Dr. Dutt tlien read his paper A
FEW
PllACTtCAL HlNTS Native Sick
the
ON and
on
DIETING Invalid.
THE
OF
Medicinal therapeutics ami bactericidal serums have at present so engrossed the attention of our profession that food, as a potent remedy, has fallen very much in the background of scientific medicine. The rapid progress of
medicine in recent times has created specialism in every one Dietetics alone remain undeveloped of its departments. into specialism. It sadly wants those researches and investigations, which are lavished on other subjects. Among the living men of light and leading in the English profession, there appears no name in connection with the science of dietetics save and except that of Pavy. His thirty (.HO) years' researches have revolutionized some of the cardinal The glucoside scientific notions formerly entertained. origin of proteid matter throws a flood of light not only on the constitution of proteids but also on the operations concerned in digestion and several pathological processes. No longer the nitrogenous element takes precedence of all other constituents of food. Carbohydrates are of equal importance ; for both carbohydrates and the nitrogenous eleHis discovery harmoment are necessary to form a proteid. nizes the processes going on for the production of proteids in both the vegetable and animal kingdoms. Brilliant and of surpassing interest as has been this discovery, it has yet exerted no influence on practical dietetics. As far as the food of the healthy is concerned, there has been a marked progress atnoug the ISuglish at home aud abroad, coincident with increasing material prosperity ; but the fo -d and the feeding of the sick remains almost the same as it was 50 years ago. Whatever changes were made they were made more in consonance with prevailing pathological views than with the intrinsic qualities of foods. The subject of dietetic improvement for the sick has been in most cases left in the hands of wholesale dealers of food in England. Scientific training in culinary art is not so commonly observed in England as in France and Germany. If any progress has been made iu this respect in India, it has been made in connection with the diet of the European sick. Thus, you will see, that there is a disparity in English medicine between food and d> ug as remedies, which appears to conFood loses iu English stitute a serious flaw in its system. medicine its priority as a curative, which we observe in the ancient systems of medicine. When English medicine was transferred on a new soil, namely, on a race greatly altered by tropical residence and social changes, a race quite unlike the English in dietetic habits and wholly unaccustomed to stimulating drinks, it developed new characteristics and
SIpitsiiQtioiiH of Judical ^oqtctics. CALCUTTA MEDICAL SOCIETY. MEKTiNGof the Calcutta Medical Society held the 9th October 1895, Dr. Crombie in the
011
chair:?
u
$
11
Dr. Maynard read his paper on the Examination of Malarial Blood. at page 412.) congratulated Dr. Maynard for his excelLately lie (Or. Crombie) has not been examining1
(Printed
Dr. Crombie
lent paper. malarial blood very much, but the few cises in which he did, he did not find the organisms. lie mentioned a case of hepatic abscess, in which there was a ri*e of temoperation. As the patient perature. a few d:iys after the the question arose whether came from a malarious district, the fever was purely malarial or there was another abscess forming To determine the point he very cirefull examined the blood of the patient, but could not find any Large doses of quinine, however, malarial organisms. fever. He remarked that the diagspeedily checked the nosis of malarious fever by the microscope was not so easy as some have supposed.
unexpected eccentricities.
As far as tha part of it known as preventive medicine or Its sanitation is concerned, it achieved wouderrul success. success in surgery has been likewise remarkable, and mainly contributed to its reputation. la purely curative medicine for idiopathic diseases English medicine acted witu the swiftness and precision of criminal law, as a kabiraj friend expressed himself once to me. Its stimulating medicines steeped more or less in alcohol, and its stimulating soup aud brandy were sure either to kill or cure. Where it cured, it maintained its ground. It is in the large field of chronic cases that it has proved failure. Its repeated trials failed to dislodge the kabiraj who has still au almost undisputed field in these disorders. It appears that this failure has been the result of almost complete ignorance of the dietetic habits of patients aud an indifference aud disregard for the existing native systems If we maintain this attitude of indifference on of dietary. this important subject and reinaiu in hope of tUe advent a of day wheu the natives of ttiis country will ?idopt t uropeau habits of diet, we are pretty sure that day will never arrive; for. however gieat may be the dietetic changes iu India iu course of time, we firmly believe, from historical, climatic an i ec moinio considerations, chat the pe >ple of India will remain vegetarians iu the main. Exulted as the position of English medicine is now in India we, as its followers, will uot lose eitiier iu oelt respect or in public esteem, if we sedulously study our Hiudu systems and supply the long-felt want for our native patients and invalids. a
488
INDIAN MEDICAL GAZETTE.
It is with the desire to rouse an interest in the subject, and to call forth that liberalism in scientific vtew, which marked tne fathers of European melicine in India, that I have ventured to submit my scanty notes on the dieting of the native sick for your consideration. The subject has already received considerable attention in the framing of the diet scales for siok soldiers aud pauper-sick. In brief, milk aud sago or arrowroot forms the diet in acute cases ; rice with fish or vegetables or flour and dal for convalescents. A sufficiency of salt, condiments, oil or clarified butter is allowed. As to quantity, quality or the nutritive value of these diets there should be no question, as their regulation has been the outcome of much scientific research and experience. Their simplicity is a strong recommendation for adoption in hospitals and lai-ge institutions. But sufficient experience makes us familiar with their defects. The articles of food may be very good, but for want of proper cooking and variation they become less inviting to our patients and fail to secure such salutary results as we desire. Cooks in charge of the English sick receive some sort of practical education ; but for the native sick, ;iny man, however worthless and ignorant, may be considered fit to undertake the duties of a cook, provided his caste is not objected to by patients Native cooks in charge of hospitals are generally men untrained for their work and unfit for ordinary avocations and callings. As a rule, native food in hospitals is badly cooked or. in other words, spoiled. It is monotonous, as the cook has no knowledge of varying the food. It recognizes no differences in the dietetic habits of the various races coming under the designation of Neither does it respect the dietetic necessities of a native. particular classes of the sick. No proper supervision can be satisfactory, since most of the subordinate staff of our hospitals are unfamiliar with native foods or object to taste the hospital food. So surprising is the ignorance of the culinary art among our younsr men that, on the occasion of an experimental cooking for prisoners, I fouud my hospital assistant fail in cooking dal. Imperfectly cooked sago, rice, or dal, badly curried vegetable often escape observation. I speak from au experience of 23 years of hospital work in Bengal, and I am sure the experience of other officers here present will coincide with mine. Our hospital cooking and kitchen organization are in urjjer.t need of reform. Proper training of native cooks is esseutially necessary, and practical dietetics should form a subject of study to the medical students. pood and feeding form au essential part of therapeutics, and should receive as much attention as they have done in France and Germany. Apart from hospital dietetics, most of us here present being private practitioners, are chiefly concerned in the dieting of those patients who come from the middle and rich classes. Our knowledge of foods for the native has been so meagre, mainly for want of study, that we often unblushingly resort to the so-called patent foods?Mellins', Benger and Nestles'?and make our patients pay a hundred-fold for articles which are indigenous and cost a trifle in this
country.
Feeding in Indian fevers.?So familiar have we grown with milk and sago from our student days that we are almost involuntarily led to prescribe it in all cases. The only change that susgrests to us is that boiled milk should be used instead of raw milk which, in certain hospitals, for the sake of a paltry economy in fuel, is issued to patients just as it comes from the milk-man. Milk is one of the best foods. It suits the European fever-patient well, being lighter than his ordinary highly nitrogenized food. With a native patient, during the first week of acute fever, milk is rather heavy for him to digest. He lives on a light farinaceous food in health ; milk is to him a comparatively highly nitrogenized food. A pint of it. which we usually prescribe in fever cases a day, is equal to a couple of mutton chops in proteid value. In fevers, then, we feed our patients with an article of higher nutriIs it at all consistent with our tive value than in health scientific princip es ? Is it on the principle of feeding fevers ? If it is. it is a bad principle to follow, at any rate, in the case of our native patients. We are taught that in the febrile state, the blood becomes charged with the effete products of metabolism and the toxineof the malaria microbe or fever germ, with considerable retardation of the processes of elimination and derangements of the digestive system. There is likewise ex-
[Nov.
1895.
cessive waste of proteMs. but its replacement must slowly The first indication in these fevers follow elimination. is elimination by purgatives, diaphoretics, and diureties. This process is slow, even with our most active medicines. When medicinal treatment has once started this process, absorption is possible, but there is still considerable congestion or catarrh of the digestive organs which require food to be administered in a dilute and easily assimilable form. The saliva, the gastric and the intestinal juices are deficient, and the liver and other abdominal glands are more or less in a state of congestion, and these pathological changes require time for their removal aud subsidence. Undue haste and irrational interference therefore retard the recuperative powers of protoplasm and produce results just contrary to our
expectations.
Do
we not exhibit a tendency towards this undue interfer? We prescribe daily a seer of milk and ajcouple of ohittalts of sago and ply our patients with complex fevermixtures. every two or three hours. Our fever-mixtures often contain purgatives, diuretics, and diaphoretics. With such mixtures we attempt the impossible, for it is a rare occurrence to observe all the excretory organs opened out at once at our bidding ; when they do so, they indicate that protoplasmic forces have ceased to act within normal or s'iffl limits. I have already shown that milk is a heavy food for our native fever-patients during the first week or the acute stasre of fever. The watery part of the milk we give is absorbed, aud there remains in the stomach and intestine, a curdled mass of caseiu and sago, which slowly undergoes digestion or fermentative changes and serves as a favourable soil for the culture and growth of pathogenic germs. Thus, we add another source of contamination and may prolong or increase the febrile process. Indeed, I am inclined to believe that our undue interference is often the cause of driving our patients into the hands of the homoeopath or the kabiraj. Let us now see, whether we can replace milk and sago by more rational, more suitable and agreeable fool in fever cases Snjee is a substance which admits of various preparations. It is the best part A thin gruel of baked of flour and is easily assimilable sujee, acidulated with lemous. sweetened to taste, and cooled with ice. will tempt; the most obstinate among our patients. It is an excellent food for Punjabees and Hinlustanees. A thin soup of baked moong dal. salted and flavoured with lemons, is another agreeable food for this class of patients. Cooked shy am a dana (panicum frumentasium) with fresh honey and rose-water will airree with the most irritable of stomachs, such a* we meet among the rich nababs surfeited The prince of feverwith their pelows and curries. foods is hurley witn its tice/re per cent, of proteids. It comIt bines higrh nutritive quality with easy digestibility. seldom disagrees or irritates. It may be given with salt, or suear and lemons, and it is admissible to all classes of
ence
patients.
How agreeable are the slightly acid rice-water, the tamarind and lemon wheys to the poor thirsty fever-patients in the hot months. There is sufficient nutriment in them, and they admit at the same time of bein^ made the vehicles for the administration of medicines. After a saline purge, our fever-patients seldom require more than an alkali, as citrate of potash or c irbonate of soda, or a little bromide of potassium to relieve pains ; and these medicines cau be mixed up with the food without affecting its taste to any appreciable extent. Tamarind whey is considered almost an infallible fevercure by our Ooryah patients. It only ranks second to ricewater in their estimation. These acidulated wheys are also liked by the Bengalee cultivators.
Klioi
flour into
(fried paddy rice), mooree (fried rice), panfal (trapar bispinosa), and even sago aud arrowroot made gi'uel, are acceptable foods to Hindu widows and the
poor classes without admixture with milk. We have still to deal with the rich, highly neurotic native ladies who go in to hystrical fits on the occurrence of slight fever or on the administration of a bitter medicine. I treat them generally We can make with barley and sherbut, half aud half. sherbnts of lemon, orange, time-apple, pomegranate or Medicines are to be concealed iu slierbut, and grapes. among medicines aconite acts remarkably well in these cases.
Remittent and typhoid fevers offer us great difficulty in the adjustment of the kind, quality and quantity of the food required for individual cases. Each case has often to be dealt with according to its requirements. No hard-and-
Nov.
1895.]
DUTT ON THE DIETING OP THE NATIVE SICK AND INVALID.
fast rale can be applied to these cases. Neither the principle of feeding fevers nor that of starving fevers is quite applicable. The rational principle will be to adjust the food-supply in accordance with the waste taking place in the body ; but since it is difficult to ascertain the exact or even the approximate wastage, our prudent course will be to begin with food in small quantity, and watch how far it agrees with our patients. Considerable discernment and experience are needed, but by caution and the exercise of patience, we can generally guide our cases within lines of safety. The following rules may be laid down roughly for
guidance:?
food every 3 hours in measured quan-
(1) tity. (2)
To
more
frequent feeding.
give liquid
To add to the food or give separately pure water up to 2 or 3 pints a day. (3) To watch carefully for symptoms of indigestion, and to reduce or alter food in cases where it passes undigested through the intestines. (?1) Never to give food in a hard and solid fo-m, as the case under our treatment may prove to be a case of typhoid fever. I generally begin with barley with 3 or 4 gre. of common salt to a cupful; 4 oz of it may be given every 3 hours. The intervals should not be less than 3 hours unless in exceptional cases. In spite of great tolerance of the stomich, it needs physiological rest, which we should not disturb by If stronger or more nourishing food are required, milk diluted with an equal bulk of barley water or an alkalin water may be cautiously given. Milk is, in my opinion, contraindicated when the hiccup sets in or, severe diarrhoea and tympanitis exist. The action of milk is often uncertain In the European it often induces constipation, but in the native, it is often its effects. relaxing in Milk boiled with a few thin dried pieces of bael corrects this tendency to looseness. A little Maltin. g oz. to a pint, Milk diluted with boiled with milk, has also this effect. one-third its bulk of water agrees well, when a little infusion of coffee is added to it. Peptonized milk often disagrees with native patients. Its stale ami bitterish taste Milk aud sago or arrowroot we should causes nausea. avoid, as these mixtures are often more indigestible than pure aud diluted milk. Neither milk agrees when ordinary milk fails. Dilute fresh broths, of chicken, pigeon or kids or jugged soups, mixed with barley are excellent foods for native patients when milk disagrees. Soups have generally a relaxing effect on the European, but I find, they have just the reverse effect on the native. Whenever there is much diarrhoea or flatulence, I substitute 8oup3 and barley or thin strained arrowroot. This, I kuow, is against European experience, but I am bound to record what I find to be beneficial in my own practice. I should not, however, continue soups except for a short time, as they are merely stimulauts and not nutritive. At any rate, no nutriment has been found in them by scientific
inquiry. Soups
do not differ from quinol wines with regard to the extracted matter which gives rise to stimulation when taken internally. If not revolting to our feelinga quiuol wines would fulfil the indications for the use of soups. Indeed, they were largely used by kabirajes a few years ago for the purpose. Only freshly-made soups or broths should be used. Stale soups or the tinned essences of meat as Braud's and Liebig's should be avoided. They rapidly decompose aud give rise to ptomaine-poisoning in the tropics. We need not add another danger to the fever germ already working its way in the patient's system. When the stomach is in an irritable state or hiccup is incontrollable, a mixture of khoi mundo (pulp of fried paddyrice) honey and rosewater, properly cooked, is often beneficial in small quantities. So is cocoa-nut milk. During convalescence from fever.?The treatment of fever cases during convalescence is principally dietetic, aud those of us who know its details owe their success in practice almost entirely to it. The kabiraj is inimitable in the cautious use of food at
this stage. With the exception of typhoid fever all other Indian fevers admit of a considerable variety of food during convalescences.
439
For the Anglicised Indian or the .Uahome ian a little soft rice with chickeu stewed iu the native fashion for the morning meal, a cup of broth with barley at mid lay and a light meal of tliia sujee, chapatees or fermented loaf may be a safe begiuning. For Hiudustanees, sujce and milk or rice and moony dal made into a dish kuown as hickory, with a lighter evening meal of milk an.i barley may be safely recommended. The Ooryah is always difficult to treat in the matter of food. Ghura or the parched aud compressed rice, may be baked and served dry, or it may be reduced into a pulp and given with salt, or for the rich patients, the pulp may be mixed witn sugar aud milk. Khoi, or the fried piddy, may be similarly given. These foods are also very agreeable to Bengalees. A su ideu or an early return to a rice ration in the case of Ooryahs and Bengalees is always to be avoided, as it is often seriously objected to by the relatives of the patient. Convalescent foods for the Bengalee form a large group ; an i auy variety of lisjht aud savoury dishes are available, for a fever-patient'slife iu Bengal would be miserable iudeed on a ration of rice, but for the various supplemental foods which only the Bengalee woman knows how to prepare out of a few simple vegetables. Sae does not spice the food so richly as the 11a Irassee does ; and yet with a few simple conditneuts she can always produce an eudless variety of dishes of remarkably delicate fla/our and ta-te. S;ie knows that; nigii art in cooking, of combining bitter and pungent, sweat and sour, aud of imparting a relistt to food, whicli ? have never observed among o.ner nations duriug my varied
experience. Oo ikin^ is
a flue art in Bengal, and as long as it is cultivate I aud not replaced bv the acquisition of foreign tastes for fo'ids ot' rich oarseuess, we may safely reckon upon a valuable sto:k ot' invilid fo - is. Uudke the European who seeis rice of larreand coarse grain-*, the Bengalee prefers the fine-grained and sweet-smelling rice For convalescents. old rice ts aloue used, Tne "atop" or the unboiled variety should, in my opinion, replace the boiled variety. Tne latter is less nucrinious aud more liable to disagree, as I found from my experiments in ttie Rungpore Jail. L'he general impression among the people is. iiowever, unfavorable to my view, butt the fact of superior health maintained by Hindu widows, pundits and Hindusttauee3 who jiive on atop rice confirms my observations in this respect " Tne variety of old rice known as Daudkhanee is preferred for convalescents. It requires slow aud iong boiling on a gentle fire to be properly cooke 1. As considerable prejudice exists against early use of rice " duriug couvalceseuce," Khoi mondo previously described, should at first; be prescribe i or strained stew of moing ilal or a stew of one of the black fishes kuown as Koi soft heart, M'lgur or Singhee. These fislies have a reddish Tnis preliminary very nutritious aud easily digestible. " '* DaudKhauee rice, aud one of course may be followed by the black fishes described above, stewe 1 iu the native fashion or a mixture of vice and moony dal known as
'
"
light
hickory.
Various appetizers may be combined ; such "
as
Siichtis
plaiutains and similar green vegetables stewed with pulwal leaves ^Pulta) or Gandhali (Pocderea Fcetida). This dish (Suckta) may be variously combined and requires considerable experience for its preparation. It is slightly bitterish, buc it is very agreeable to all classes of Bengalees. Gandhali eujoys a great reputation as a cooling and appetizing adjunct. Boiled vegetables mixed with salt and mustard oil, known convalescent food. as bhurtas, are delicious adjuncts to They may be made of potatoes, bringal. green plantains, &c. Vegtftables fried in mustard oil or gliec (clarified butter) rightly enjoy their reputation as agreeable accessories. Puiwals and pulwal leaves are used chiefly in this way. Rice, khoi or chura and milk made up iu the form of a light Payesh for Hindus and Kirnec for Mohamedana will be agreeable eveuiug meals. Acid stew known as Amhal" of the various preparations of yreen mango, such as Amehur, Amshutta, of Amra, of green papaya and plantains with old tamarind, are cnarming appetizers aud adjuncts. They are much appreciated by vegetarians. These vegetable acids add to tne blood, their combinations with the alkalies, so necessary for vegema
le up of
?'
tarians.
"
puiwals,
green
"
"
In almost all meals there is
one
or more
of these
440
INDIAN MEDICAL GAZETTE.
acid preparat ons in food for the healthy. These are of the foods p-ocurab e for convalesoents from fever.
a
lew
Dieting in bowel complaints Proper regulation of food is of far greater imp >rtance in diseases of the alimentary These diseases offer a system than in fever in India. larire field is for practice which is almost a monopoly of the kabiraj The homoeopath has of late successfully entered this field. As for ourselves, regular practitioners of medicine, we are making a very tardy progress indeed, and the reason is not far to seek In no class of disorders is there such a wide divergence We hold that physiobetween our principles ano practice. logical rest is of the utmost importance in injuries of the stomach or the intestines and withhold food in all such cases for 48 or 72 hours, giving sips of hot water to allay thirst or in extreme cases of depressed small hectal unemata of half-digested food. In acute idiopathic affections of these organs, on the other hand, we follow almost blindly the practice adopted in antiquated times, when most of these disorders were supposed to be the expression of general or constitutional In the treatment of these disorders we have not aiiments. moved with the times. We begin with milk and sago, and on the appearance of slight depression wind up with soups and brandy. It is a common thing to observe a case of acute dysentery receiving his pint of milk and a cupful of sago three hours after his dose of 20 grains of ipecacuanha. The observant kabiraj or the homoeopath gives scarcely His medicines may be very indifferaway substantial food. ent, but his practical adoption of a great principle gives him due pre-eminence and success. Patient watchfulness and not active interference should be our rule of practice in these cases. In acute gastric or gastro-duo lenal catarrh or inflammation, our main reliance after a mercurial or saline purgative, should be au complete abstention from food. Beyond sips of barley water with common salt or, much better, cocoanut milk, food should be interdicted for two or even three days This is g-enerally enough for a cure. If there are pains, hot fomentation would be much preferable to strong doses of opium. But I need not go over the treatment of the disease. In cases of acute diarrhoea, the same principle of rigid abstention from food is necessary, but here greater watchfulness is required, for undue depression is to be avoided. Lemon whey or sulphuric whey is t< e best form of food in profuse fluxes, and in the inflammatory forms attended with the discharge of much mucus, whey with alkalies, specially magnesia and bismuth is invaluable. Medical treatment is called for from the beginning ; but it should be different from the active use of astringeuts and large doses of opium, small doses of castor oil, perchloride of mercury salol, belladonna, camphor and opium are required both for purposes of evacuating the bowels and of disinfecting the
surface. hi cholera, the administration of irritating stimulants and drinks has. in my opinion, justly brought our system into opprobrium with the people of our country. The regular practitioners are shunned by them ; and the homoeopath flourishes in this field of practice where we should have secured a firm hold. By the frequent administration of his drops of thousand mucous
the homoeopath does not disturb the physiological His harmless intervention is the of the intestines. cause of his success, and teaches us a lesson of non-interference in this foimidable disease.
dilutions,
rest
Small doses of calomel and drop-doses of a saturated solution of camphor in chloroform, which I found gave the best results in the great epidemic of cholera at Coutai in the Midnapore District in 1874, havebeeu found to yield similar
results in the last cholera epidemic at Hamburgh. Treatment based on such a rationale will likely succeed. Sips of iced water or coffee. and not pints of fluid recklessly poured into the stomach, can be borne during collapse. If the blood wants saline water it can be supplied only in one way. viz.. by hvpo dermic injection of saline water and not by filling the intestines with iced water, which does not undergo absorptiou from its mucous surface.
When reaction sets in in cholem, nothing is so agreeable and beneficial to the patient as freshly prepared lemon whey,
[Nov.
1895.
in small quantities and mixed with a few grains of cit'ate of eaffciu ; the latter to stimulate the heart and promote enureses by relieving congestion of the kidneys. Whey contains sufficient nutriment and lactose to be useful at this stage of t> e disease. To ply the patient with frequent draughts of brandied broth or milk is pure quackery and is against the dictates of physiological science.
given
There is
no
disease where
abstention from food
is so
salutary in its effects as in the first stage of acute dysentry. Nothing but barley water should be given in small quantities with common suit and a few drops of Ptychotes water to relieve thirst duriug the first 48 or 72 hours. Milk and soups are to be avoided Ipecacuanha is our only remedy in hospital patients, soldiers or prisoners compulsion can be used, the medicine larly successful. Mix. as we may,
this disease ; as far as are concerned or where in large doses is singueither with opium or
chloral hydrate, Ipecacuanha generally produces persistent and often vomiting. This is a great draw-back
nausea
its
employment in^private patients. The active principle ipecacuauha is still uncertain, but recent pharmacological experiments indicate that emetin is its medicinal principle, and tabloids containing emetin in small doses deserve a trial among our native patients. to
of
The success attending: other kinds of treatment shows that the disease may be treated in several ways. A brisk purge, jvercubials or salines or a hydragogue vegetable puige followed by small doses of castor oil emulsion with opium or hemp and perchloride of mercury, gives as good results as ipecacuanha in the sub-acite forms in which the disease often appears in natives. But the first condition for success is total ab^teution from food.
The most intractable diseases
we have to treat in India the chronic forms of dyspepsia and bowel complaints. Judicious dieting is here of paramount importance. The glandular and motor functions of the stomach and the intestines are seriously impaired and the power of digestion We cannot by heroio becomes greatly deteriorated. feeding and drinking counteract the great emaciation and piostratiou which are the inevitable consequences of im. are
paired digestion.
The administration r-f strong soups and alcoholic stimucases, simply irritates accelerates death by inanition. This, I think, is the main cause of our failure in the treatment of these cases. The kabiraj scores the His method is to highest success by careful feeding. cautiously feed the patient with a un-stimulating and a fairly nutritious food. One great dietetic principle he teaches us is the administration of food in a state of pulp or in a pure solid state, and not in a liquid form, and the restriction of water or liquid of any sort duriug the meals. Beyond the emperical knowledge that such foods do goon, the kabiraj cannot give satisfactory reasons for his method. But a slight physiological consideration will indicate to us that his method is a practical illustration of a scientific principle. Food in a pulpy state and in a state of minute division, calls forth both the glandular and motor functions of the stomach and intestines, and does not dilute the already weakened digestive secretions. Its state of fine division renders it also easily assimilable,
lants, which we often adopt in these the already impaired digestion and
And now a few words as to their management. In chronic gastritis or a dyspepsia with foetid eructations and flatulence appearing a couple of hours after a meal and showing deficient secretion of gastric juice, the indications for treatment are well known to all of us, viz. the clearance of the excessive mucus from the stomach, and the reduction of food both in quantity and quality to suit the digestive capacity of our patients. The first indication is met by a dose of Carlsbad or a mild saline aperient, and the second by administering measured quantities of food, such as old rice pulp strained, about 4 oz., with half its quantity of moong dal pulp flavoured by lemonjuice and partially digested by a few drops of papaya juice. When we find this food disagree, we may further attenuate it without diminishing its nutritive aliments. Pulp of rice or khoi mixed with dahi or buttermilk is an ideal food for this disorder. In another class of dyspepsia where excessive acidity i due to fermentative changes or excessive secretion of gastrij juice, the addition of one of the black fishes, previously
Nov.
1895.]
SOUTH INDIAN
BRANCH,
BRITISH MEDICAL ASSOCIATION.
mentioned, or the flesh of goat, well stewed, to ohl rice, for the midday meal, and the administration of lighter foods at intervals of 4 hours will relieve the symptoms. No liquid should be drunk during the meals, but somecccoanut milk should be given an hour or so after the midday meal. Here the indications are to neutralize its abnormal acid secretions of the stomach, and these are met by frequent administration of food, specially rich in proteid aliment. Chronic diarrhoea and dysentery affords greater chances of recovery by dietetic than by medicinal means. Careful observation is necessary to find out the digestive capacity of patients by beginning food in small quantity or by following the method already stated under dyspepsia. Milk with farinaceous food is badly borne by these patients. Pure milk mixed with one-fourth of its bulk of lime water or fluid magnesia given in small quantities, sometimes agrees ; but, as a rule, cow's milk is too rich for the impaired digestive power of our patients. Goat's milk, fresh and undiluted, often agrees in small quantities, but as their milk has a tendency to form large clots, it will be advisable to mix it with one-fourth its bulk of boiled shamadama. In the majority of these cases, milk does not agree, and it will be necessary to try other combinations of food. Old rice pulp with one of the black fishes with dalii, or a mango preparation as Amchur or Amsutto as an adjunct, will be found very useful. Where rice disagrees, fried chura or lthoi pulp with dahi may be tried. The cooked pulp of green plaintains mixed with dalii succeeds where other forms of food fail. A little green papaya cooked with Amada (Curcuma amada) and old tamarind is a serviceable adjunct. Food should not be given more than two or three times a day. When a third meal is given it should consist of a little barley or arrowroot. Betelnut should be prohibited, as the pieces of woody matter may irritate therulcerated mucous membrane. Where the patient cannot be prevented from hi3 habitual pan, the betelnut should be ground to a powder and given with the usual ingredients of pan. Pan is a digestive stimulant, antacid and astringent, and is therefore admirably suited as an adjunct after vegetable meals. The pepper leaf is a carminative and dialagogue, lime is antacid and catechu is astringent, and betelnut is not only a vermifuge, but from its containing the alkaloid anecaline it acts as a stimulant to the nervous system. Potatoes and cereals (dais) disagree in these chronic bowel complaints. Green plantains, country figs, (Colocasia Indica), pulwals and briugals are valuable in these
diseases. In diseases of the kidney, milk is almost a cure, and we have already borrowed this milk treatment from the kabiraj without acknowledging our debt.
I fear I have already tired you with an imperfect sketch of the subject of my address and must therefore stop. I .only wish the claims of the poor native malt will not escape your attention in these days of revolutionary changes in medicine. Dr. Simpson said that the above subject is very much There is ouly one journal in everywhere. America which is devoted to this subject, viz., '? The DieteHe thought that practical tic and Hygienic Gazette.'' dietetics should form a part of the curriculum of studies The most successful physicians of the medical student. A waut were those who paid particular attention to diets. of knowledge of the proper diet did a good deal of harm.
neglected
Dr. B. C. Sen said that the injudicious administration of food does greater harm than starvation. He hoped that there should be investigators on this subject. Dr. PILGRIM thought that the kabirajes and hakims go much the other way, viz., they starve the patient. The high mortality of children was, according to him, due to star-
vation.
Dr. Maynard said that he made some experiments with had great digestive powers 011 know in which diseases it ie
papain, and found that it proteids. He wanted to efficacious.
Dr. Crombie wanted to know why natives of Beiifal so much to the use of rice in fever. Dr. D. D. Roy said that rice is quite innocent in fevers and the objection is groundless, and people blindly follow long established custom.
object
Dr. Dutt briefly replied.
441
PROCEEDINGS OF A SPECIAL MEETING OF THE SOUTH INDIAN BRANCH OF THE BRITISH MEDICAL ASSOCIATION HELD IN THE CENTRAL MUSEUM, ON FRIDAY, 20TH SEPTEMBER, AT 5-30 p.m. Surgn.-Maj.-Genl. SIBTHORPE, f.r.c.im., m.r.i.a., President, in the Chair. The Miuutes of the last Meeting were read and confirmed. By request of the President, the Honorary Secretary explained the circumstances which necessitated the present Special Meeting of the Branch. It appeared that at a meeting of the Branch Council, held on 9th September, the resolution on Sanitary Administration in India passed by the
Public Health Section of the British Medical Association at its Annual Meeting in Loudon in August last, was under consideration. It appeared to the Council that that liesolution was based on a mass of misleading statements made by the Editor of our Journal in his speech as President of the Section, and that it wcs the clear duty of the profession in India to take some steps both to clear up their own reputation from the slanderous accusations of Mr. Hart, and to enlighten their brethren at home as to the true state of affairs in this country in sanitary matters. It was accordingly resolved that a small committee should be appointed to draw up a formal protest to be laid befox-e a Special Meeting of the Branch, and, if adopted, to be forwarded to our Representative on the Council of the Association. The following gent'emen constituted the Special Committee : ?
Surgeou-Major-General C. Sibtliorpe, F.R.C p.i. Surgeon-Lieucenant-Colonel Bran foot, Ji.B, (Lond.) Surgeon-Major John Maitlaud, jj.d., (Edin.) Surgeon-Major John Smyth, M.D. (R.u.I.) Secretary.
This Committee had
completed their task, and the to give expression of opinion not only on the protest which would be laid before it for consideration, but on the general question of the misrepresentation of our Editor, the hurried Resolution of the Section of Public Health, and the Sanitary Adminispresent Special Meeting
now
was
convened
tration of India, particularly of our own Presidency at the present moment. Aft^r this Surgeon-Lieutenant-Colonel explanation, Bran foot moved the following resolution : He said that as the members were now fully aware of the circumstances under which this meeting had been called, he would not occupy unnecessary time, but would at once read the resolution proposed to be sent to England :? Resolved that the accompanying protest be forwarded with a letter from the Secretary of the Branch to the Representative of the Branch in England, with a request that he will be good enough to lay the matter before the Couucil on the first opportunity, with a view to that body taking such steps as may prevent the Editor of the Journal from defaming, either from the platform or through the medium of the Journal, a large body of the profession in India, many of whom are members of the Association, ?
PROTEST. The Members of the South Indian Branch of the British have read with much surprise the Association Medical resolution which was passed in the Section of Public Medicine at the Annual Meeting of the Association lately held in Loudon, and founded on the address delivered by the Editor of the British Medical Journal. They wish to point out that the whole of that address so far as it refers to the civil portion of the Indian Medical Service is full of inaccuracies and unjust statements calculated to reflect discredit in a most unwarrantable mauner upon a large body of the profession in India. They feel certain that, had the members present at that meeting been in possession of the truth facts regarding Sanitary progress in India, and the work done during the past 30 years in India, in both the Civil and Military Departments, they would not have been induced to accept all Mr. Hart's statements and to pass such an ungenerous resolution which reflects adversely on them and on the Government they have the honour to serve, 'lhey trust that the Council will see fit to give the same publicity to this protest as they have given to the Editor's erroneous and defamatory statements.
Surgeon-Lieutenant-Colonel Sturmer said he had great pleasure in seconding the resolution.
442
INDIAN MEDICAL GAZETTE.
In support of the resolution before the Meeting'. SurgeonLieutenant-Colonel W. G. King spoke a5! follows:?? Mr. President,? Mr Hart's recent visit to this country is
-
still fresh in the memory of the members of this Branch We received that gentleman with the courtesy due to his position as Editor of the organ of our Association, and an active and useful member of its Parliamentary Committee, and with the hospitality for which Anglo-In
FEW
PllACTtCAL HlNTS Native Sick
the
ON and
on
DIETING Invalid.
THE
OF
Medicinal therapeutics ami bactericidal serums have at present so engrossed the attention of our profession that food, as a potent remedy, has fallen very much in the background of scientific medicine. The rapid progress of
medicine in recent times has created specialism in every one Dietetics alone remain undeveloped of its departments. into specialism. It sadly wants those researches and investigations, which are lavished on other subjects. Among the living men of light and leading in the English profession, there appears no name in connection with the science of dietetics save and except that of Pavy. His thirty (.HO) years' researches have revolutionized some of the cardinal The glucoside scientific notions formerly entertained. origin of proteid matter throws a flood of light not only on the constitution of proteids but also on the operations concerned in digestion and several pathological processes. No longer the nitrogenous element takes precedence of all other constituents of food. Carbohydrates are of equal importance ; for both carbohydrates and the nitrogenous eleHis discovery harmoment are necessary to form a proteid. nizes the processes going on for the production of proteids in both the vegetable and animal kingdoms. Brilliant and of surpassing interest as has been this discovery, it has yet exerted no influence on practical dietetics. As far as the food of the healthy is concerned, there has been a marked progress atnoug the ISuglish at home aud abroad, coincident with increasing material prosperity ; but the fo -d and the feeding of the sick remains almost the same as it was 50 years ago. Whatever changes were made they were made more in consonance with prevailing pathological views than with the intrinsic qualities of foods. The subject of dietetic improvement for the sick has been in most cases left in the hands of wholesale dealers of food in England. Scientific training in culinary art is not so commonly observed in England as in France and Germany. If any progress has been made iu this respect in India, it has been made in connection with the diet of the European sick. Thus, you will see, that there is a disparity in English medicine between food and d> ug as remedies, which appears to conFood loses iu English stitute a serious flaw in its system. medicine its priority as a curative, which we observe in the ancient systems of medicine. When English medicine was transferred on a new soil, namely, on a race greatly altered by tropical residence and social changes, a race quite unlike the English in dietetic habits and wholly unaccustomed to stimulating drinks, it developed new characteristics and
SIpitsiiQtioiiH of Judical ^oqtctics. CALCUTTA MEDICAL SOCIETY. MEKTiNGof the Calcutta Medical Society held the 9th October 1895, Dr. Crombie in the
011
chair:?
u
$
11
Dr. Maynard read his paper on the Examination of Malarial Blood. at page 412.) congratulated Dr. Maynard for his excelLately lie (Or. Crombie) has not been examining1
(Printed
Dr. Crombie
lent paper. malarial blood very much, but the few cises in which he did, he did not find the organisms. lie mentioned a case of hepatic abscess, in which there was a ri*e of temoperation. As the patient perature. a few d:iys after the the question arose whether came from a malarious district, the fever was purely malarial or there was another abscess forming To determine the point he very cirefull examined the blood of the patient, but could not find any Large doses of quinine, however, malarial organisms. fever. He remarked that the diagspeedily checked the nosis of malarious fever by the microscope was not so easy as some have supposed.
unexpected eccentricities.
As far as tha part of it known as preventive medicine or Its sanitation is concerned, it achieved wouderrul success. success in surgery has been likewise remarkable, and mainly contributed to its reputation. la purely curative medicine for idiopathic diseases English medicine acted witu the swiftness and precision of criminal law, as a kabiraj friend expressed himself once to me. Its stimulating medicines steeped more or less in alcohol, and its stimulating soup aud brandy were sure either to kill or cure. Where it cured, it maintained its ground. It is in the large field of chronic cases that it has proved failure. Its repeated trials failed to dislodge the kabiraj who has still au almost undisputed field in these disorders. It appears that this failure has been the result of almost complete ignorance of the dietetic habits of patients aud an indifference aud disregard for the existing native systems If we maintain this attitude of indifference on of dietary. this important subject and reinaiu in hope of tUe advent a of day wheu the natives of ttiis country will ?idopt t uropeau habits of diet, we are pretty sure that day will never arrive; for. however gieat may be the dietetic changes iu India iu course of time, we firmly believe, from historical, climatic an i ec moinio considerations, chat the pe >ple of India will remain vegetarians iu the main. Exulted as the position of English medicine is now in India we, as its followers, will uot lose eitiier iu oelt respect or in public esteem, if we sedulously study our Hiudu systems and supply the long-felt want for our native patients and invalids. a
488
INDIAN MEDICAL GAZETTE.
It is with the desire to rouse an interest in the subject, and to call forth that liberalism in scientific vtew, which marked tne fathers of European melicine in India, that I have ventured to submit my scanty notes on the dieting of the native sick for your consideration. The subject has already received considerable attention in the framing of the diet scales for siok soldiers aud pauper-sick. In brief, milk aud sago or arrowroot forms the diet in acute cases ; rice with fish or vegetables or flour and dal for convalescents. A sufficiency of salt, condiments, oil or clarified butter is allowed. As to quantity, quality or the nutritive value of these diets there should be no question, as their regulation has been the outcome of much scientific research and experience. Their simplicity is a strong recommendation for adoption in hospitals and lai-ge institutions. But sufficient experience makes us familiar with their defects. The articles of food may be very good, but for want of proper cooking and variation they become less inviting to our patients and fail to secure such salutary results as we desire. Cooks in charge of the English sick receive some sort of practical education ; but for the native sick, ;iny man, however worthless and ignorant, may be considered fit to undertake the duties of a cook, provided his caste is not objected to by patients Native cooks in charge of hospitals are generally men untrained for their work and unfit for ordinary avocations and callings. As a rule, native food in hospitals is badly cooked or. in other words, spoiled. It is monotonous, as the cook has no knowledge of varying the food. It recognizes no differences in the dietetic habits of the various races coming under the designation of Neither does it respect the dietetic necessities of a native. particular classes of the sick. No proper supervision can be satisfactory, since most of the subordinate staff of our hospitals are unfamiliar with native foods or object to taste the hospital food. So surprising is the ignorance of the culinary art among our younsr men that, on the occasion of an experimental cooking for prisoners, I fouud my hospital assistant fail in cooking dal. Imperfectly cooked sago, rice, or dal, badly curried vegetable often escape observation. I speak from au experience of 23 years of hospital work in Bengal, and I am sure the experience of other officers here present will coincide with mine. Our hospital cooking and kitchen organization are in urjjer.t need of reform. Proper training of native cooks is esseutially necessary, and practical dietetics should form a subject of study to the medical students. pood and feeding form au essential part of therapeutics, and should receive as much attention as they have done in France and Germany. Apart from hospital dietetics, most of us here present being private practitioners, are chiefly concerned in the dieting of those patients who come from the middle and rich classes. Our knowledge of foods for the native has been so meagre, mainly for want of study, that we often unblushingly resort to the so-called patent foods?Mellins', Benger and Nestles'?and make our patients pay a hundred-fold for articles which are indigenous and cost a trifle in this
country.
Feeding in Indian fevers.?So familiar have we grown with milk and sago from our student days that we are almost involuntarily led to prescribe it in all cases. The only change that susgrests to us is that boiled milk should be used instead of raw milk which, in certain hospitals, for the sake of a paltry economy in fuel, is issued to patients just as it comes from the milk-man. Milk is one of the best foods. It suits the European fever-patient well, being lighter than his ordinary highly nitrogenized food. With a native patient, during the first week of acute fever, milk is rather heavy for him to digest. He lives on a light farinaceous food in health ; milk is to him a comparatively highly nitrogenized food. A pint of it. which we usually prescribe in fever cases a day, is equal to a couple of mutton chops in proteid value. In fevers, then, we feed our patients with an article of higher nutriIs it at all consistent with our tive value than in health scientific princip es ? Is it on the principle of feeding fevers ? If it is. it is a bad principle to follow, at any rate, in the case of our native patients. We are taught that in the febrile state, the blood becomes charged with the effete products of metabolism and the toxineof the malaria microbe or fever germ, with considerable retardation of the processes of elimination and derangements of the digestive system. There is likewise ex-
[Nov.
1895.
cessive waste of proteMs. but its replacement must slowly The first indication in these fevers follow elimination. is elimination by purgatives, diaphoretics, and diureties. This process is slow, even with our most active medicines. When medicinal treatment has once started this process, absorption is possible, but there is still considerable congestion or catarrh of the digestive organs which require food to be administered in a dilute and easily assimilable form. The saliva, the gastric and the intestinal juices are deficient, and the liver and other abdominal glands are more or less in a state of congestion, and these pathological changes require time for their removal aud subsidence. Undue haste and irrational interference therefore retard the recuperative powers of protoplasm and produce results just contrary to our
expectations.
Do
we not exhibit a tendency towards this undue interfer? We prescribe daily a seer of milk and ajcouple of ohittalts of sago and ply our patients with complex fevermixtures. every two or three hours. Our fever-mixtures often contain purgatives, diuretics, and diaphoretics. With such mixtures we attempt the impossible, for it is a rare occurrence to observe all the excretory organs opened out at once at our bidding ; when they do so, they indicate that protoplasmic forces have ceased to act within normal or s'iffl limits. I have already shown that milk is a heavy food for our native fever-patients during the first week or the acute stasre of fever. The watery part of the milk we give is absorbed, aud there remains in the stomach and intestine, a curdled mass of caseiu and sago, which slowly undergoes digestion or fermentative changes and serves as a favourable soil for the culture and growth of pathogenic germs. Thus, we add another source of contamination and may prolong or increase the febrile process. Indeed, I am inclined to believe that our undue interference is often the cause of driving our patients into the hands of the homoeopath or the kabiraj. Let us now see, whether we can replace milk and sago by more rational, more suitable and agreeable fool in fever cases Snjee is a substance which admits of various preparations. It is the best part A thin gruel of baked of flour and is easily assimilable sujee, acidulated with lemous. sweetened to taste, and cooled with ice. will tempt; the most obstinate among our patients. It is an excellent food for Punjabees and Hinlustanees. A thin soup of baked moong dal. salted and flavoured with lemons, is another agreeable food for this class of patients. Cooked shy am a dana (panicum frumentasium) with fresh honey and rose-water will airree with the most irritable of stomachs, such a* we meet among the rich nababs surfeited The prince of feverwith their pelows and curries. foods is hurley witn its tice/re per cent, of proteids. It comIt bines higrh nutritive quality with easy digestibility. seldom disagrees or irritates. It may be given with salt, or suear and lemons, and it is admissible to all classes of
ence
patients.
How agreeable are the slightly acid rice-water, the tamarind and lemon wheys to the poor thirsty fever-patients in the hot months. There is sufficient nutriment in them, and they admit at the same time of bein^ made the vehicles for the administration of medicines. After a saline purge, our fever-patients seldom require more than an alkali, as citrate of potash or c irbonate of soda, or a little bromide of potassium to relieve pains ; and these medicines cau be mixed up with the food without affecting its taste to any appreciable extent. Tamarind whey is considered almost an infallible fevercure by our Ooryah patients. It only ranks second to ricewater in their estimation. These acidulated wheys are also liked by the Bengalee cultivators.
Klioi
flour into
(fried paddy rice), mooree (fried rice), panfal (trapar bispinosa), and even sago aud arrowroot made gi'uel, are acceptable foods to Hindu widows and the
poor classes without admixture with milk. We have still to deal with the rich, highly neurotic native ladies who go in to hystrical fits on the occurrence of slight fever or on the administration of a bitter medicine. I treat them generally We can make with barley and sherbut, half aud half. sherbnts of lemon, orange, time-apple, pomegranate or Medicines are to be concealed iu slierbut, and grapes. among medicines aconite acts remarkably well in these cases.
Remittent and typhoid fevers offer us great difficulty in the adjustment of the kind, quality and quantity of the food required for individual cases. Each case has often to be dealt with according to its requirements. No hard-and-
Nov.
1895.]
DUTT ON THE DIETING OP THE NATIVE SICK AND INVALID.
fast rale can be applied to these cases. Neither the principle of feeding fevers nor that of starving fevers is quite applicable. The rational principle will be to adjust the food-supply in accordance with the waste taking place in the body ; but since it is difficult to ascertain the exact or even the approximate wastage, our prudent course will be to begin with food in small quantity, and watch how far it agrees with our patients. Considerable discernment and experience are needed, but by caution and the exercise of patience, we can generally guide our cases within lines of safety. The following rules may be laid down roughly for
guidance:?
food every 3 hours in measured quan-
(1) tity. (2)
To
more
frequent feeding.
give liquid
To add to the food or give separately pure water up to 2 or 3 pints a day. (3) To watch carefully for symptoms of indigestion, and to reduce or alter food in cases where it passes undigested through the intestines. (?1) Never to give food in a hard and solid fo-m, as the case under our treatment may prove to be a case of typhoid fever. I generally begin with barley with 3 or 4 gre. of common salt to a cupful; 4 oz of it may be given every 3 hours. The intervals should not be less than 3 hours unless in exceptional cases. In spite of great tolerance of the stomich, it needs physiological rest, which we should not disturb by If stronger or more nourishing food are required, milk diluted with an equal bulk of barley water or an alkalin water may be cautiously given. Milk is, in my opinion, contraindicated when the hiccup sets in or, severe diarrhoea and tympanitis exist. The action of milk is often uncertain In the European it often induces constipation, but in the native, it is often its effects. relaxing in Milk boiled with a few thin dried pieces of bael corrects this tendency to looseness. A little Maltin. g oz. to a pint, Milk diluted with boiled with milk, has also this effect. one-third its bulk of water agrees well, when a little infusion of coffee is added to it. Peptonized milk often disagrees with native patients. Its stale ami bitterish taste Milk aud sago or arrowroot we should causes nausea. avoid, as these mixtures are often more indigestible than pure aud diluted milk. Neither milk agrees when ordinary milk fails. Dilute fresh broths, of chicken, pigeon or kids or jugged soups, mixed with barley are excellent foods for native patients when milk disagrees. Soups have generally a relaxing effect on the European, but I find, they have just the reverse effect on the native. Whenever there is much diarrhoea or flatulence, I substitute 8oup3 and barley or thin strained arrowroot. This, I kuow, is against European experience, but I am bound to record what I find to be beneficial in my own practice. I should not, however, continue soups except for a short time, as they are merely stimulauts and not nutritive. At any rate, no nutriment has been found in them by scientific
inquiry. Soups
do not differ from quinol wines with regard to the extracted matter which gives rise to stimulation when taken internally. If not revolting to our feelinga quiuol wines would fulfil the indications for the use of soups. Indeed, they were largely used by kabirajes a few years ago for the purpose. Only freshly-made soups or broths should be used. Stale soups or the tinned essences of meat as Braud's and Liebig's should be avoided. They rapidly decompose aud give rise to ptomaine-poisoning in the tropics. We need not add another danger to the fever germ already working its way in the patient's system. When the stomach is in an irritable state or hiccup is incontrollable, a mixture of khoi mundo (pulp of fried paddyrice) honey and rosewater, properly cooked, is often beneficial in small quantities. So is cocoa-nut milk. During convalescence from fever.?The treatment of fever cases during convalescence is principally dietetic, aud those of us who know its details owe their success in practice almost entirely to it. The kabiraj is inimitable in the cautious use of food at
this stage. With the exception of typhoid fever all other Indian fevers admit of a considerable variety of food during convalescences.
439
For the Anglicised Indian or the .Uahome ian a little soft rice with chickeu stewed iu the native fashion for the morning meal, a cup of broth with barley at mid lay and a light meal of tliia sujee, chapatees or fermented loaf may be a safe begiuning. For Hiudustanees, sujce and milk or rice and moony dal made into a dish kuown as hickory, with a lighter evening meal of milk an.i barley may be safely recommended. The Ooryah is always difficult to treat in the matter of food. Ghura or the parched aud compressed rice, may be baked and served dry, or it may be reduced into a pulp and given with salt, or for the rich patients, the pulp may be mixed witn sugar aud milk. Khoi, or the fried piddy, may be similarly given. These foods are also very agreeable to Bengalees. A su ideu or an early return to a rice ration in the case of Ooryahs and Bengalees is always to be avoided, as it is often seriously objected to by the relatives of the patient. Convalescent foods for the Bengalee form a large group ; an i auy variety of lisjht aud savoury dishes are available, for a fever-patient'slife iu Bengal would be miserable iudeed on a ration of rice, but for the various supplemental foods which only the Bengalee woman knows how to prepare out of a few simple vegetables. Sae does not spice the food so richly as the 11a Irassee does ; and yet with a few simple conditneuts she can always produce an eudless variety of dishes of remarkably delicate fla/our and ta-te. S;ie knows that; nigii art in cooking, of combining bitter and pungent, sweat and sour, aud of imparting a relistt to food, whicli ? have never observed among o.ner nations duriug my varied
experience. Oo ikin^ is
a flue art in Bengal, and as long as it is cultivate I aud not replaced bv the acquisition of foreign tastes for fo'ids ot' rich oarseuess, we may safely reckon upon a valuable sto:k ot' invilid fo - is. Uudke the European who seeis rice of larreand coarse grain-*, the Bengalee prefers the fine-grained and sweet-smelling rice For convalescents. old rice ts aloue used, Tne "atop" or the unboiled variety should, in my opinion, replace the boiled variety. Tne latter is less nucrinious aud more liable to disagree, as I found from my experiments in ttie Rungpore Jail. L'he general impression among the people is. iiowever, unfavorable to my view, butt the fact of superior health maintained by Hindu widows, pundits and Hindusttauee3 who jiive on atop rice confirms my observations in this respect " Tne variety of old rice known as Daudkhanee is preferred for convalescents. It requires slow aud iong boiling on a gentle fire to be properly cooke 1. As considerable prejudice exists against early use of rice " duriug couvalceseuce," Khoi mondo previously described, should at first; be prescribe i or strained stew of moing ilal or a stew of one of the black fishes kuown as Koi soft heart, M'lgur or Singhee. These fislies have a reddish Tnis preliminary very nutritious aud easily digestible. " '* DaudKhauee rice, aud one of course may be followed by the black fishes described above, stewe 1 iu the native fashion or a mixture of vice and moony dal known as
'
"
light
hickory.
Various appetizers may be combined ; such "
as
Siichtis
plaiutains and similar green vegetables stewed with pulwal leaves ^Pulta) or Gandhali (Pocderea Fcetida). This dish (Suckta) may be variously combined and requires considerable experience for its preparation. It is slightly bitterish, buc it is very agreeable to all classes of Bengalees. Gandhali eujoys a great reputation as a cooling and appetizing adjunct. Boiled vegetables mixed with salt and mustard oil, known convalescent food. as bhurtas, are delicious adjuncts to They may be made of potatoes, bringal. green plantains, &c. Vegtftables fried in mustard oil or gliec (clarified butter) rightly enjoy their reputation as agreeable accessories. Puiwals and pulwal leaves are used chiefly in this way. Rice, khoi or chura and milk made up iu the form of a light Payesh for Hindus and Kirnec for Mohamedana will be agreeable eveuiug meals. Acid stew known as Amhal" of the various preparations of yreen mango, such as Amehur, Amshutta, of Amra, of green papaya and plantains with old tamarind, are cnarming appetizers aud adjuncts. They are much appreciated by vegetarians. These vegetable acids add to tne blood, their combinations with the alkalies, so necessary for vegema
le up of
?'
tarians.
"
puiwals,
green
"
"
In almost all meals there is
one
or more
of these
440
INDIAN MEDICAL GAZETTE.
acid preparat ons in food for the healthy. These are of the foods p-ocurab e for convalesoents from fever.
a
lew
Dieting in bowel complaints Proper regulation of food is of far greater imp >rtance in diseases of the alimentary These diseases offer a system than in fever in India. larire field is for practice which is almost a monopoly of the kabiraj The homoeopath has of late successfully entered this field. As for ourselves, regular practitioners of medicine, we are making a very tardy progress indeed, and the reason is not far to seek In no class of disorders is there such a wide divergence We hold that physiobetween our principles ano practice. logical rest is of the utmost importance in injuries of the stomach or the intestines and withhold food in all such cases for 48 or 72 hours, giving sips of hot water to allay thirst or in extreme cases of depressed small hectal unemata of half-digested food. In acute idiopathic affections of these organs, on the other hand, we follow almost blindly the practice adopted in antiquated times, when most of these disorders were supposed to be the expression of general or constitutional In the treatment of these disorders we have not aiiments. moved with the times. We begin with milk and sago, and on the appearance of slight depression wind up with soups and brandy. It is a common thing to observe a case of acute dysentery receiving his pint of milk and a cupful of sago three hours after his dose of 20 grains of ipecacuanha. The observant kabiraj or the homoeopath gives scarcely His medicines may be very indifferaway substantial food. ent, but his practical adoption of a great principle gives him due pre-eminence and success. Patient watchfulness and not active interference should be our rule of practice in these cases. In acute gastric or gastro-duo lenal catarrh or inflammation, our main reliance after a mercurial or saline purgative, should be au complete abstention from food. Beyond sips of barley water with common salt or, much better, cocoanut milk, food should be interdicted for two or even three days This is g-enerally enough for a cure. If there are pains, hot fomentation would be much preferable to strong doses of opium. But I need not go over the treatment of the disease. In cases of acute diarrhoea, the same principle of rigid abstention from food is necessary, but here greater watchfulness is required, for undue depression is to be avoided. Lemon whey or sulphuric whey is t< e best form of food in profuse fluxes, and in the inflammatory forms attended with the discharge of much mucus, whey with alkalies, specially magnesia and bismuth is invaluable. Medical treatment is called for from the beginning ; but it should be different from the active use of astringeuts and large doses of opium, small doses of castor oil, perchloride of mercury salol, belladonna, camphor and opium are required both for purposes of evacuating the bowels and of disinfecting the
surface. hi cholera, the administration of irritating stimulants and drinks has. in my opinion, justly brought our system into opprobrium with the people of our country. The regular practitioners are shunned by them ; and the homoeopath flourishes in this field of practice where we should have secured a firm hold. By the frequent administration of his drops of thousand mucous
the homoeopath does not disturb the physiological His harmless intervention is the of the intestines. cause of his success, and teaches us a lesson of non-interference in this foimidable disease.
dilutions,
rest
Small doses of calomel and drop-doses of a saturated solution of camphor in chloroform, which I found gave the best results in the great epidemic of cholera at Coutai in the Midnapore District in 1874, havebeeu found to yield similar
results in the last cholera epidemic at Hamburgh. Treatment based on such a rationale will likely succeed. Sips of iced water or coffee. and not pints of fluid recklessly poured into the stomach, can be borne during collapse. If the blood wants saline water it can be supplied only in one way. viz.. by hvpo dermic injection of saline water and not by filling the intestines with iced water, which does not undergo absorptiou from its mucous surface.
When reaction sets in in cholem, nothing is so agreeable and beneficial to the patient as freshly prepared lemon whey,
[Nov.
1895.
in small quantities and mixed with a few grains of cit'ate of eaffciu ; the latter to stimulate the heart and promote enureses by relieving congestion of the kidneys. Whey contains sufficient nutriment and lactose to be useful at this stage of t> e disease. To ply the patient with frequent draughts of brandied broth or milk is pure quackery and is against the dictates of physiological science.
given
There is
no
disease where
abstention from food
is so
salutary in its effects as in the first stage of acute dysentry. Nothing but barley water should be given in small quantities with common suit and a few drops of Ptychotes water to relieve thirst duriug the first 48 or 72 hours. Milk and soups are to be avoided Ipecacuanha is our only remedy in hospital patients, soldiers or prisoners compulsion can be used, the medicine larly successful. Mix. as we may,
this disease ; as far as are concerned or where in large doses is singueither with opium or
chloral hydrate, Ipecacuanha generally produces persistent and often vomiting. This is a great draw-back
nausea
its
employment in^private patients. The active principle ipecacuauha is still uncertain, but recent pharmacological experiments indicate that emetin is its medicinal principle, and tabloids containing emetin in small doses deserve a trial among our native patients. to
of
The success attending: other kinds of treatment shows that the disease may be treated in several ways. A brisk purge, jvercubials or salines or a hydragogue vegetable puige followed by small doses of castor oil emulsion with opium or hemp and perchloride of mercury, gives as good results as ipecacuanha in the sub-acite forms in which the disease often appears in natives. But the first condition for success is total ab^teution from food.
The most intractable diseases
we have to treat in India the chronic forms of dyspepsia and bowel complaints. Judicious dieting is here of paramount importance. The glandular and motor functions of the stomach and the intestines are seriously impaired and the power of digestion We cannot by heroio becomes greatly deteriorated. feeding and drinking counteract the great emaciation and piostratiou which are the inevitable consequences of im. are
paired digestion.
The administration r-f strong soups and alcoholic stimucases, simply irritates accelerates death by inanition. This, I think, is the main cause of our failure in the treatment of these cases. The kabiraj scores the His method is to highest success by careful feeding. cautiously feed the patient with a un-stimulating and a fairly nutritious food. One great dietetic principle he teaches us is the administration of food in a state of pulp or in a pure solid state, and not in a liquid form, and the restriction of water or liquid of any sort duriug the meals. Beyond the emperical knowledge that such foods do goon, the kabiraj cannot give satisfactory reasons for his method. But a slight physiological consideration will indicate to us that his method is a practical illustration of a scientific principle. Food in a pulpy state and in a state of minute division, calls forth both the glandular and motor functions of the stomach and intestines, and does not dilute the already weakened digestive secretions. Its state of fine division renders it also easily assimilable,
lants, which we often adopt in these the already impaired digestion and
And now a few words as to their management. In chronic gastritis or a dyspepsia with foetid eructations and flatulence appearing a couple of hours after a meal and showing deficient secretion of gastric juice, the indications for treatment are well known to all of us, viz. the clearance of the excessive mucus from the stomach, and the reduction of food both in quantity and quality to suit the digestive capacity of our patients. The first indication is met by a dose of Carlsbad or a mild saline aperient, and the second by administering measured quantities of food, such as old rice pulp strained, about 4 oz., with half its quantity of moong dal pulp flavoured by lemonjuice and partially digested by a few drops of papaya juice. When we find this food disagree, we may further attenuate it without diminishing its nutritive aliments. Pulp of rice or khoi mixed with dahi or buttermilk is an ideal food for this disorder. In another class of dyspepsia where excessive acidity i due to fermentative changes or excessive secretion of gastrij juice, the addition of one of the black fishes, previously
Nov.
1895.]
SOUTH INDIAN
BRANCH,
BRITISH MEDICAL ASSOCIATION.
mentioned, or the flesh of goat, well stewed, to ohl rice, for the midday meal, and the administration of lighter foods at intervals of 4 hours will relieve the symptoms. No liquid should be drunk during the meals, but somecccoanut milk should be given an hour or so after the midday meal. Here the indications are to neutralize its abnormal acid secretions of the stomach, and these are met by frequent administration of food, specially rich in proteid aliment. Chronic diarrhoea and dysentery affords greater chances of recovery by dietetic than by medicinal means. Careful observation is necessary to find out the digestive capacity of patients by beginning food in small quantity or by following the method already stated under dyspepsia. Milk with farinaceous food is badly borne by these patients. Pure milk mixed with one-fourth of its bulk of lime water or fluid magnesia given in small quantities, sometimes agrees ; but, as a rule, cow's milk is too rich for the impaired digestive power of our patients. Goat's milk, fresh and undiluted, often agrees in small quantities, but as their milk has a tendency to form large clots, it will be advisable to mix it with one-fourth its bulk of boiled shamadama. In the majority of these cases, milk does not agree, and it will be necessary to try other combinations of food. Old rice pulp with one of the black fishes with dalii, or a mango preparation as Amchur or Amsutto as an adjunct, will be found very useful. Where rice disagrees, fried chura or lthoi pulp with dahi may be tried. The cooked pulp of green plaintains mixed with dalii succeeds where other forms of food fail. A little green papaya cooked with Amada (Curcuma amada) and old tamarind is a serviceable adjunct. Food should not be given more than two or three times a day. When a third meal is given it should consist of a little barley or arrowroot. Betelnut should be prohibited, as the pieces of woody matter may irritate therulcerated mucous membrane. Where the patient cannot be prevented from hi3 habitual pan, the betelnut should be ground to a powder and given with the usual ingredients of pan. Pan is a digestive stimulant, antacid and astringent, and is therefore admirably suited as an adjunct after vegetable meals. The pepper leaf is a carminative and dialagogue, lime is antacid and catechu is astringent, and betelnut is not only a vermifuge, but from its containing the alkaloid anecaline it acts as a stimulant to the nervous system. Potatoes and cereals (dais) disagree in these chronic bowel complaints. Green plantains, country figs, (Colocasia Indica), pulwals and briugals are valuable in these
diseases. In diseases of the kidney, milk is almost a cure, and we have already borrowed this milk treatment from the kabiraj without acknowledging our debt.
I fear I have already tired you with an imperfect sketch of the subject of my address and must therefore stop. I .only wish the claims of the poor native malt will not escape your attention in these days of revolutionary changes in medicine. Dr. Simpson said that the above subject is very much There is ouly one journal in everywhere. America which is devoted to this subject, viz., '? The DieteHe thought that practical tic and Hygienic Gazette.'' dietetics should form a part of the curriculum of studies The most successful physicians of the medical student. A waut were those who paid particular attention to diets. of knowledge of the proper diet did a good deal of harm.
neglected
Dr. B. C. Sen said that the injudicious administration of food does greater harm than starvation. He hoped that there should be investigators on this subject. Dr. PILGRIM thought that the kabirajes and hakims go much the other way, viz., they starve the patient. The high mortality of children was, according to him, due to star-
vation.
Dr. Maynard said that he made some experiments with had great digestive powers 011 know in which diseases it ie
papain, and found that it proteids. He wanted to efficacious.
Dr. Crombie wanted to know why natives of Beiifal so much to the use of rice in fever. Dr. D. D. Roy said that rice is quite innocent in fevers and the objection is groundless, and people blindly follow long established custom.
object
Dr. Dutt briefly replied.
441
PROCEEDINGS OF A SPECIAL MEETING OF THE SOUTH INDIAN BRANCH OF THE BRITISH MEDICAL ASSOCIATION HELD IN THE CENTRAL MUSEUM, ON FRIDAY, 20TH SEPTEMBER, AT 5-30 p.m. Surgn.-Maj.-Genl. SIBTHORPE, f.r.c.im., m.r.i.a., President, in the Chair. The Miuutes of the last Meeting were read and confirmed. By request of the President, the Honorary Secretary explained the circumstances which necessitated the present Special Meeting of the Branch. It appeared that at a meeting of the Branch Council, held on 9th September, the resolution on Sanitary Administration in India passed by the
Public Health Section of the British Medical Association at its Annual Meeting in Loudon in August last, was under consideration. It appeared to the Council that that liesolution was based on a mass of misleading statements made by the Editor of our Journal in his speech as President of the Section, and that it wcs the clear duty of the profession in India to take some steps both to clear up their own reputation from the slanderous accusations of Mr. Hart, and to enlighten their brethren at home as to the true state of affairs in this country in sanitary matters. It was accordingly resolved that a small committee should be appointed to draw up a formal protest to be laid befox-e a Special Meeting of the Branch, and, if adopted, to be forwarded to our Representative on the Council of the Association. The following gent'emen constituted the Special Committee : ?
Surgeou-Major-General C. Sibtliorpe, F.R.C p.i. Surgeon-Lieucenant-Colonel Bran foot, Ji.B, (Lond.) Surgeon-Major John Maitlaud, jj.d., (Edin.) Surgeon-Major John Smyth, M.D. (R.u.I.) Secretary.
This Committee had
completed their task, and the to give expression of opinion not only on the protest which would be laid before it for consideration, but on the general question of the misrepresentation of our Editor, the hurried Resolution of the Section of Public Health, and the Sanitary Adminispresent Special Meeting
now
was
convened
tration of India, particularly of our own Presidency at the present moment. Aft^r this Surgeon-Lieutenant-Colonel explanation, Bran foot moved the following resolution : He said that as the members were now fully aware of the circumstances under which this meeting had been called, he would not occupy unnecessary time, but would at once read the resolution proposed to be sent to England :? Resolved that the accompanying protest be forwarded with a letter from the Secretary of the Branch to the Representative of the Branch in England, with a request that he will be good enough to lay the matter before the Couucil on the first opportunity, with a view to that body taking such steps as may prevent the Editor of the Journal from defaming, either from the platform or through the medium of the Journal, a large body of the profession in India, many of whom are members of the Association, ?
PROTEST. The Members of the South Indian Branch of the British have read with much surprise the Association Medical resolution which was passed in the Section of Public Medicine at the Annual Meeting of the Association lately held in Loudon, and founded on the address delivered by the Editor of the British Medical Journal. They wish to point out that the whole of that address so far as it refers to the civil portion of the Indian Medical Service is full of inaccuracies and unjust statements calculated to reflect discredit in a most unwarrantable mauner upon a large body of the profession in India. They feel certain that, had the members present at that meeting been in possession of the truth facts regarding Sanitary progress in India, and the work done during the past 30 years in India, in both the Civil and Military Departments, they would not have been induced to accept all Mr. Hart's statements and to pass such an ungenerous resolution which reflects adversely on them and on the Government they have the honour to serve, 'lhey trust that the Council will see fit to give the same publicity to this protest as they have given to the Editor's erroneous and defamatory statements.
Surgeon-Lieutenant-Colonel Sturmer said he had great pleasure in seconding the resolution.
442
INDIAN MEDICAL GAZETTE.
In support of the resolution before the Meeting'. SurgeonLieutenant-Colonel W. G. King spoke a5! follows:?? Mr. President,? Mr Hart's recent visit to this country is
-
still fresh in the memory of the members of this Branch We received that gentleman with the courtesy due to his position as Editor of the organ of our Association, and an active and useful member of its Parliamentary Committee, and with the hospitality for which Anglo-In
