Part 106

As a stomach may become over-distended and permanently dilated by long gluttony or by the accumulated ingesta which a slow and feeble peristalsis refuses to move on, so may it also become contracted from the habitual want of sufficient victualling, sometimes to such a degree that the introduction of enough food can only be accomplished after the gradual dilatation of its receptacle. This may be effected by increasing the frequency of meals. The custom, common in America, of leaving a long interval between them is the reverse of that desirable for those who require extra feeding. The ordinary European arrangement adopts a system which is worthy of imitation, a “little and often” being the motto of the eater. It is useless to attempt too much at one time. The stomach conforms slowly, and rebels at a certain limit, but a brief respite and a short intermission put it in a less antagonistic attitude. If, for the reasons given, or from mere disinclination, 2 meals have been all which the subject under treatment declares can be “got down,” as is often the case, then 3 must be taken or the time between successive feedings shortened to 2 hours, according to the aggregate amount of nourishment intended to be given and the readiness with which its forced consumption is effected. It is an advantage, therefore, that certain periods of the day, not precisely fixed, but approximate, should be established as meal times. For instance, before rising, at the usual breakfast hour, in the middle of the forenoon, at the accustomed luncheon, in the middle of the afternoon, at the regular dinner, and on going to bed.

It is a common impression that to take food immediately before going to bed and to sleep is unwise. Such a suggestion is answered by a reminder that the instinct of animals prompts them to sleep as soon as they have eaten; and in summer an after-dinner nap, especially when that meal is taken at midday, is a luxury indulged in by many. Neither darkness nor season of the year alters the conditions. If the ordinary hour of the evening meal is 6 or 7 o’clock, and of the first morning meal 7 or 8 o’clock, an interval of 12 hours, or more, elapses without food, and for persons whose nutrition is at fault this is altogether too long a period for fasting. That such an interval without food is permitted explains many a restless night, and much of the head and back ache, and the languid, half-rested condition on rising, which is accompanied by no appetite for breakfast. This meal itself often dissipates these sensations. It is, therefore, desirable, if not essential, when nutriment is to be crowded, that the last thing before going to bed should be the taking of food. Sleeplessness is often caused by starvation, and a tumbler of milk, if drunk in the middle of the night, will often put people to sleep when hypnotics would fail of their purpose. It should be borne in mind that a full bladder is a frequent cause of early morning wakefulness. Rising and passing water will often send restless sleepers back to bed for a refreshing nap, which, without relief from this source of reflex irritation, would not have occurred.

Food before rising is an equally important expedient. It supplies strength for bathing and dressing, laborious and wearisome tasks for the underfed, and is a better morning “pick-me-up” than any hackneyed “tonic.”

Skilful feeding by a nurse who recognises the art which may be exhibited in coaxing food into the stomach is often of advantage. Food thus administered must be introduced in large mouthfuls. Every gourmet knows how necessary this is for the satisfaction of the palate, and the correctness of the fact is substantiated by reason and by analogy. Well-shaped wisely-seasoned, large morsels make a relishing and appetising mouthful, inviting repetition. In divided bits they quickly satiate or excite repugnance. By this epicurean method the stomach is rapidly and persuasively charged with a sufficient supply of nourishment, as it never can be by the feeble pickings of an apathetic eater.

In cases where food is urgently called for, its artificial introduction is an easy and beneficial manœuvre. It does not require a stomach tube, and has but little resemblance to the procedure resorted to with the insane. It may be practised with insignificant discomfort by means of a soft rubber catheter, not exceeding a No. 12 in size, fitted to a small glass funnel, into which the nutriment is poured, or it may be sent through the tube by a Davidson’s syringe. The catheter need enter but a short distance into the œsophagus. If no resistance be offered, the operation can be performed by almost any one, even by the patient himself. Milk, cream, broth, eggs, and homogeneous liquids are thus readily deposited, and to the desired extent, in the stomachs of those disinclined to eat.

The number of females, especially those who “do their own work,” whose food consists almost wholly of bread and tea is very large. How inadequately they are nourished is shown by the statement that, in order to get the required amount of aliment, persons who eat nothing else must consume about 4 lb. of bread. As this is so much more than any one can dispose of with comfort, the practice of eating butter with bread is almost universal. This not only meets the necessity for a heat-producing, non-nitrogenous food; but the unattractive character of dry bread as an eatable is compensated for by the relish of a savoury addition. In proportion as the use of butter is increased, the requisite quantity of bread may be decreased. To eat “more butter than bread” should not therefore be the reproach to growing children which it is often made, and the large amount of the former which may be profitably disposed of by the underfed, without “disturbing their stomachs,” is not surprising if the process by which oleaginous substances are taken into the system is recalled. “Fat, butter, and oily matter in general require no digestion; the emulsion into which they are mechanically converted, chiefly by the pancreatic and duodenal secretions, passes (almost directly) into the general circulation of the blood.” For reasons similar to those which make cream and butter such useful articles of diet, and because the habitual food of insufficient eaters is so lacking in fatty matter, cod-liver oil has acquired its well-deserved place among therapeutic and alimentary agents.

The tendency of those whose appetite is deficient to lay great stress upon their readiness to take food which does not require mastication makes them willing consumers of soup. And yet of all articles entering into the common dietary soups are perhaps the most deceptive, and certainly the most important to discountenance with the underfed. They fill up the stomach at the expense of solid, “staying” nourishment, and contain so little in the way of sustenance that they are therapeutically almost worthless. As a rule they are but some form of meat tea, and are now known to have a food value not unlike that which wine would possess, and which they resemble chemically. “They may have on the system a stimulant action somewhat analogous to theine. They may render more prompt and efficacious the assimilation of any wholesome food with which they may be associated, and they may even give so effective a fillip to an exhausted system as to enable it to dispense for a time with real food; but it is clear that they must not be looked to for direct nutrition.”

Broths, however--that is, soups which contain large quantities of solid matter, disintegrated meat, vegetables, macaroni, vermicelli, _pâté d’Italie_, rice, barley, sago, tapioca, &c.--are often, and in proportion to the consistency thus given, excellent alimentation. They are palatable and easily consumed in considerable quantities at a time. _Soupe à la Reine purée de gibier_, various vegetable _purées_, chowder of fish, _bisques_ of oyster, clam, lobster, are illustrations of the perfection of this kind of cookery. That they may be what is sometimes called “rich” is no objection. The digestive powers of the underfed are usually good, though the owners of them may not think so. They are apt to be active and ravenous, even if the appetite is not.

The meat from which soup is made, allowed to become cold, should be compounded to a paste in a mortar, and then returned to the soup. Veal, pigeon, and rabbit are especially adapted to this procedure. “French” cooks prefer to make “chicken broth” from rabbit.

Notwithstanding its capacity to digest, there is, invariably, something repulsive to an insensible stomach in what are conventionally called “roasted joints.” This antipathy, together with considerations of convenience as regards the size of portions to be cooked, makes it almost imperative, for protesting but frequent eaters, that meats should be either broiled or stewed; and steaks of various kinds, chops, cutlets, chicken, game, some kinds of fish, and shell-fish become, therefore, the only really available resources of the caterer of an ill-ordered appetite. And yet no more difficult undertaking can be given non-hungry patients than that of eating beefsteak. Apart from its somewhat uncertain quality, nothing requires more mastication, and the class named always declare that there is no item of food of which they are already more “tired.” Any other variety of meat--mutton, veal, venison, &c.--cooked in the form of steak is more readily eaten. The short, compact fibre of mutton chops, especially those from the loin, makes them less likely than beefsteak to be badly cooked, and far easier to be consumed. Well-selected, carefully-cut lamb chops, in their proper season, are a delicacy of the highest order, and rarely fail to be appreciated by the most benumbed eater.

Meats stewed, or semi-stewed, and then partially browned in the oven (braised, as it is called in the language of cookery), are attractive and submissive preparations, and this method of cooking is an excellent one for purveying small portions of animal food. In the various forms and denominations of stewing and braising, the _cordon bleu_ finds scope for the highest aspirations of culinary art.

They impart an appetising flavour to viands cooked to extreme tenderness, the perfection of these methods being found in their application to sweetbread--a costly luxury, but an article which, by its slight demand for mastication and its nutritious qualities, is peculiarly adapted to the requirements of an invalid eater. Others of the viscera, besides the pancreas, and the thymus gland--namely, the brains, the liver, the kidneys, the testicles of lambs, successfully lend themselves to this process of cookery, and like calves’ heads, pigs’ feet, and sheep’s tongues, are converted into delicate and easily-assimilated nutriment for those who are ignorant of, or can overcome, the associations which they suggest.

Of various mechanical processes available for rendering food easily eaten, preparatory mincing offers great advantages, and is particularly applicable to chicken and veal. A common and attractive method of serving both in the form of minced meat is that of _croquettes_, which are most easily prepared by the aid of Lovelock’s mincing machine.

Dr. Hodges does not hesitate to assert that of all the modes in which minced meat may be presented, the calumniated and much-libelled sausage is, in winter time, one of the most useful and successful articles for frequent feeding. Lean and fat meats, more digestible together than separately, are discriminately mixed in the compact and appetising form of this ubiquitous and popular comestible, the sole secret of whose easy digestion is that it should not be eaten except when it has become thoroughly cold after cooking. Bread and butter can be tolerated with complete immunity when hot buttered toast would provoke exasperating dyspepsia, and it is exactly thus that sausage cold stands in relation to that which is served hot. Presenting the albuminates and fat in an economical, savoury form, easily obtained and made ready for consumption, sausage, in some countries, might almost be said to have become a national food, and it offers to the fastidious or indifferent eater an article of diet from which great benefit may be derived. A trial of this stigmatised edible will be followed by a ready recognition of its alimentary value in the class of cases under consideration.

As has been remarked already, food, to be taken outside the conventional meal hours, must be of a kind easily obtained anywhere, readily “kept in the house,” and which does not demand preparation or delay. Few persons can command the services of a “professed cook,” or of a good “plain” cook, or have either at their disposal every two hours in the day. The practical articles of diet which meet these restricted requirements of convenience are few, and of these the chief in importance are eggs, milk, cream, butter, and bread.

“Raw albumen is one of the most digestible of foods; coagulated, it is comparatively indigestible.” Eggs, to be easily digested, must be eaten uncooked, since albumen under prolonged heat acquires progressive degrees of toughness. Eggs should not be cooked by boiling, but by placing them in hot water, and allowing them to remain there for 7-10 minutes.

When cooked, buttered, salted, and peppered, they are soon tired of as articles of food, and alleged to be “bilious.” Cooking, moreover, involves waiting and preparation. An uncooked egg is always ready and at hand, is clean to be kept anywhere, and scarcely needs to be broken into a glass. With a little knack it may be swallowed direct from the shell, as most persons know if in childhood they have had access to country barns. A raw egg weighs 2-2¼ oz., and is said to contain about the same flesh-forming and heat-giving material as an equal amount of butcher’s meat. It offers in perfection the quickest and neatest mode of taking a large equivalent of substantial and nutritious food at a swallow. Beaten-up eggs are a certain provocative of dyspepsia. When subjected to this process, an inviting draught of creamy froth is brought to the unfortunate recipient--a tumblerful of air, which has been introduced in the largest possible amount to a given quantity of egg, milk, wine, sugar, and nutmeg--than which nothing could be better devised to promote indigestion, abominable eructations, and the most uncomfortable flatulence or acidity. Every beer drinker has the good sense to blow off the “head” of his mug of beer, or to wait patiently for the froth to subside, before he imbibes the draught; and if crotchety persons will not learn the trick of swallowing an egg whole, they can compromise the difficulty by slowly stirring the white and the yolk, which may be thus mixed together, and made to seem a less revolting dose without the incorporation of air by beating. Taken as a medicine, and looked upon as such, eggs are at least equally palatable with cod-liver oil, for which they offer an equivalent substitute, adapted to winter or summer, as the latter hardly is, and far more rapidly digested. There is no limit to the number which may be taken with advantage continuously and for months at a time. Eighteen eggs are required to furnish the flesh-forming materials and other nutrients sufficient for the various needs of an adult man in one day.

Milk and cream are convenient, and therefore important and desirable articles of food. It is a common assertion of patients that milk “always disagrees with them”--that they have “never been able to take it.” This statement, which, as a rule, may safely be attributed to mere prejudice, is also in some cases a true one, simply for the reason that the milk is drunk too rapidly, or because it is not rich enough, an easy remedy being to take the given quantity more slowly, or to increase by addition the amount of cream which the milk naturally possesses, the trouble being due, in the first instance, to the fact that a large and solid cheese curd is suddenly formed in the stomach by the rapidity with which the milk is deposited in that organ, and in the second, to the hardness of the casein derived from milk with an insufficient percentage of cream, which is always inconstant in amount (varying between 10 and 15 per cent.) or in composition, the water alone ranging from 45 to 65 per cent. Milk is often too poor, but never too rich, for purposes of enforced nutrition, and the fact is incontrovertible that it is the model food for digestibility.

By adding cream to milk the amount of fat is increased and the curd is softened; and its digestion can be still further facilitated by the disintegration of its coagula, accomplished by crumbling in bread, cracker, &c., or by the addition of a small amount of cooked meal or flour.

By this latter means cold milk is made warm, which gives it an increased efficacy. This end may also be attained and the distastefulness of warm milk removed by flavouring it with the preparations of cocoa, weak coffee, or some of the inert substitutes for the latter sold by grocers, the best of which perhaps is that known as “New Era coffee,” consisting simply of roasted and ground wheat. But, as hot milk demands a certain amount of trouble, cold milk alone, or with bread broken into it, is, after all, the only practical resource so far as its use for frequent nutriment is concerned; and 2 qt. of milk, or 3 pints of milk and 1 pint of cream, are not more than the minimum quantity desirable for ingestion in 24 hours. Clear cream may be administered in doses of a wineglassful after each meal, as any other medicine might be, and a great deal can be disposed of by eating it liberally added to cooked fruit and various dessert dishes.

Blanc mange, Italian cream, and the various forms in which many delicate farinaceous articles are cooked, may thus be made more eatable through the zest given them by this accompaniment. There is a great difference in the palatableness as well as digestibility of cream which is obtained from milk by centrifugal force, as is largely done for the market, and that which is skimmed after “setting.” This distinction should be borne in mind in prescribing cream which is to be taken uncooked. The last-named product is by far the more desirable article.

Very few patients, especially women, drink a sufficiency of water to maintain their health or an adequate nutrition. Water is an important constituent of food, is, indeed, the carrier of food into and through the system, and forms more than ⅔ of the whole body. Neglect to keep up the supply of water leads to a diminution in the quantity of blood, and lessens the body’s strength.

When it is remembered that there are daily eliminated 18-32 oz. of water from the skin by perspiration, 11 oz. from the lungs, and 50 oz. from the kidneys, it is easy to see that the amount consumed by many persons falls short of the demand, and that their bodies must be insufficiently supplied with the requisite degree of moisture; some 66 oz. of water alone, and in tea, coffee, beer, &c., being required for a daily supply over and above that which is contained in the solid food of a full ration to make good the average regular waste. The constipation which is so common in ill-nourished persons is largely due to a want of liquid in the intestinal canal. This, therefore, will be ameliorated by the free use of water, as is also the constipating tendency of milk, which is sometimes complained of, the curds being liquefied and reduced in size, and thereby made more readily digestible. Its effect on hardened fæcal masses or accumulated mucus in the intestines is equally obvious, and explains in part the intention as well as the success of the hot-water craze at present so popular.

The underfed are benefited, and the process of feeding is helped, by alcohol. But the amount of alcohol which such persons may take as a food adjunct with advantage is very small. The cumulative effects of a medicinal dose at stated intervals are of greater utility than the more instant result of a larger allowance swallowed in a single drink. A measure of alcohol which produces an effect quickly--that is, which flushes the face, or exhilarates, as a sherry-glass of wine does with most females, for instance--is a toxic dose, and will be followed by reaction. It is a quantity short of this which is allowable. A teaspoonful, or at most a dessertspoonful, three or four times a day, is usually as much as can be borne without such sequelæ as are above alluded to.

Spirits serve their purpose better than wine, for the reason that the relative quantity of alcohol administered is more measurable. Wines vary in strength; spirits are comparatively uniform. Tinctures even, or elixirs, may be given when spirits are objected to either on principle or from prejudice. In any case there should be a large dilution with water, as a more gradually stimulating effect is thus produced. Alcoholic medicines ought never to be taken on an empty stomach.

Great pains should be taken to discountenance everything which reduces the bodily heat, and employments or amusements which in any sense tax the strength ought to be abandoned when a forced diet is attempted. Even ordinary exercise is often objectionable, and its complete discontinuance sometimes so important that confinement to bed is a necessity. Those who raise animals are practically made aware that a restless disposition is fatal to successful growth in vigour and flesh. The truthfulness of this observation is equally apparent with human beings who need “building up” in the literal sense of these remarks.

Mere fattening is not the object of full feeding, but it is to a certain extent its necessary accompaniment. The motive of the measure, as has already been stated, is to add to the quantity and quality of the blood, and it is hardly possible for an individual to grow fat without a decided increase in the volume of his blood. Weighing at stated intervals is therefore an important procedure, and there is no other way to make sure that the subjects of treatment are sufficiently well fed to gain blood. Persons who put on fat rarely fail to improve in colour; their comfort is enhanced; warmth of body is gained, in itself no slight improvement; the pulse becomes fuller; the cheeks grow redder; the spirits are raised; the general mien becomes brighter; and these phenomena are explainable only by admitting that there has been an accession to their stock of blood. The scales thus become a thermometer of improving health and strength, by the aid of which the physician measures the progressive results of his regimen. Like the “pass book” used at banks, they reveal in a ready and serviceable way the healthful standing of an individual, the relation of his resources to the wear and tear checks which he is continually drawing, and whether his account is nearly or quite overdrawn, or superfluously plethoric. They ought not to be put into requisition too frequently, and only when there is reason to think that an encouraging increase of weight has taken place. This should manifest itself soon after systematic feeding has begun, and continue at the rate of 2 lb. a week, and not less than 1 lb., so long as improvement seems desirable, or until a weight has been reached, the minimum of which shall be equivalent to 2 lb. for each inch of stature.