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malarial fever, which were a severe test of the nutritive qualities of any dietary.
It is difficult to make a good fruit flour, for many fruits when dried form a mucilagenous mass like the fig or a sticky material like the raisin, or shrivel to a stringy substance like the apple and the apricot. But the banana, in some varieties and conditions, and when thoroughly dried, can be ground into meal or even into a flour, making as fine a powder as arrow-root, having a white or pale grayish or yellowish color, and an agreeable faintly aromatic odor and taste.
For a series of experiments conducted at the Loomis Laboratory, I procured various examples of floured bananas, as made in several different localities, all of which would be very nutritious and digestible foods. For requirements with the sick I took a floured product designated bananose, in which, either from the selection of the fruit, or the method of preparation, the starch had been carried further towards fruit sugar, making a desirable pre-digestion.
I found that an unboiled saturated aqueous solution of banana flour contained a very large percentage of sugar, and bananose held from half to three-fourths as much as certain of the best known prepared sacchar. ine foods for infants, to which sugar has been added artificially. A dog was killed during pancreatic digestion and a fresh glycerine extract of the pancreatic gland was prepared, with which I made the following experiments Equal quantities of oatmeal, farina, corn-starch and banana flour (bananose) were each boiled separately in the same amount of distilled water for the same length of time, so as to make a thick solution or paste. Test tubes were filled with the four solutions, and to each variety of starch 4cc. of the fresh glycerine extract of pancreas was added. The tubes were placed in a digesting oven and allowed to remain at a temperature of 100° F. for an hour and a half. The amount of each digested solution required to precipitate all the copper from 5.cc of Fehling's solution was as follows:
It is thus apparent that the bananose, at the end of an hour and a half of pancreatic digestion, was capable of developing nearly twice as much sugar as the same quantity of oatmeal or farina, and approximately one and a half times as much sugar as the cornstarch. A similar series of experiments, in which fresh saliva was used instead of pancreatic extract, showed the bananose to possess a ready digestibility with ptyalin.
In clinical experiments with the sick I have used the bananose flour as having the starch already partially converted into sugar. The bananose is readily
made into a thin gruel or a porridge by addition of either water or milk. In fact, when thoroughly boiled with milk and eaten with cream, it constitutes a truly delicious article of invalid diet. For those craving an acid flavor, lemon juice with powdered sugar on the porridge seemed satisfactory and refreshing.
I have recently employed both the gruel and porridge extensively in some fifty cases treated at the New York and Presbyterian hospitals, and they seemed to agree with all. I found the food especially useful in several cases of simple acute gastritis, and in subacute gastritis due to chronic congestion. It is well borne, almost never vomited, and does not tend to produce acidity, flatulence and eructation like so many other forms of farinaceous and saccharine food. It does not cause diarrhoea, nor have I been able to attribute any laxative action to its use.
In the case of a child of four years, with chronic intestinal catarrh and frequent diarrhoea, it was particularly well digested. I gave it with decided benefit to a number of patients with typhoid fever during convalescence, and in other cases during the febrile period of the disease, whenever a change from an exclusive milk diet seemed indicated either by the patient's dislike for that food, or by its causing dyspepsia. Some patients did not at first fancy the taste of the flour, but it is easy to modify the flavor in preparation of the gruel, and the majority found it much more palatable than the conventional arrowroot, corn-starch and farina.
It is certainly a decided gain to be able to enlarge the list of starchy foods adapted to feeble digestion by a fruit-flour which presents the following advantages: an agreeable variety of taste; a high percentage of nitrogen, dextrin and glucose; ready digestibility; high nutritive value; the property of keeping indefinitely in a concentrated dry state, ready for immediate use.
THE SUCCESSFUL TREATMENT OF CHRONIC DISEASES. A PLEA FOR THEIR MORE METHODICAL MANAGEMENT.1
BY SIMON BARUCH, M.D., PHYSICIAN TO THE MANHATTAN GENERAL HOSPITAL, NEW YORK JUVENILE ASYLUM AND MONTEFIORE HOME FOR CHRONIC INVALIDS.
(Continued from page 3.)
Formerly it was thought absolutely essential to send phthisical patients to the South. A semi-arctic region like the Adirondacks would have been regarded by our forefathers as absolutely detrimental, if not
1 Read at the 86th Annual Meeting of the Medical Society of the State of New York, February 2d, 1892
fatal. To-day many consumptives find relief and cure in the cold, dry air of mountainous New York and in distant Colorado, as well as in the mild atmosphere of the south of France, or Algeria, or Florida.
To resume our analogy. The discussion as to the superiority of sublimate, the comparative merits of iodoform and boracic and carbolic acid, which were replete with interest and profit at one time, are now of secondary interest, since we know that pure, undefiled manipulation of the wound is the chief object of asepsis. When contending climates have exhausted their arguments (which are as interesting and profitable in connection with phthisis-therapy as once were the arguments on the various vaunted antisepties in surgery) the cardinal principle of treatment will stand out in bold relief. It will then be clearly apparent that it is not this or that particular climate; it is not this or that particular altitude which is most conducive to recovery, but methodical treatment under conditions which afford the patient the best opportunity for outdoor life, in air that is free from dust and other vicious elements; these are the true curative factors.
This idea has been most successfully, because most intelligently, carried into practical execution at Falkenstein, where Dr. Dettweiler looks with disfavor upon medicinal remedies and pins his faith chiefly to the curative influence of pure air, to which he exposes his patients, without regard to the rigorous climate in winter even, at all seasons. The discipline of this institution is rigid, and almost military in exacting obedience. At 8 A.M. the patients are expected to be down-stairs, under penalty of a fine. Then each one stretches himself upon his reclining chair, of which there are a very large number in the large halls, which he leaves five or six times during the morning to take a ten or fifteen minutes' walk. "Patients are advised to walk slowly, on a gentle slope, with shoulders erect, and every fifteen minutes to fill their lungs to their full capacity by inhaling through the nose.' Breakfast is served, consisting largely of milk, after which the patient returns to his reclining chair, and the rest of the day is passed in the same manner as the morning. Dettweiler is most autocratic among his patients, and teaches them to cough only three times a day. Hence each cough is followed by expectoration, and he never allows them to cough uselessly. Three times a day each patient takes his own mouth temperature and notes it upon the chart. At 10 P.M. each one returns to his bedroom, which has remained open the entire day; the window is left partly open the entire night, covered by a light blind.
No drugs whatever are used at Falkenstein, and and still the results are most satisfactory, thirty-seven per cent., including all grades, recovering completely.
Prof. Bouchard has recently introduced this treatment into France. He says: "The windows must be
left open, even during winter nights. Certain precautions are necessary, but if the treatment is begun in the summer time one is easily accustomed to it. In the beginning it is best to leave the window open and draw the blind, and in very cold weather even the curtain may be pulled down. If patients object strongly to this, the windows in an adjoining room may be opened and the door left open. By this means a constant supply of fresh air is obtained. If the temperature goes below 50° F. a fire had better be lighted in the room. There is no danger of taking cold as long as one is well covered in bed.
Dr. Nicaise has reported to the French Academy of Medicine his experience with this treatment, during the winter -'88-'89, on the Mediterranean. finds that there is no danger in leaving the window open during the coldest nights in winter without a fire, provided the temperature does not go below 50° F. Below this point it is not advisable to allow the temperature to go. The aim is to enable the patient to inspire perfectly fresh (not cold) air, which is constantly made to stream in through open windows, chimneys and doors or window-cracks.
This "open-window" method of treating phthisis has recently been practised with great success by Dr. M. Moizard, of the Hôpital Tenon, at Paris. He adopts Dr. Dettweiler's ideas in toto. "The rooms," says he, "must be ventilated in such manner as to avoid the possibility of a draught. The patient must not be covered with too many blankets, but should wear a warm night-gown, flannel underwear and a woollen vest. He should be taught to breathe through the nose." Dr. Moizard first accustoms his patients to sleep with open windows in the summer. The sleeping apartment chosen for his experiments had a lofty ceiling and a window on each of the four sides ; four beds were placed in it, each being occupied by a man. A large window facing to the south was left open day and night, but covered with a blind at night to prevent too great reduction of the temperature. The temperature of the room, which was observed from the beginning of the experiment, varied from 8° to 17o C. Towards the end of November it fell to 5° C. without giving rise to unfavorable symptoms in the patients. It was thought best, however, to keep the room heated during the cold weather. In this manner, while in the middle of January the temperature outside was as low as 0.10° C., that in the room never fell below 8° C.
The most striking result observed was the increase of appetite, followed by a gain in weight. A certain number of patients, especially those suffering from incipient tuberculosis, gained in weight as much as three pounds every week. Cough and expectoration were diminished, and the night-sweats disappeared rapidly. The fever due to pulmonary congestion and
breaking down of the tuberculous foci was promptly reduced; but fever caused by the broncho-pulmonary complications was not modified, and these patients had to be removed from the influence of the cold air. If we eliminate the latter cases it may be said that the benefits derived from this treatment are almost equivalent to a cure.
The indications of hydrotherapy are very extensive. Patients in the third stage of phthisis, with cachexia and high fever, are, however, not likely to be benefited. The most favorable cases are those in which there is a tendency to the formation of fibrous tissue, as in cases of chronic bronchitis, fibroid phthisis, emphysema and rheumatism. Fever and hæmoptysis, although considered as serious symptoms in chronic tuberculosis, do not constitute a contra-indication to this treatment. On the other hand the inhalation of cold air will often prevent hemorrhages and reduce temperature of the body. In conclusion, Dr. Moizard states that, with the exception of cases of acute tuberculosis and broncho-pneumonia, this method affords much relief in the ordinary progressive form of phthisis, arresting denutrition, fever, night-sweats and diarrhea, especially if it is resorted to at an early period.
At Brehmer's Institute, at Goerbersdorf, the same principle has long been adopted. The patient is almost constantly exposed to fresh air, without drafts, and well protected against too sudden changes. Even the dining-rooms are kept at a temperature of 65° F. at all seasons, and the air is renewed five times every hour. The results obtained by this Nestor of simplified therapy are gratifying in the extreme. Of 554 cases of phthisis treated in 1888, 49 (i. e. 8.8 per cent.) were completely cured, 71 (13 per cent.) were nearly cured—that is, neither bacilli nor elastic fibres were longer present in the sputum-28 were not helped and 34 died. The others were helped somewhat, as shown by a gain in weight averaging 11 pounds.
Of the 150 who remained in the institution. during the winter 1887-88, 17 died, 6 remained unchanged, and the other 127 showed a gain in weight averaging 19 pounds."
This principle involving the paramount importance of a continuous supply of fresh air, seems to be so well established that it should be made the guiding star in all cases, whether they be under institutional or private treatment.
II. The second indication is to endow the system with the power of resisting the inroads of the established disease and treating complications and sequelae. That indication may be met by the fulfilment of the first indication, residence in an appropriate climate, by a proper and carefully regulated diet and hygiene, by certain medicinal agents, and last, but not least, by a judicious hydrotherapy. It is not my aim to dis
cuss here the medicinal agents that have from time to time been recommended in phthisis, from cod liver oil to the more recent hypodermic medications. I desire chiefly to dwell upon the non-medicinal agenciesagencies whose value has been thoroughly tested and approved. Among these a brief reference to the errors of omission but too often practised, and which sad experience has taught me to learn, is the necessity of careful regulation of exercise. Much attention is usually given to regulation of the diet. While I regard this as important, it is secondary to exercise, because when the patient is suffering from invincible onorexia nothing but the most simple food will be taken and assimilated. It is not so with exercise.
Consumptives who are not bedridden are but too frequently allowed, if not advised, to indulge in exercise short of fatigue. This is an error which has cost many lives and much misery. If we would reflect that we have a localized inflammatory action to deal with the fallacy of advising anything that must increase the labor of the inflamed organ must at once become apparent. No argument should be needed to enforce the most absolute quiescence of the diseased organ. On the other hand the lung needs thorough ventilation, the affected parts require the contact of pure air, the blood needs its invigorating influence; the nervous system cries out for it. To "steer between Scylla and Charybdis" in these cases is, indeed, a difficult problem. It is, in my experience, always best to err on the side of rest so long as the evening temperature is above 100°. If the morning temperature reaches 99°, moderate, gentle walking on level ground, with frequent respites or carriage exercise, may be resorted to at that time. The plan adopted by Dettweiler and Brehmer of exposing the patient to the constant influence of pure air and sunshine without the possibility of chilling them, is the most useful, and may be accomplished in private practice also, as I shall show. Abstention from exercise, then, when the temperature is habitually above 100°, should be the rule. But it would be equally unsafe to allow the patient to rest in illy-ventilated chambers; indeed, it would be more unsafe to let him breathe the air vitiated by himself or others.
The lungs should be treated as is every other inflamed organ. So long as active inflammation exists they should be kept at rest, or slowly and gently expanded. When the presence of fever precludes outdoor exercise simple out-door life must be substituted with massage or passive movements to stimulate the muscular system. Much of the ill-effect of absolute quiescence will be counteracted, as I shall show, by hydrotherapy.
In this measure we possess an agent whose power for good is incalculable, and which has given me more valuable assistance than all other means combined. The judicious application of cold or cool
water to the periphery produces a stimulus to the sensory nerves which is transmitted to the central nervous system, and thus refreshes every function dependent upon the latter. (To be continued.)
DIETETICS OF DISEASES OF THE STOMACH.' BY DR. I. BOAS.
Among all the remedial agents which are at our disposal in diseases of the stomach the foremost place must be assigned to the diet. It is therefore the duty of the physician to make his diagnosis the basis of a careful study as to the method of nutrition most suitable in any given case. This is one of the most difficult aims to accomplish in the whole range of therapeutics, but its results are among the most satisfactory observed in the healing art.
Two important indications confront us in the discussion of the question regarding the most suitable dietary to adopt ; first, to increase the strength and vital resistance of the patient, or, at any rate, not to diminish them; and second, to administer nutriments in such form and quantity as adapts them most readily to the anomalous functions of the digestive organs and of the entire body. In addition to this, attention must be paid to the regulation of the time of eating and the duration of the meal, although our modern mode of living by favoring irregularities in the hours of working and the times of eating and sleeping, renders any rational measures in this direction well-nigh impossible.
It is therefore much easier to formulate a system of dietetics on theoretical grounds than to carry it out practically. The question at once arises: How much do we know concerning the quantity of food required and the condition of assimilation in digestive disturbances? Our knowledge on this subject is still rudimentary, and it is therefore necessary to content ourselves for the present with applying the general fundamental principles underlying the nutrition of the sick to the treatment of patients suffering from digestive disorders.
If these principles are carefully considered we will not fall into the error of keeping patients for weeks on an exclusive diet of milk, meat or eggs, of prohibiting all fats, or withdrawing the amount of fluids or salts requisite for the normal process of nutrition. In other words, we will-except in cases of severe acute diseases-preserve the normal proportions established by the Munich School, which have been generally accepted for purpose of comparison.
According to these an adult requires of albumens 110 grammes; fats, 50 grammes; carbo-hydrates, 450 grammes; (for females the amounts of the different proximate principles are 90 grammes, 40 grammes, and 350 to 400 grammes.
Allgemeine Diagnostik und Therapic
Translated from der Magen-Krankheiten.'
Until we possess a clearer insight into the minutia of the processes of assimilation in morbid conditions of the digestive tract we will do well to accept these figures as a basis for comparison, although I am ready to concede that they are only applicable to healthy, vigorous persons. With the assistance of the tabulated data regarding the composition of the most important foods (especially the tables compiled by König and Chr. Jürgensen), it will be possible to construct, at least approximately, a dietary which will in a great measure fulfil the above named requisites and at the same time not overtax the digestive organs.
An important factor in dietetic therapeutics is a knowledge of the utilization of the food substances.
In general we will select those substances as foods for patients suffering from stomach diseases which are most completely assimilated in the gastro-intestinal canal. We have the more occasion to pay attention to this point in the selection of foods, since it must be assumed that in all severe cases the utilization is less perfect than normal, this being the more marked the greater the quantity of digestive fluids required to effect the digestion and assimilation of the nutriment.
Considerable allowance should also be made for the patient's habits of life, his social position and occupation, and we will do well to change his customary diet as little as possible if it is not contra-indicated by the nature of the disease.
In the special selection of foods for individual cases we still encounter much uncertainty. Several methods have been followed to overcome the difficulties of choosing a proper dietary. In the first place the patient's own inclinations have been made the basis for the selection of a diet, and this method has warm adherents at the present day. Thus, Hoffmann says: "Strict dietetic regulations are attended with the greatest danger in these cases. We have not sufficient knowledge of the conditions to justify us in resorting to them; and the physician who attempts their use will find that the dietary which he prescribes is not at all borne by the patient, while another which he regards as dangerous may agree perfectly. In such cases the old practical axiom holds good: 'A person suffering from gastric disease is himself the best judge as to the diet which agrees with him."" Uffelmann also emphasizes the necessity of always considering the personal observations of the patient. I can only adopt these views to a certain extent; for the judgment of the laity as regards the compatibility or incompatibility of any article or articles of food does not afford us even approximate data for our treatment. Besides, the patient is not always in a position to make a positive decision, since, as a rule a number of different food substances and fluids are combined in the preparation of his meal, be it ever so simple.
On the other hand, in view of our imperfect knowl
edge of the minute details of the process of digestion, especially when it is disturbed, we cannot completely dispense with the patient's objective observations, at least for certain articles of food.
First, as regards milk, we know that there are healthy persons with whom milk does not agree in any form; and in patients suffering from gastric diseases this is observed in a still greater degree. It is difficult to say in individual cases upon what this intolerance for a food, apparently so readily assimilated, is based. It is most easily explained in cases of severe chronic inflammation of the gastric mucous membrane with diminished secretion of gastric juice. In such cases we can readily convince ourselves by aspiration of the stomach contents of the marked fermenta
tion of the milk which has not undergone curdling. In other instances where the lab-ferment is still present in small amount, there is a formation of compactcasein coagula, inasmuch as these are not peptonized, owing to the absence of hydrochloric acid and pepsin, or only imperfectly. In still other cases where an examination of the stomach reveals perfectly normal functions we are compelled to assume that the milk provokes disturbances which are falsely located by the patient in the stomach.
The same may be said of eggs and foods prepared from them. There are some persons who manifest an inexplicable intolerance toward the albumen of a hen's egg, which sometimes provokes severe acute intestinal catarrh. In only a single condition can we count with certainty upon the fact that eggs will agree, and that is in stomach affections attended with hyperacidity. In these cases the albumen absorbs a large amount of the superfluous acid, and thus protects the mucous membrane from its irritant effects. The converse applies to patients suffering from gastric pneumatosis, marked flatulence, chronic diarrhea, and similar conditions. According to my own experience in such cases the egg albumen (perhaps on account of the sulphuretted hydrogen developed from the sulphur of the albumen) is apt to give rise to the most disagreeable and subjective and objective disturbances. As a possible cause of this poor tolerance I would refer to an observation frequently made by me, that fragments of albumen remain clinging to the folds of mucous membrane in the stomach and duodenum, and there provoke local irritation.
In certain conditions there is a marked sensitiveness of the stomach for fats, which, as I observed in a case of neurasthenia, may become exaggerated into an idiosyncrasy toward fatty articles of food. On the whole, however, fats in moderate quantities are much better borne in digestive disorders than was formerly believed.
Among nutriments, which it is sometimes important to consider with reference to their influence upon the subjective condition, we must mention the alec
holies. We shall show further on, on the ground of recent investigations, that the unfavorable influence on digestion attributed to alcohol in nowise exists. Perhaps the subjective poor tolerance of alcoholics depends upon the temperature of the beverages, which must in general be regarded as utterly unhygienic because usually much too cold. On the whole, alcohol in proper form and dose, is much better borne than is apparently thought; and I therefore proscribe alcoholics only in those conditions where my experience has shown them to produce disturbances, or where a priori unfavorable effects are to be expected (gastrectasia, intestinal catarrh, recent ulcer of the stomach, etc.
The appearance and character of the tongue is still regarded as affording us some data for our dietetic regulations. I have already spoken of the slight diagnostic value of the condition of the tongue, and the same applies to any therapuetic conclusions deduced therefrom.
I am certain that a reflex action between the mucous membrane of the tongue and stomach does not take place, although both are sometimes acted upon by the same influences. Thus a patient suffering from periodontitis or gingivitis, alveolar pyorrhoea, etc., has no appetite, simply because the purulent matter affects unfavorably the different functions both in the mouth and stomach.
(To be continued.)
HYDROTHERAPY IN THE ERUPTIVE FEVERS.
BY DR. GUINON.
[Translated from Revue des Maladies de l'Enfance, November, 1891.]
A large number of physicians, even of those who use the cold water treatment in typhoid fever, are opposed to the use of the same agent in eruptive fevers. When we seek the cause of this opposition we find it to be due to the belief that cold has a disturbing effect on the evolution of the rash, and decreases the cutaneous congestion, producing in consequence visceral troubles; hydrotherapy was applied for the first time in scarlet fever in 1798 by Currie, in the form of cold affusions; he thus treated successfully his two sons, affected with the malignant form. He used cold water in any disease which presented the following conditions: delirium, convulsions, profuse diarrhea, excessive vomiting, temperature above 105. Reid, Murray, and Gregory followed his example, and praised the effects of this treatment. Giannini of Milan (1805) favored immersions for five to fifteen minutes in cold water, as a means more easy and quite as efficient. Later, Priessnitz extolled the successful effects of the wet pack. Finally, Liebermeister, Leichtenstern, Vogel, Steiner, and Winternitz