Popular Science Monthly/Volume 43/May 1893/Dietary for the Sick
|DIETARY FOR THE SICK.|
By Sir DYCE DUCKWORTH, M.D., LL. D.,
PHYSICIAN AND LECTURER ON MEDICINE AT ST. BARTHOLOMEW'S HOSPITAL; HON. PHYSICIAN TO H. R. H. THE PRINCE OF WALES.
IN the practice of medicine as now carried on, one marked feature is the particular and detailed attention directed to the diet. It thus happens that as much heed is paid to "kitchen physic" as to pharmaceutical agents. Dietetics, according to modern enlightenment, has secured careful study, more particularly within the last quarter of this century, and the subject was certainly insufficiently appreciated before that time. Now, guided by the researches of the physiologist and the chemist, we have more exact knowledge to bring to bear in the dietetic treatment of many morbid states, and a good deal of this knowledge is now well established and beyond dispute.
The duty of the practical physician is to apply this knowledge and to test it in his efforts to re-establish health. And here, as in the case of the employment of drugs, we have to consider the clinical side of the question, apart from the researches of the physiologist and the chemist in their laboratories. The progress of our art depends on the steady work of both sets of investigators. The ultimate appeal is to the clinical results. In the matter of diet we meet with strange differences of opinion—differences relating to the employment and value of sometimes very simple forms of aliment. Some of these plainly arise from ignorance in respect of the properties and qualities of certain foods. Some of them result from the foisting of mere personal or of very limited experience of such articles on patients; and some of them can only be described as mere vagaries and "fads."
The whole subject has naturally a large interest for several classes of patients, notably among the well-to-do, the luxurious, the hypochondriacal, and the dyspeptic. Such persons having exhausted many methods of drug treatment, resorted to spas, undergone massage with incarceration, and found temporary salvation in sipping hot water, pass from one consultant to another seeking the last new paradox in dietetics. They will continue to do so, and the more if they fall into the hands of those who give them really judicious advice. They dislike that, and it is indeed seldom helpful to such persons. In this brief communication I shall have nothing to say in respect of them.
We may fairly remark that we are in danger of being perplexed by the number of patent and proprietary articles of food daily brought under our notice. The chemists, especially the Continental and American, try to help us in our daily work by contriving the most subtle, and often palatable, preparations of nutrient materials. And, not content with this, they would fain abolish almost the entire Pharmacopœia, and offer food and physic in one; aiding themselves in this bold effort by the most fantastic and obtrusive advertisements, which pass one's best ingenuity to escape from. Strange to say, they compel attention from persons who should know better, and should use calm judgment in sweeping most of them aside. So it happens that one frequently finds many of these vaunted preparations in use by persons who have not even a bare knowledge of their qualities and powers for good or evil.
The mischief of all this in respect of foods and new drugs is, as I have before now stated, that the practitioners in trying, as they think, to keep pace with the times, lose their hold of wellapproved methods and therapeutic agents, which drop out to make way for something new and unapproved. They thus fail in the art of medicine, which I make bold to say is less well established to-day than it was, in many respects, half a century ago, and chiefly because of this pursuit of novelties.
We have witnessed many changes of opinion respecting some of the commonest articles of diet for the sick. The old view, that calves'-feet jelly was of exceeding nutritive value, was at one time so controverted that the jelly ceased to be much used. It is now sanctioned as having a place in dietetics, and I believe it may be safely regarded as a temporary form of nourishment of no inconsiderable value.
Beef-tea has been in and out of repute, but we have, or should have, no doubt now as to its stimulant and reparative properties. We can not think lightly of it as commonly prepared, for it can certainly prove harmful, when not desirable, as in the case of rheumatic fever. I believe it is right to withhold it in such cases. Again, it is so far apt to act as an aperient that it is best not to employ it in enteric fever, or in diarrhœea, when the bowels are in an irritable condition. Mutton, veal, or chicken essences can, however, be used, having no such aperient action. We have to distinguish between a dietary suitable for acute disease, when we have to wait and tide over difficulties, and one that may be better adapted to restore a convalescent or weakly patient. The highest nutritive value may not be (I think it is not) the most essential point to have regard to in selecting a dietary in acute diseases.
In most cases of acute disease, beef tea, freshly prepared, can well be taken and digested. It is now often peptonized, and I believe for clinical purposes this is generally unnecessary, unless there is manifest failure of secretion of gastric juice. This remark applies equally to milk, which is also too often given peptonized. I feel sure that we do best to administer nutriment in the most natural and unaltered forms when possible—that is, with as little of culinary or medicinal interference as may be; to give it, in fact, fresh from Nature's laboratory.
In many illnesses it is well to vary the broths given, changing from beef to mutton, veal, or chicken, and so providing variety for the patient. Milk and veal broth may often be given together Alcoholized liquids are best not administered with animal broths. These are better given separately, but brandy, rum, or whisky may be given with milk.
It is, unfortunately, a good rule to boil milk before using it, especially in the case of children and young persons. This no doubt averts many of the evils of milk diet, and may also prevent some specific diseases. I say unfortunately, because I suspect boiling much damages the nutritive value of a secretion such as milk. Dilution with barley water, lime water, or the addition of sodium bicarbonate, certainly aids its digestibility in children and adults, both in health and disease; the bicarbonate being preferable if there is constipation. Whey is of considerable value for many dyspeptics, and also in enteritis, typhlitis, and intestinal obstruction, and may be freely given. Isinglass boiled in milk is very useful, and children readily take this in the form of blanc-mange when not too firm in consistence. Alum whey is of much avail in diarrhœa, and in cases of enteric fever with hæmorrhage. One drachm of powdered alum is added to a pint of hot milk, and the whey strained off. Cream with an equal volume of hot water can often be taken when milk disagrees.
Koumiss has considerable value in cases of great irritability of the gastric mucous surface. Koumiss one week old I find the most useful, and I have often known troublesome vomiting checked by it. Few plans are better than that of employing milk with one third of its volume of lime water, given in teaspoonful doses each, quarter of an hour by the clock, in rebellious vomiting of reflex origin. This quantity will be retained when larger ones will be rapidly rejected.
The inability to digest amylaceous food when pyrexia is present is generally recognized: hence the principle of milk and beef-tea diet in fever. I would strongly urge the employment of occasional draughts of pure water in fever. This is much neglected. Patients are plied with strong essence of beef. Brand's jelly, and milk with stimulants—all this ad nauseam, but a cooling draught of water is withheld. Water, however, is generally relished, and is of real service. It promotes appetite for the next food, and cleans the mouth.
The nutritive value of purely amylaceous foods has been decried, but, I think, with no satisfactory clinical reason. Arrowroot prepared with water only, or with milk, is certainly sufficiently sustaining for many invalids who temporarily can not take bread. In gastric and gastro-enteric catarrh it is of much service, and diarrhoea may sometimes be checked by stirring into a cupful of milk-arrowroot half a teaspoonful of raw arrowroot powder, and ten grains of powdered cinnamon.
Eggs often disagree because of their albuminous constituents. The yolk alone can often be taken with advantage in soup or in milk, or beaten up with spirit.
In the treatment of febrile states, tea and coffee are too often omitted, without reason, from the dietary. They will enable cases to go on well with a diminished amount of alcohol. Cold tea with cream is an excellent refreshment early in the morning after profuse sweats in phthisis. One meets with patients who have been forbidden butcher's meat, but allowed to eat chicken or game. I am at a loss to understand the reason for this. I recognize the greater digestibility of the latter as a rule, although I much doubt if there is really any difference if the beef or mutton be tender and of good quality. If, as I conceive, there is an idea that the one tends to plethora and vascular tension, or is apt to induce uric acid disturbances, while the other does not, I should be prepared to controvert that idea, believing that all these flesh foods fall into the same category. With fish the case is different, and large meat eaters may sometimes with advantage be ordered to substitute fish. It is hardly possible for any one to overeat himself on fish, and, whatever may be the explanation of the fact, I am satisfied that great mental energy and capacity may be secured by occasional meals of white fish to the exclusion of other animal food.
It were well if greater heed were paid to the treatment of the patient than is commonly bestowed on that of the disease. One not rarely finds measures adopted for the latter, and no thought bestowed on the subject of it. It is always necessary to treat the patient, and sometimes what is seemingly necessary for his ailment is very poor treatment for him, if too long kept up. We especially note this in respect of the employment of wine and stimulants, and in the conduct of cases of Bright's disease and of chronic gout,
I think well of the skim-milk treatment in cases of chronic tubal nephritis. But it is not always well borne by the patient. He may fail to be sufficiently nourished by it, and a time comes when the diet must be altered. There is a large variety of foods available in this condition: bread, biscuit, butter, light farinaceous pudding, sometimes with egg in it, potatoes, spinach and other green vegetables, with cooked fruit. The albuminuria is often not materially increased in chronic cases if fish be given once a day, or the yolks of two eggs be added to the diet. Fat bacon may also be taken. And on alternate days we may sometimes give a little mutton or chicken, without any apparent harm to the disease, and with material benefit to the patient. The condition of the urine must be carefully noted in making these amendments. Certainly, in some cases, the "large white kidney" is an expression of a frail and feeble constitution, and has not always the same significance. A better level of general nutrition, directed in relation to the renal adequacy, may much aid in helping the kidneys to recovery. It is surely wrong to starve the patient while aiming only to rid him of his ailment. Of course, age, habits, constitution, and tissue-proclivity must be had regard to in all such cases.
The treatment of acute phases of dysentery by absolute milk diet I believe to be excellent; and I agree with those Indian authorities who forbid the least addition of animal broth or of farinaceous matters to it, possibly for many consecutive weeks.
In many cases of gout and gouty habit of body I often find inadequate diet prescribed, and a frail, painful condition of body as the result. In such cases, again, each person is to be studied as to his previous habits, inherited proclivities, and textural condition. The prohibition of meat and wine is often bad, and gouty manifestations will be held in check, not seldom, by a good diet and the use of some trustworthy wine. The tendency now is to make all gouty persons avoid meat, and drink whisky in routine fashion, or to take to water-drinking. The latter plan has its place, but many sufferers from gout, in both sexes, are better with some wine. If they starve themselves of what they formerly took, perhaps in moderation, and of what their progenitors took perhaps too freely, they will not so much have gout as gout will have them—as has been quaintly remarked. Such persons must attain their highest level of good health, and live above their gout, or they will never be free from-untoward symptoms, and will become miserable. Water-drinking at this stage of our social evolution is not, I feel very sure, the summum bonum for humanity.
The tendency to drink whisky, now so common, is not all due to medical prescription, as is often alleged. If good wines were readily procurable at fair prices, especially at hotels, more would be drunk. People resort to whisky because they know it is commonly to be depended on, whereas wine is dear and bad, and they seek at once to relieve their digestion and save their purses. They take far more alcohol, and lose the wholesomeness of the many other good things to be found in a moderate use of honest and sound wine. "Cheap claret" has done no good in England, but much harm, and intelligent persons now hardly know the difference between a vintage of the Médoc and the abominable stuffs that issue from Bordeaux, gathered from all other wine-growing countries, and called "claret." This has been well termed "red ink at a shilling, or, it may be, six shillings, a bottle." These compounds are disastrous to digestion, and it is small wonder that invalids and others resort to whisky. Real Médoc wine is never advertised for sale, but consumers have now ready means of knowing where to procure it.
The present agitations in favor of temperance, which should rather be termed efforts to abolish all alcoholic drinks, have, I believe, led members of our profession to neglect this important part of the subject of dietetics, and prevented their gaining an adequate knowledge of the nature and qualities of wine, a knowledge every physician should possess. Were this more commonly in possession, we should not hear such discrepant statements respecting wines dogmatically laid down by members of our profession.
Perhaps I should offer an apology for many of the remarks I have ventured to make in this communication, both because I have set down little that is new, and may also have appeared to uproot some well-grown opinions. I will only add, however, that I believe I have stated nothing that will not be found to be true and helpful in the daily practice of our art.—The Practitioner.
- Thus alcohol, which is by some denied to have any nutrient property whatever, will, with water, maintain life for days in some cases of acute illness, to the exclusion of any other articles of diet I consider alcoholized liquids as food, for both ordinary and clinical purposes