Billeder på siden
PDF
ePub

other twelve on farinaceous; and this arrangement was continued for four weeks, during which time their physical and mental conditions were closely observed from day to day, and the number of epileptic seizures accurately noted. At the end of four weeks the weights were again taken and the diet changed, those previously on nitrogeneous diet being transferred to farinaceous, and those on farinaceous to nitrogeneous. After another period of four weeks, during which the condition of the patients was from time to time noted, and compared with that which had been observed in the previous period, the weights were again ascertained, and the patients again allowed to resume their ordinary dietary."

The mental condition of many of the patients changed after assumption of nitrogeneous diet. They became much more dull and stupid, but changed for the better so soon as farinaceous diet was adopted. With regard to the number of fits, the time for observation was too short to make positive deductions, but whenever a diminution of the number, even though slight, coincided with improvement in the mental condition and general health, the effect must be regarded as beneficial.

"It will thus be seen that out of twenty-four cases observed, there was in fourteen a decided decrease in the number of fits during the period of farinaceous diet; the average number of seizures for the farinaceous period in these fifteen was 107, as compared with 283 for the nitrogeneous period. Of the remaining ten cases, four had the same number of fits under each diet. There are, therefore, only six left in which the advantage is on the side of the nitrogeneous regimen, and of these we have seen that two cannot be fairly regarded as telling against farinaceous diet. I think then that, after making due allowance for the short period of observation, and the limited number of cases observed, there is still a certain indication that the actual number of fits is less under a farinaceous dietary than under nitrogen."

Although this testimony is not sufficiently positive, it may serve as an incentive for further investigations in a field which offers much fruitful results, and as a guide in the treatment of a disease, which ordinarily bids defiance to other measures.

DIETETICS OF DISEASES OF THE STOMACH. BY DR. I. BOAS.

[Continued from the February Number.]

The "scale of digestibilities" established by the investigations of Beaumonts on the Canadian, St. Martin, and of Ch. Richet on a gastrotomized patient, still exerts a marked influence upon our recent views on dietetics. In both of these cases (especially that of Beaumont), the digestion was considerably

[ocr errors]

disturbed at times, so that the figures obtained are only applicable to the special cases in question, but not at all to digestive disturbances in general. Moreover, the data furnished by Richet exhibit such marked differences in themselves, that for this reason alone we cannot be too skeptical as regards generalizations from the same. A few figures will show this: According to Richet, meat is digested during periods varying from one and a half to five and a half hours; while the digestion of a substance like spinach may require from one to four hours, and "onion soup remains in the stomach for three hours. In view of our simplified methods of the present day, it would certainly be an easy matter to obtain correct values by making similar experiments on healthy persons. For this purpose the stomach should be emptied at stated periods after meals consisting of certain substances which have been weighed. Yet it would not be proper to draw deductions from the data thus obtained, since experiments on healthy persons could not be made to apply directly to the conditions of digestion existing in the sick.

Of even more limited value are the so-called experiments in artificial digestion, the results of which are still utilized in dietetic prescriptions. Aside from the fact that in artificial digestion only one of the digestive functions, the peptic, is considered, the data obtained even in this one particular, cannot be brought into analogy with the process of digestion in the stomach. Thus, for instance, a substance added to the artificial gastric juice may arrest its function, or leave it unaffected, while the same substance intra vitam may directly stimulate the secretion of gastric juice. Examples of this are sodium bicarbonate and alcohol. In the test flasks both produce diminution in the formation of peptones in small amounts, while if introduced into the stomach they stimulate the glandular secretion, and hence act favorably on gastric digestion. But even if, as regards this one function, the experiment in the flask corresponded with that made on the stomach of a living person, we cannot leave out of consideration the marked influence of thes drugs upon the motor activity of the stomach (upon absorption and sensation), upon fermentative processes in the intestinal canal, effects which may far surpass the peptic function in importance. Thus we know from the experiments of Einhorn with strychnia that this drug powerfully stimulates the motor functions in a similar manner as the galvanic

current.

On this basis we may estimate the value of the experiments, recently made at a great expense of time and labor, regarding the efforts of various medicaments upon gastric digestion.

Leube has furnished more scientific and useful criteria by which to judge the digestibility of various. ubstances by determining the time during which a

certain meal remains in the stomach. In this manner we are able to inform ourselves regarding the extent of digestion and the motor activity, if the period of observation is sufficiently long. On the other hand, the motor action is only one of the factors of gastric digestion, although a very important one.

It would be equally wrong to regard a food substance which is rapidly carried out of the stomach as very digestible, or, vice versa, a substance which remains for a long time in the stomach as always indigestible or difficult of digestion.

On the ground of his investigations has been led to adopt a special diet in diseases of the stomach, which consists of four varieties.

1. In cases where the digestive powers are very low, the following foods are most easily disposed of: Bouillon, meat solution, milk, soft boiled or raw eggs;

2. Boiled calf's brain, boiled thymus gland, broiled chicken and pigeon, mucilaginous soups and milk porridge.

3. If the condition of digestion is improved, we may allow beef, half broiled or raw, or scraped raw ham, with some potatoe purrée, also a small quantity of freshly baked bread, and, for experiment, small amounts of tea or coffee with milk;

4. Roasted chicken or pigeon, venison, quail, roast beef, roast veal, pike, bass, macaroni, rice boiled in bouillon, and small amounts of wines.

All vegetables, except spinach, and all fats are regarded by Leube as unsuitable in cases of stomach trouble.

It may be asked is diet 1 and 2 really easy of digestion? Certainly not for all patients suffering from gastric disorders, and, indeed, in cases of atony of the stomach, or even dilatation, I would consider it as quite indigestible. Besides this, milk is an essential constituent of diet 1 and 2, the subjective toler ance of which, as already emphasized, is very variable.

Diet 1 and 2 of Leube, has further the disadvantage that it does not conform to the need for nourishment of the organism, as has been justly mentioned by Germain-Sée, and as I have recently shown in another article (Beri. Klin. Wochenschr., 1890, No. 20-23); it is therefore suitable only for short periods and in special cases.

How far Leube's verdict against vegetables and fats is justified, I will endeavor to show farther on. Although the advantages of Leube's plan of diet should not and cannot be denied (the brilliant results of its originator would not permit this), we see that it is too much restricted to be a generally applicable method, and that it has too little regard for individual requirements. We cannot generalize as to the dietetic regimen indicated in severe and slight gastric disturbances, because this would pre suppose an

accurate knowledge of all the functions of the gastrointestinal tract in individual cases.

I also regard as a desiratum exact directions as to the quantities of food to be taken, which are wanting in our dietetic charts. The rules in vogue up to the present time, which are based upon the patient's own will and endurance, are decidedly insufficient.

A complete dietary, in my opinion, should contain: 1. An exact statement as to the time at which the different meals are to be taken.

2. A complete list of all foods and luxuries that may be permitted.

3. Exact data regarding the quantities of foods and drinks expressed in terms of weights.

4. Short notices regarding the preparation of foods, the temperature of drinks, together with remarks applicable to individual cases.

5. Detailed information regarding prohibited foods, or, at any rate, those which are permitted.

I. It is desirable to regulate the time for the different meals, because an irregularity in this respect is frequently the cause, or, at any rate, an accompanying factor of digestive disturbances. In general, the rule should be observed of giving small and frequent meals, but this is not useful or necessary in all cases. Frequent indigestion is associated with the disadvantage, not to be overlooked, that it does not afford the diseased organ sufficient periods of rest. The latter are especially requisite in cases of abnormally augmented glandular secretion. As a general rule, frequent and small meals are indicated in all conditions of hypotony or stenosis, in which the muscular apparatus of the stomach is well able to dispose of small quantities of food, but powerless in the presence of large quantities. But even in the first-named class of cases an accurate regulation of the time of taking meals is desirable, in order to avoid overloading the stomach, or excessive secretion of gastric juice, with its ill effects upon the gastric mucous membrane.

II. According to my experience errors are frequently found in lists of prohibited articles of food and luxury. We prohibit more and allow less than is good for the patient. I am of the opinion that it is the physician's duty whenever he prescribes a certain food to ask himself the question whether this prohibition can be really based upon the pathological condition present. The objection that more harm is done. by free indulgence than by the opposite is not pertinent, inasmuch by excessive restriction we injure the entire organism and deprive it of the possibility of making good the loss of nutrition due to the imperfect and diminished assimilation. It should not be forgotten that by too greatly restricting the number of permitted foods, a certain degree of monotony or even disgust toward the diet is easily brought about, which manifests itself either by a temporary anorexia, or worse still by a violent infraction of all dietetic

regulations, and thus increases the existing trouble

III. The importance of exact quantitative dosage of the ingesta requires no explanation. It is not difficult to effect this if we have once formed a clear and practical conception of the quantities of foods and drinks (in figures of weights and volumes) which are required by healthy persons. We need not proceed too pedantically and conscientiously in this direction, but we should be careful not to select such measures of volume as are apt to vary greatly (teacups, wineglasses, teaspoons, plates, etc.

Annotations.

Milk Diet.-A diet composed of milk, either alone or associated with bread and a few other farinaceous articles, has been recommended by physicians in certain cases from very early times; indeed, some say that it is as old as medicine itself. According to good authorities, however, it has never been so highly esteemed as at the present day, and has produced such excellent effects in diseases of the heart, of the kidneys and of the digestive organs, that it would be resorted to still more frequently, but for certain popular prejudices concerning it.

Patients themselves, as a general thing, have no insurmountable aversion to living on milk; it is their friends and attendants who are opposed to its exclusive use, on the mistaken ground that this will lead to starvation-in the case of adults, that is, for it is admitted to be very suitable for children. When it is urged that milk is the chief of animal aliments, that it is a complete food in itself, uniting in due proportions all the nutritive principles required by each of the organs, and that nothing is more digestible, they regard these arguments as unsound, and are still convinced that no other diet, for grown persons at least, can replace that to which they are accustomed, of bread, meat and vegetables.

If we admit the physiological axiom laid down by Bouchardat-that it is not what is eaten, but what is digested, that affords nourishment-then it can easily be shown that, when the system has become accustomed to it, milk taken in prescribed quantities, is actually more nutritious than the mixed diet.

All other foods must undergo a complicated form of digestion and assimilation which render their nutritive value somewhat unstable.

In the case of milk, the digestive process is greatly simplified. When this food reaches the stomach, a selection of its directly nutritive principles immediately begins; the albuminoids and butter solidify and coagulate, while the sugar, remaining dissolved in the whey, passes into the bowels, and may there be at once absorbed, unchanged, to be ultimately employed as respiratory aliment. This absorption in

volves no waste of nutritive substance.

Meanwhile, the albuminoids are peptonized and absorbed, also, it may be said, without leaving any residiuum. The same is true of the butter, and even to a greater degree, since it is the most digestible of all the fatty bodies. bodies. Yet it is owing to this constituent that some patients, whose pancreatic digestion is impaired, cannot tolerate a diet of milk unless it has been skimmed. But whenever it is well-borne, the amount of intestinal débris which is left after its digestion, is trifling in amount and even foreign, in some degree, to its very nature. This lately ascertained fact corroborates what has been shown by the previous figures, viz., that a few liters of milk afford more nourishment than the mixed army ration.-Rpertoire de Pharmacie.

Experiments on the Dietetic Use of Fat. Prof. N. Zunz says, Fat being the most concentrated of all our alimentary substances, and its digestion being performed at a very small expense of force, it is to be concluded that fat should be an excellent means of raising weakly persons in their nutrition. Unfortunately fat, when taken in notable quantities, easily impairs the stomachic digestion, and it was necessary, therefore, to find a modification of fat which would, especially by facile emulsiveness, remove this drawback.

The investigations of various scientists, especially Buchheim's, have demonstrated that in this respect a moderate proportion of free fatty acids constitutes an important condition for the easy digestion of fats.

The author was informed recently by Prof. Von Mering that he has succeeded in reducing the fat of chocolate to a condition of facile emulsiveness without impairing its savor, and that he thought he had discovered in this preparation a succedaneum of codliver oil and similar dietetic fats which seemed to be as agreeable as efficient.

He performed a series of investigations and feeding experiments on a dog which was given pure cocoa-butter with addition of oleic acid, finally cocoa-butter mixed with neutral olive-oil.

It was found that the addition of free fatty acid had increased the digestibility of fat, especially of cocoa-butter, in a considerable proportion, i. e., that in this case very little fat was discovered in the fæces, while the addition of olive-oil was without influence.

The author now performed experiments on his own. person by first ascertaining the quantity of prepared chocolate he could take without molestation, eating at the same time meat and bread in sufficient portions to fully cover the alimentary requirements of the organism.

The alimentation thus determined and uniformly taken for three days consisted daily of: 416 grm.

chocolate, 390 grm. white bread, 158 grm. lean roast beef from which all visible fat had been removed, and 15 grm. sugar.

In this combination the quantity of alimentary substance was much more than needed by a man of sixty-seven kilograms in weight, and of little muscular activity, as the author.

Examination of the fæces produced showed 13.25 grm. of fat. Consequently the average daily secretion of fat had been 4,416 grm. (4.88 per cent. of the 90.46 grm. of fat daily ingested).

This proves that the fat of the chocolate had been taken up in an excellent proportion.

It has to be noticed that the chocolate, in spite of its large quantity, was very well supported and taken without repugnance.-Therapeut. Monatshefte.

Summer Diarrhea of Infants.-Clinical experience, as shown in the successful treatment of gastric disorders by irrigation of the stomach, and the antiseptic treatment of the entire alimentary canal, forces the conviction that these disorders which are under discussion are the result of decomposition processes, which are caused by bacterial agencies. Starting with the hypothesis that the contents of the alimentary canal are the substratum from which the intoxication which gives rise to gastrointestinal disease proceeds, the following questions are submitted:

(1) Do the contents of the stomach in dyspepsia in young children have a relatively greater quantity of micro-organisms than the contents of the stomach of healthy children?

(2) Is there a relation which can be determined between the relative quantity of germs in the stomach of sick infants, and the intensity of the disease from which they are suffering?

(3) What are the relations between the relative quantity of germs in the contents of the stomach and the intensity of the disease on the one hand, and cli. matic factors, which influence the destruction of the milk, the factor of temperature particularly, on the other hand?

To answer the foregoing questions, a quantitative bacteriological analysis was necessary, of contents taken from the stomach of a living child.

Investigations of this character on an extensve scale were made by the author, and from these it was concluded that in the acute dyspepsias of infants one has to deal with spores, which are antagonistic to the acid of the contents of the stomach, are introduced with the nutriment, and develop luxuriantly at the temperature of the body. The phenomena of severe dyspepsias, and especially those of cholera infantum, are the phenomena of acute intoxication; hence, it is reasonable to seek for the cause of the disease in the poisons generated by the saprophytes of the contents of the stomach.

These diseases are most destructive at the time when high temperature, through the action of microorganisms, works destructive changes in food substances, and almost disappear when the weather becomes cool. There are also cases which have the character and etiology of general infectious diseases.— Jahrbuch of Kindersheilk.

Hygienic Treatment of Bright's Disease.-Chiron in L'Union Médical, June 23d, gives a review of the different dietetic treatments of Bright's disease, and says, as a general rule, dark meats, such as wild fowls, and extracts of meat, such as Liebig's, should be avoided. The chief danger in such foods is the toxic properties of the ptomains they contain. In the periods when the disease is not active, white meats can be used, all condiments to be avoided. Some patients bear fish badly, but shell-fish can be used in moderation. Some patients bear milk and vegatable diet badly, and, in such, meats can be cautiously used, the urine being frequently examined to see that the albumen does not increase. Eggs are a disputed article; sometimes they agree well and sometimes badly. When, however, the digestive tract is in good condition they usually are well borne. Milk diet is, as a rule, the one best borne; it acts as a diuretic, diminishes the albumen, and increases the Three and a half to four litres a day may be used. Certain patients cannot use an absolute milk diet, however, and in them a mixed diet is useful. A grape diet, skimmed milk or koumyss may be used with advantage. Most authors allow beer and a slight amount of light wines. In acute Bright's disease physical effort often increases the albuminuria. In this condition, and in the acute exacerbations of chronic nephritis, a patient should be in bed. In the chronic condition slight exercises are admissible, but where there is much polyuria or hypertrophy of the heart it is not to be permitted. Patient should avoid being chilled, and in winter should remain in a temperature as near as possible 75° to 80°, and should wear flannel underclothing. The functions of the skin should be carefully looked after; baths, tepid and hot, followed by frictions and massage, are recommended by most authors, though Lecuché and Talamon recommend the cold baths.- University Medical Magazine, October.

urea.

A Resume of the History and Practical Application Peroxide of Hydrogen in Surgical Affections.-In concluding my article, I think from the clinical as well as from the experimental evidence which has been deduced, we can safely sum up the action of peroxide of hydrogen in the treatment of surgical affections as follows: 1. Hydrogen peroxide is a positive germicide, and a possible stimulant to granulating tissues. 2. Owing

to its special property of eliminating oxygen, it is of unparalleled value in the distention of suppurating sinuses and cavities, especially in the mastoid region or where it is almost impossible to reach unhealthy surfaces by other means. 3. The diluted solution is perfectly harmless and can with safety be used in any quantity. 4. The strong concentrated solution, syrupy in consistence, is a direct irritant to all tissues and should never be used. 5. It possesses healing and cleansing qualities as well as those germicidal in nature. 6. When exposed to light, it loses strength; care should therefore be exercised in keeping the bottles well stopped with rubber corks, and in a cool, dry place. 7. Fibrin, cellular tissue, and some metals. instantly decompose it. In contact with sugar and starch it eliminates carbon dioxide. Albumen, gelatine, urea and cutaneous tissues have no effect upon it, while ammonia, aconite, tobacco and hydrocyanic acid increase its stability. 8. In washing suppurating surfaces, it should be used until oxidation ceases, thus showing a complete destruction of all existing purulent material.-Dr. Pott in Med. and Surg. Reporter.

The Parturient Woman's Bed.-Much has been said and written in the last few years regarding the question of antisepsis in midwifery practice, and yet, how little attention has been given to the proper arrangement of the parturient woman's bed, and to the dressing to be applied to the vulva after delivery.

The bed is ordinarily prepared by spreading a sheet of rubber or oil cloth over the mattress, to prevent it from becoming soiled, while upon it is placed an old ragged quilt, which has seen many years of service in various capacities. A sheet is spread over all, and the bed is ready for antiseptic midwifery (?). Worse than this is the feather bed. The patient is put to bed, with perhaps a sheet pinned around her waist, and her long night gown drawn up from under her hips.

During the pains of labor the patient rolls and tosses, her night gown works down under her hips,

ers.

the sheet around the waist slips up under her shouldShe is delivered with a gush of water and blood; her night gown is soaked and she is wet to the shoulders. Thus wet and cold she lies for half an hour or more, when the old quilt and rags are drawn away, some more rags from the pile on the chair are tucked under her, the wet night dress is, after much trouble, removed and a roll of the same old cloths is placed against the gaping vulva, the swollen labia and the torn perineum.

By a little attention, on the part of the physician, to the preparation of the bed, many of the annoyances and dangers incident to parturition can be removed. Commence with a good, firm mattress; eschew feathers. Cover the mattress with a rubber sheet, and

over it spread the cloth sheet. Have the patient wear, in lieu of a night gown, a short sack scarcely reaching the hips. After she takes her bed, place under her hips a pad of absorbent cotton, covered with cheese cloth, about thirty inches square and one inch thick. Place a similar pad, folded, under the small of the back and resting upon the upper margin of the first pad.

The pads under the hips will absorb all the fluids incident to labor, while the one under the back will prevent fluid creeping up to the patient's shoulders. After labor, withdraw the pads. With them will come all the fluids, and the patient, with no annoyance or trouble, finds herself in a clean and dry bed. Now place a pad eighteen inches square under the hips, and one or two inches in diameter and seven or eight inches long against the vulva, to absorb subsequent discharges. Burn the soiled pads; they are cheap. Pads or accouchement-sheets can be purchased of the Hygienic Wood Wool Co., ready-made, as can the vulvar pads. The vulvar pads should be changed as soon as they become soiled. The large pad placed under the hips after delivery can remain for from twelve to twenty-four hours, after which time the vulvar pads will be sufficient to absorb all discharge.

In referring to the efficacy of these pads and sheets Dr. Geo. H. Rohe, Director of the Maryland Maternite, in a recent communication, says:

"The confinement pads were found to thoroughly absorb all the discharges without allowing any fluids to pass through to stain or even moisten the sheet underneath. Of course it is possible that in some cases, where the liquor amnii is in excess, the pad would not absorb it all, but no such case occurred among those with whom the test was made. The menstrual pads were used as vulvar pads after delivery. For the first two or three days the discharge rapidly saturated the pads, so that frequent renewals were necessary. After the third day, however, these pads answered admirably to absorb the lochial discharge. I would suggest that a slightly wider and longer pad than the menstrual pad be made, to be

used as a vulvar pad after delivery. This, it seems to me, would help along the cause of antiseptic midwifery, as any old rags are usually thought to be good enough to be used as vulvar pads."—Amer. Jour, of Gynecology.

Is Uric Acid a Prime or Sole Factor in the Causation of Rheumatism?-In an ar ticle, "The Dietetic Treatment of Some Important Neuroses" (The Medical Neurs, January 2, 1892), Dr. John Ferguson, of Toronto, states that uric acid is a prime or the sole factor in producing many neuroses --epilepsy, chorea, hysteria, etc.--by its action as an irritant poison, circulating through the tissues of the

« ForrigeFortsæt »