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turn his attention to the neglected subject. Probably he does not make the discovery that some knowledge of food and feeding is desirable until by some accident the subject is forced upon his attention. Yet he is far from indifferent about the subject when it has once been borne in upon him, as the readiness with which he seizes upon anything that will help him when he has once awakened up to the importance of the matter testifies. This is a matter which will come before the practitioner from the moment he gets his first patient, yet no preparation is made for it. He never dreams of buying barks and roots in the natural state of the raw material, yet he is compelled to know them. How he has to direct the dietetic management of sick persons (and still more in pyrexial states) is never pointed out to him, yet surely such knowledge would be very useful to him-and to his patient.
Some time ago, in conversation with the manageress of one of the many Homes now springing up where paying patients can be nursed, the subject of feeding sick persons cropped up, and she was very enthusiastic about "a twenty minutes' pudding," but of what it consisted did not transpire. A tentative remark about the digestion of the starchy materials of our food flew past her unheeded. It was soon clear that of any rational ideas of digestion, theorectically or practically, she was in unillumined ignorance; all she knew was a little empirical knowledge, and of that she did not possess a superabundance. Who, then, is to know
this matter of feeding? Who is to tell the student of the difference betwixt raw or uncooked starch and cooked starch?—that in the latter the insoluble starch granule is not only cracked, but the starch is largely converted into soluble dextrin by exposure to heat? that by the addition of some such soluble carbo-hydrate to meat-broths they endow these broths with a decided food-value? and that the meat-broth itself is but an agreeable vehicle for some food? Yet this is what he ought to be instructed in, if he is to be fitted to meet disease. When the patient sinks of exhaustion, of what does he die? His stores of force are run out; but what is the material which constitutes the body force? I should read with delight a lecture upon this topic by Dr. Austin Flint, or Dr. Da Costa-or perhaps some less illustrious physician will grapple with the topic. We know that when a patient declines all food he will die in a given number of days. If a healthy person be hungered, as by shipwaeck, he also will live a number of days. In the latter case death will come all the sooner if the surrounnding temperature be low. In the former case the duration of life will be shorter as the body-temperature rises. There is a question of combustion involved. It may not be the whole question, but it is an important factor! Alcohol is a readily-combustible
hydro-carbon; it is used freely in critical times. Does not the idea naturally suggest itself that somehow the store of glycogen-the body-fuel -is a cardinal matter? If this be so, it is evidently desirable to keep up the stock of this material so that it may not be exhausted. If raw or uncooked starch be employed, probably it is little acted upon by the diastase of the saliva, or even the diastase of the pancreas, both organs being crippled by the general malaise. But a starch which has been rendered soluble by previous baking or by the matting process has been so modified that it is highly soluble.
I do not know how the matter stands in the United States, but as regards the mother-country, litle, very little use indeed is made of those prepared foods spoken of sometimes derisively- as "Baby-Foods," either in cases of primary dyspepsia or in that debility of the digestive organs which is involved in serious morbid conditions. Yet by the addition of cooked starch, as bisquit-powder, to meat-broth, and of maltpreparations to milk or milk somewhat diluted with water, foods nutritive and at the same time readily assimilable are furnished to the sick person. Of the advantage of a fairly competant knowledge of such foods, both in their chemical elements on the one hand and in their variety on the other, probably no one can be better aware than myself: and such knowledge has been of infinite service to me, or some grave delusion exists in my mind. We must, too, remember another aspect of the subject-viz., variety. While we are in health we are apt to growl about the lack of variety in our food; how much more, then, the sick man! If the changes can be rung by different forms of meat-broths combined variously with different prepared foods, how much variety can be furnished to sick persons, and with that how much inducement to take that nourishment, so badly wanted and so hard to supply in many instances! Sago, tapioca, and rice or barley can all be placed in a slow oven and baked for an hour without scorching, and so be prepared for use in the sick room. When the patient is convalescing, a milk pudding can be prepared of such material, which requires but little of the digestive act. Or there are various forms of plain biscuit which are admirably adapted for use with broths or soups (the Channel Islanders always thicken their soups with biscuit broken fine or powered). By such means a good and indeed substantial meal can be furnished to a phthisical person with softening tubercle and a feverish temperature,-a typical instance of enfeebled digestion due to general malaise. And as for gastric catarrh or atonic dyspepsia, such a meal would not be likely either to become enfolded in a layer of mucus or to present any difficulty as to the solubility.
These may seem very simple matters, scarcely worth putting on paper; but the professional acquaintance with them is not as ample as it might be with advantage to invalids and sick persons. When a medical man lifts his eyebrows or protrudes his lips when "Baby-foods" are mentioned in relation to dyspeptics and persons acutely sick, the impression he makes on my mind is this: that he has not made a study of the matter of food and its digestion, and that he has yet to learn some matters which, when acquired, will enlarge his usefulness and strengthen his hands when he stands by the bedside of his patient.-Extract from Letter Phil. Med. Time.
SYPHILITIC OSTEITIS OF THE TIBIA.
ABSCESS OF THE THIGH AND ARTHRITIS OF THE KNEE. : HYDROCELE,
Delivered at the Hospital of the University of Pennsylvania.
I shall to-day show you an interesting case of bone disease. This little girl, without any definite history, presents a painful enlargement of the tibia. The swelling is circumscribed and very painful. It is what is spoken of as a node. This is a general term, common to all periosteal swellings of a circumscribed character, the word node signifying a knot. The outline of the right tibia is altered; there is marked bulging and also lateral thickening. The part is hard There is no fluctuation. There is, of course, periostitis, but, more than this, there is inflammation of the bone itself, which may or may not have gone on to the production of pus. In some cases there is a circumscribed abscess of the bone, a condition which is often spoken of as "Brodie's abscess," having been described by Sir Benjamin Brodie, who discovered it in a limb after amputation. The condition had, however, been well described before Brodie's time. A good account of it will be found in the Memoirs of the French Royal Academy of Surgery, and clear directions for its treatment given.
In cases of this kind we may find a circumscribed collection of pus, or a simple inflammation of the bone which has not gone on to suppuration, or there may be found necrosis.
I think that we may find in the present case simple inflammation of the bone, which may be either softened or hardened. The entire medullary cavity may be converted into dense bone, giving the condition termed sclerosis of bone, or, on the other hand, the compact substance may be much softened, resembling the medullary substance.
The treatment of a case of bone disease of this kind with intense pain, is to make an incision through the soft parts, and if nothing is found to account for the pain to make an opening into the bone with Hey's saw or a small trephine. If a sequestrum is found it may be removed. If there is pus, the front wall of the abscess must be cut away so that it may heal from below. If there is sclerosis, it may be sufficient to make an opening into the bone and pass a drill in various directions through the hardened mass.
We have a patient in the hospital at the present time who was treated in this way. The disease affected the ulna, and was the result of syphilis. The bone was opened, and the whole medullary canal was found in a condition of sclerosis. After removing the anterior wall of the ulna and making a large cavity, a drill was passed in difierent directions through the bone, in order to relieve the tension. Since the operation there has been no pain.
In all these operations on bones we use the Esmarch apparatus, which prevents the loss of blood, and, as the blood is kept from the wound, the view is not obscured. The wound may be dressed before the bandage is removed, and thus all hemorrhage be prevented.
I believe that in the present case the disease has its origin in hereditary syphilis. There is flattening of the nose, and there are little cicatrices about the angles of the mouth. I think that this condition is quite as significant as any other symptom of hereditary syphilis-certainly as much as the notched teeth, which are often found, although they are absent in this case..
In the left ulna there is a similar deformity to that in the tibia, but this gives no trouble. It has probably been painful at one time, but now the disease has taken its course The tibia is one of the most satisfactory bones to operate on, as it is very superficial and can be readily exposed. On the other hand, the femur and the humerus are unsatisfactory to operate on, as they are situated deeply in the midst of muscles, and it is impossible to make a full exposure of them without dividing the muscles transversely.
I shall now make an incision through the soft parts down to the bone, over the enlarged portion. I scrape back the periosteum, saving it as much as possible. This should be done in all operations on the bones. By so doing the attachment of muscles is not interfered with, there is a better chance of the reproduction of bone, and there is less hemorrhage. Having removed the periosteum, I shall next, with a small trephine, remove a disk of bone, and then decide what further may be
required. Having removed quite a thick disk of bone, I find that it will be necessary to resort to the gouge and mallet. With these I remove a considerable portion of bone. The medullary cavity has disappeared, being filled with hard bone. I now reach yellow bone, the color of which is due partly to fatty degeneration and partly to the presence of pus. I shall smooth the sides of this cavity which I have formed, and pass the drill in different directions through the bone, in order to make sure that the tention is completely relieved. Having done this, the wound is thoroughly washed and packed with oiled lint. The dressing will be allowed to remain until it becomes loosened. After a time we shall dress
the wound with resin cerate, and, at a still later period, with oxide of zinc ointment. The wound will heal with a depressed cicatrix. I feel as sure as it is possible to be that the patient will be relieved of her pain. After the acute condition resulting from the operation passes off, she should be put on iodide of potassium, which is useful in all fibrous in_ flammations. If, as we suspect in the present case, the disease be due to a syphilitic taint, there is a liability that some other bone may become affected. Even where there is no suspicion of syphilis, iodide of potassium is useful in inflammations of the periosteum, and of the fibrous tis sues generally.
The wound having now been dressed with the packing of oiled lint, held in position with a compress and bandage, the Esmarch tube is removed, and in order to prevent the blood entering the limb with too much force, I keep it elevated for a few minutes.
Abscess of the Thigh, with Arthritis of the Knee.-This boy was admitted to the hospital one week ago, suffering from an abscess, ready to open, in the popliteal space. An incision was made, and a large amount of pus was discharged. The evacuation of the abcess has not afforded the relief which we had hoped to give. Two days ago I again examined the patient very carefully, and found what I thought were evidences of pus in the muscular tissues of the thigh. There is also destructive inflammation of the knee joint, and I have no doubt that eventually excision of the knee will be required. We do not like to perform excision in a case of acute disease, or when the patient has fever, and is in a state of constitutional irritation, and I should therefore prefer waiting until the symptoms have ameliorated.
If, to-day, I still find evidences of pus beneath the muscles of the thigh, I propose to evacuate the abscess. This I shall do in the following method: First, make an incision through the skin and superficial fascia, and then pass a director into the supposed abscess. Having found