken broth, the bones should be used as well as the flesh, and all chopped up. An old fowl will make a more nutritious broth than a young chicken; it should then be boiled three hours.

Pearl barley, rice, vermicelli, or tapioça may be boiled with the meats, if desired, to give general

nourishing power. Oatmeal, after being well cooked, may be added to beef tea. One tablespoonful of the former should be mixed with two of boiling water, and then added to a cupful of strong beef tea; this should be brought to the boiling point.

Cold made meat infusions possess a very high nutritive value. The objection to them is their raw flavor, which to many is highly disagreeable. The unpleasant taste can, however, be disguised by adding ordinary beef tea or the prepared extracts of meat; some patients prefer to have them made sour by the addition of a slice of lemon or a small quantity of

claret. The bloody appearance of these infusions is quite likely to create an aversion, and when made from beef or mutton it is well to serve them in a red glass. When made from veal the coloration is much paler; and meat off the breast of a chicken, being nearly white, yields a liquid extract which is almost colorless. In making cold infusions, the meat should be minced and added to half its weight in water, allowed to stand for two hours, and then pressed through a cloth. It will be necessary to keep these liquids on ice, as they change quickly, or, still better, to prepare them as needed and serve at once. If administered warm, alone, or added to beef tea, they should not be heated above 114 degrees Fahr.

Raw eggs are among the most valuable resources in feeding the sick. They supply a liquid food which is not only highly nutritious, but also easily digestible. Few patients will care to attempt to swallow them whole, and by slowly stirring to blend the white and the yolk the dose is rendered less unpleasant. Eggs should never be beaten to a froth, as in that state they are indigestible, and invite flatulence and other dyspeptic symptoms. The whites of eggs are a form of nourishment admirably suited to stomach and intestinal disorders attended with inflammation. This food has, also, emollient qualities which tend to lessen the irritation in such affections as dysentery, and thereby assists nature in her efforts to effect recovery.

In a case recently reported, a patient had chronic diarrhoea of long standing, and was much emaciated. The stomach, from taking a great many nauseous medicines, had become so irritable that the patient was in danger of starving to death from inability to retain anything in the way of nutriment. All medication by the mouth was stopped, and the invalid was put upon a diet of raw albumen, prepared and administered thus: The whites of six raw eggs were beaten up in a pint of cold water, a little sugar and flavoring added, and the mixture given ad libitum, to be taken by sips during the day. The number of eggs was gradually increased until it reached fifteen or eighteen per diem. Under this diet, and with less important local treatment, the patient commenced to improve on the third day, and five weeks later entirely recovered, having gained sixteen pounds in weight during that time.

To prepare oatmeal gruel: Mix thoroughly one tablespoonful of groats with two of cold water, and pour over them one pint of boiling water, stirring all the while. Boil for ten minutes and still continue to stir. Sweeten with sugar, and add, if desired, a little sherry or brandy. Milk may be used instead of water, if required. Another way of making oatmeal gruel is as follows: Boil a tablespoonful of oatmeal in a pint of water for three-quarters of an hour; then put

through a strainer. If too thick, reduce with boiling water. Season with salt. Still another method is to add half a pint of oatmeal to a quart of water, and allow it to stand over night. In the morning, add more water if necessary, and boil for an hour. Squeeze through a fine strainer as much as possible, and blend it thoroughly with a pint of boiling milk. Boil the mixture for five minutes and salt to taste.

Of the so-called fortified gruels, Dr. William Roberts observes, although not precisely in the language which follows, that a very important kind of liquid food is furnished by gruels made with the several kinds of cereals or leguminous seeds. Gruels are not of themselves an agreeable kind of food; they lack flavor. But mixed with milk or beef tea, they constitute a valuable addition to our resources in feeding the seriously sick. When prepared from cereal flours in the usual way, they can only be made of a feebly nutritive power, if their liquid character is to be preserved. These flours are very rich in starch, and gruels made from them become thick and pasty if the proportion of flour used in their composition rises to four or five per cent.; a gruel of that strength contains very little of the more important elements. But if the meal be mixed beforehand with one-eighth of its weight of ground malt, gruels of a much higher nutritive value can be prepared from these flours and still retain their liquid character. The diastase of the malt acts upon the thickening starch as the heat rises, and converts it into soluble starch and dextrin. These fortified gruels can be made with as much as twenty per cent. of meal, and still retain the liquid state. Such gruels, being rich in constituents essential to nutrition, are admirably adapted, combined with milk or beef tea, to supply a varied kind of liquid food of highly nutritious character. Mixtures of this class seem especially suited for nourishment of cases of typhoid fever.

Among other foods which are useful additions to the diet in disease are gelatine, tapioca and arrowroot. It should be remembered that none of these are nutritive, but tend to retard waste and loss of vital power. To prepare arrowroot: Mix thoroughly two tablespoonfuls with three tablespoonfuls of cold water, and pour on to them half a pint of boiling water, stirring well during the time. If the arrowroot does not thicken, it should be boiled until that change takes place. This may be sweetened, and flavored with lemon peel or nutmeg; sherry or brandy can be added, if required. Another method is to mix a teaspoonful of pure arrowroot with four of cold milk. Stir it slowly into half a pint of boiling milk, and allow it to simmer for five minutes, during which time it must be stirred constantly. Some prefer to flavor it with half a teaspoonful of sugar, a pinch of salt, and one of cinnamon, if desired, or with half a teaspoonful of

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