which require a strong hand. But on the whole matter, and certainly as far as dietetics is concerned, kinesitherapeutics is a gentle, artificial substitution of the provisions of nature, in the arthritic arrangement of our body, to relieve the rising circulation, by accelerating its declension and thereby restoring their equilibrium.

THE DIETETICS OF DISEASES OF THE STOMACH.

BY DR. J. BOAS.

[Continued from the April Number.]

2. Motor Disturbances.-The diet in this class of cases varies greatly according to the cause, and the degree of the motor disturbances. If we have to deal simply with atonic or hypotonic conditions of the gastric muscular structures, with normal, or, as is frequently the case, augumented secretion, our plan of action is simple: we must seek to avoid all over-exertion of the flabby muscular tissues and establish conditions favorable for peristalsis by the frequent administration of small quantities of food poor in water and as rich as possible in albumen. An absolutely dry dietary, such as from the time of Van Swieten up to the present day has found favor with some experienced clinicians, I cannot recommend. For the withdrawal of fluids is attended with the greatest danger to the integrity of the organism, as has been sufficiently demonstrated by the "Oertel cures" in the domain of circulatory disturbances, and as is shown by the observations of Tetanie in advanced forms of gastrictasiæ.

On the contrary,

we must counteract the lack of water in the blood and tissues which is the result of defective absorption in the alimentary canal, at least in the severe cases. It should be our aim, therefore, to deprive the stomach, but not the entire system, of fluids, and we will have to seek for vicarious means of supplying the system with water.

For this purpose enemata are especially suitable, partly of water and partly in form of nutritive enemata. The greater the mechanical insufficiency of the stomach, the more extensive must be the supply of fluids by clysters. I am in the habit of limiting the quantity of fluid ingesta to one litre (in single amounts of 100 to 150 grammes); an equal quantity divided in two doses I administer in the form of

enemata.

This manner of supplying fluids, I would emphasize, is only indicated in those cases where the stomach is incapable of expelling the chyme, as in shown by examination of the empty stomach or after the adminstration of the Leube's "test meal." In all other cases where there is simply delayed expulsion of a few hours' duration, the withdrawal of fluids is,

in my opinion, unnecessary. It is sufficient here to administer the customary duantity of fluid in repeated small doses. Such quantities can be disposed of even by an atonic stomach, and it will not refuse to functionize until a disproportion exists between its dynamic working capacity and the amount of labor exacted from it.

Persistent atony of the stomach is not infrequently combined with conditions of secretory exhaustion, obviously the result of the pressure of the constantly acting and irritating column of fluid. Indeed, in cases of this kind an atrophy of the gastric fallicles may be directly produced. For these reasons the dietary demands the same regulations which we have pointed out above as necessary in cases of secretory insufficiency. Absorption is also impaired by long continued adynamia of the gastric muscular layer, and hence it is desirable to select easily assimilable substances for the dietary.

It is scarcely necessary to say that in all cases of atomy and hypotomy, our main object-aside from the adoption of an appropriate diet-should be to restore the tone of the relaxed muscular structures.

Much more difficult and complicated are the conditions in the second group of motility disturbances, these due to the stenosis of the pylorus or of a section of the duodenum. In the slighter grades of the affection and at the beginning of the development of the stenosis, the symptoms differ only slightly from those of atony, and the dietetic regulations completely accord with those outlined above. In the other cases, however, we have to deal not only with impairment of the gastric functions, but also, as Minkowski justly remarks, of the intestinal functions. For the fermenting and partially decomposed substances pass from the stomach into the intestines which form a soil especially adapted for putrefactive processes, and disturb the course of intestinal digestion, a condition which is the more baneful since the faulty digestion in the stomach imposes upon the intestine an increased amount of work. Gradually a process of "stomach putrefaction" results, which it is our therapeutic aim to restrict as much as possible. This may be accomplished by emptying the stomach from time to time and also by banishing easily fermentable substances from the dietary to as great an extent as is compatiable with the preservation of the organisim. As regards beverages the above mentioned axioms hold good; restriction of fluids per of and substitution of these by enemata.

As regards the dietary, we must further avail ourselves of the experience that actual putrefaction of albuminous substances occurs only in the extreme grades of stagnation, and usually in ulcerative processes of the gastric mucous membrane (cancer of the stomach,etc.). In these, fortunately rare, con

ditions the most scrupulous selection of foods is, of course, necessary. The varieties of meats which have been rendered by smoking, corning, etc., most resistant to decomposition, are here in place. Of the carbo-hydrates the best are different kinds of white bread, toasted or stale; the fats, even if well borne, should be allowed only in small quantities.

In these cases the quantity of food should also be greatly restricted, and for the time being we should seek to make good the deficiency of food by nutritive

enemata.

If we have to deal only with fermentation of carbohydrates, which is usually combined with abnormal decomposition of fats (characterized by the presence of yeast fungi and sarcinal, of lactic and butyric acids), it is necessary, above all, to restrict the consumption of starches and fats. To what extent and for how long a time such restriction may be enforced without impairing the integrity of the organism is a question on which individual circumstances play so important a part that we are scarcely justified to make specific statements. At any rate, we are warranted in saying that in cases of marked fermentation of carbo-hydrates, with presence of sarcinal and yeast fungi; a temporary meat-diet (for a period of eight to fourteen days) is certainly indicated. Minkowski also praises the results of an exclusive meat diet in this condition. As is known to every experienced physician, however, the enforcement of this regula. tion in practice is soon opposed by insurmountable obstacles which render all curative intentions illusory. 3. Our knowledge regarding disturbances of absorption as symptoms of gastric disease is meagre if for no other reason than that we are not as yet sufficiently informed concerning the normal course of absorption. Sufficient data are not at hand to settle the question whether independent, genuine disturbances may occur in the lymphatic apparatus of the stomach. In general, far less clinical significance should be attributed to this anomaly of function than to those already mentioned. The experiments of Ogota on animals have demonstrated that the intestines suffice perfectly for absorption, and a number of cases of atrophy of the mucous layer of the stomach recently observed likewise show that condition is not necessarily attended with direct disturbance of digestion. The greatest disturbance of absorption occurs obviously in all conditions of atony; for otherwise it would not be conceivable why fluids easy of absorption remain for a number of hours in the stomach. In diseases of the gastric blood and lymphatic vessels (varicosity, amyloid degeneration, etc.), and likewise in degenerative process of the nerve plexuses and ganglia, disturbances of absorption occur as a rule. In the first named conditions which are alone suscep

tible of clinical observation, the avoidance of food. substances difficult of absorption is absolutely indicated; in these cases peptones, dextrine and similar nutriments may be employed with advantage.

4. Sensory disturbances of gastric origin are either the expression of organic disease, or a symptom of so-called nervous dyspepsia in its varied aspects.

In some cases, especially the first group, we are able by dietetic regulations to effectively relieve the discomfort manifested during digestion. Thus, in gastralgias which result from the ingestion of cold drinks, we can prevent the attacks by strict regulation of the temperature of the beverages. In other cases where similar symptoms are produced by the ingestion of highly spiced, sour foods, the avoidances of such is the proper remedy.

It is somewhat difficult in nervous dyspepsia and allied disorders. In these cases we have no positive data. This is sufficiently obvious from the fact that in this condition that foods are sometimes well borne, while at other times they give rise to severe discomfort. Among these aliments are not, as might be supposed the so called indigestible foods, but rather those whose digestibility is generally recognized. In these cases careful experimentation is required.

As far as my observations have taught me, in all these cases of capricious stomach constant changes are an essential requisite for affording relief; a milk diet and similiar " cures "are nowhere less appropriate than in neurasthuenia.

Of course, examination of the condition of the stomach will furnish some data on which to base a regimen; in general, stringent regulations are not well adapted to any of these cases.

The same may be said of the protean forms of nervous vomiting." Frequently in these cases some charlatan, by prescribing those nutriments which are most difficult of digestion and which the careful practitioner would have never dared to administer, scores a cheap victory.

5. Disturbances of single functions are rare in chronic disorders of the digestive tract; it is only our predilection for this theme that led us to speak of the individual functional anomalies in the foregoing pages. It is therefore essential to consider all the different functions of clinical significance in order to, formulate a rational plan of nutrition in individual

cases.

What has been said is only applicable to cases of idiopathic gastric disturbances, while in cases of secondary impairment of the digestive apparatus the dietetic consideration of the original disease is necessary. That the knowledge of the condition of the digestive functions constitutes, however, an important factor in the treatment of these cases as well, goes without saying,

Medical Society Notes.

NEW YORK ACADEMY OF MEDICINE. STATED MEETING, APRIL 21, 1892. ALFRED L. LOOMIS, M.D., PRESIDENT, IN THE CHAIR.

HYDROTHERAPY.

Dr. William H. Draper said that he included mineral waters in his subject because he regarded the chief benefit from these to be due to the waters. He classified mineral springs according to the ingredients which they contained, referring to several of the celebrated springs as examples.

Passing to a consideration of the physiological and theraupeutic effects of hydrotherapeutics, he believed it was generally accepted that so far as the temperature was concerned it did not matter whether the water was mineralized or not. The immediate effect The immediate effect of cold upon the cutaneous surface was to contract the cutaneous blood vessels. And if this were long continued the heart's action would become weakened and there would be an accumulation of the blood in the systemic veins with the usual signs of collapse. It was the reaction which was usually sought in applying cold water to the surface, a reaction consisting in dilatation of the cutaneous vessels, stimulation of the heart action, rapid re-establishment of the equilibrium in the circulation, even where it was desired to abstract heat from the body in hyperpyrexia. The good effects were probably due largely to the stimulating influence on the nervous system. Nothing was more striking than the influence of the cold bath on the function of the brain and in strengthening the heart's action in certain conditions of hyperpyrexia. Any one who had seen the application of cold for insolation, or high fever, with marked disturbance of the sensorial and spinal functions, must have recognized the startling effect of the cold bath. In emotional shock, spinal irritation, hysteria, and other nervous affections, the influence of cold in reviving the organic functions should be more widely recognized.

The administration of cold required much intelligence, and could hardly be accomplished without the advantages of a well-appointed establishment. There was almost no end to the variety of ways of applying cold in hydrotherapeutic institutions, but it was probable that the method of application was less important than the regulation of the temperature, the force, and wisely and strictly carrying out the discipline. Besides the great value of cold in nervous affections, reference was made to its advantages in arthritic conditions, etc.

The application of heat produced the opposite effect to that of cold upon the cutaneous circulation, causing dilatation instead of contraction of the cutaneous capillaries, to be followed, however, by contrac

tion. The warm bath had been much more commonly prescribed than the cold one. It was mainly indicated in weakly conditions, in muscular and rheumatic affections, sexual excesses, alcoholism, overwork, etc. The warm springs were the last resorts of invalids who had thrown drugs to the dogs. It was difficult to say how much the benefit was due to the baths alone, and how much to the repose, the diversion, the change of air, the hygienic rules enforced at the springs. There was no evidence that absorption through the skin played any important part in bathing with the mineral waters.

The value of water taken internally depended not alone upon the mineral ingredients which it might contain, but also upon the fact that the system called for a large amount of fluids for carrying on healthful function. The whole system of hydrotherapy is a system of scientific hygiene based on physiological principles. Dr. S. Baruch regards hydrotherapy as one of the most potent remedies. In order to entitle a remedy to acceptance by the profession it should fulfill three conditions.

1. Its action must be explicable upon a rational basis. 2. It must be adaptable to exact dosage. 3. It must stand the test of clinical use at the bedside. All these qualifications, Dr. Baruch said, are possessed by hydrotherapy. Its influence upon the nervous system by an excitation of the peripheral nerves followed by a contraction or dilatation of the blood vessels, has been shown by experiments made by Dr. Max Schuller, who trephined a rabbit, thus exposing the pia mater. On putting a cold compress about the rabbit, the vessels of the pia mater were seen to dilate, while on the other hand, when a warm compress was used, the vessels contracted. Dr. Baruch stated that he has successfully treated a number of desperate cases of insomnia by carrying out the idea shown in this experiment, which furnishes a physiological explanation of the action of water.

The dosage of this remedy can be graduated from a minimum effect, by simply using a sponge, to a very severe effect by means of the douche; the thermic effect can be graded from 35 to 110° F. The duration may also be graded. Thus we may dose water better than any medicinal agent.

The clinical test has been again and again satisfactorily applied. In typhoid fever our own Peabody and Dr. Wilson of Philadelphia have confirmed the claims of Brand, Vogil and Zemmossen.

In nervous diseases we have the testimony of Erb and Nothnagel and many others in Germany, and Charcot in Paris. At the Montefiore Home in this city we have succeeded in restoring to their families individuals who have been sent there from other hospitals simply to die. Hydriatic treatment has accomplished this in Phthisis, Chronic Rheumatism, Hystero-Epilepsy and Hysteria.

ditions the most scrupulous selection of foods is, of course, necessary. The varieties of meats which have been rendered by smoking, corning, etc., most resistant to decomposition, are here in place. Of the carbo-hydrates the best are different kinds of white bread, toasted or stale; the fats, even if well borne, should be allowed only in small quantities.

In these cases the quantity of food should also be greatly restricted, and for the time being we should seek to make good the deficiency of food by nutritive

enemata.

If we have to deal only with fermentation of carbohydrates, which is usually combined with abnormal decomposition of fats (characterized by the presence of yeast fungi and sarcinal, of lactic and butyric acids), it is necessary, above all, to restrict the consumption of starches and fats. To what extent and for how long a time such restriction may be enforced without impairing the integrity of the organism is a question on which individual circumstances play so important a part that we are scarcely justified to make specific statements. At any rate, we are warranted in saying that in cases of marked fermentation of carbo-hydrates, with presence of sarcinal and yeast fungi; a temporary meat-diet (for a period of eight to fourteen days) is certainly indicated. Minkowski also praises the results of an exclusive meat diet in this condition. As is known to every experienced physician, however, the enforcement of this regula. tion in practice is soon opposed by insurmountable obstacles which render all curative intentions illusory.

Our knowledge regarding disturbances of absorption as symptoms of gastric disease is meagre if for no other reason than that we are not as yet sufficiently informed concerning the normal course of absorption. Sufficient data are not at hand to settle the question whether independent, genuine disturbances may occur in the lymphatic apparatus of the stomach. In general, far less clinical significance should be attributed to this anomaly of function than to those already mentioned. The experiments of Ogota on animals have demonstrated that the intestines suffice perfectly for absorption, and a number of cases of atrophy of the mucous layer of the stomach recently observed likewise show that condition is not necessarily attended with direct disturbance of digestion. The greatest disturbance of absorption occurs obviously in all conditions of atony; for otherwise it would not be conceivable why fluids easy of absorption remain for a number of hours in the stomach. In diseases of the gastric blood and lymphatic vessels (varicosity, amyloid degeneration, etc.), and likewise in degenerative process of the nerve plexuses and ganglia, disturbances of absorption occur as a rule. In the first named conditions which are alone suscep

tible of clinical observation, the avoidance of food substances difficult of absorption is absolutely indicated; in these cases peptones, dextrine and similar nutriments may be employed with advantage.

4. Sensory disturbances of gastric origin are either the expression of organic disease, or a symptom of so-called nervous dyspepsia in its varied aspects.

In some cases, especially the first group, we are able by dietetic regulations to effectively relieve the discomfort manifested during digestion. Thus, in gastralgias which result from the ingestion of cold drinks, we can prevent the attacks by strict regulation of the temperature of the beverages. In other cases where similar symptoms are produced by the ingestion of highly spiced, sour foods, the avoidances of such is the proper remedy.

It is somewhat difficult in nervous dyspepsia and allied disorders. In these cases we have no positive data. This is sufficiently obvious from the fact that in this condition that foods are sometimes well borne, while at other times they give rise to severe discomfort. Among these aliments are not, as might be supposed the so called indigestible foods, but rather those whose digestibility is generally recognized. In these cases careful experimentation is required.

As far as my observations have taught me, in all these cases of capricious stomach constant changes are an essential requisite for affording relief; a milk diet and similiar "cures "are nowhere less appropriate than in neurasthuenia.

Of course, examination of the condition of the stomach will furnish some data on which to base a regimen; in general, stringent regulations are not well adapted to any of these cases.

The same may be said of the protean forms of "nervous vomiting." Frequently in these cases some charlatan, by prescribing those nutriments which are most difficult of digestion and which the careful practitioner would have never dared to administer, scores a cheap victory.

5. Disturbances of single functions are rare in chronic disorders of the digestive tract; it is only our predilection for this theme that led us to speak of the individual functional anomalies in the foregoing pages. It is therefore essential to consider all the different functions of clinical significance in order to, formulate a rational plan of nutrition in individual

cases.

What has been said is only applicable to cases of idiopathic gastric disturbances, while in cases of secondary impairment of the digestive apparatus the dietetic consideration of the original disease is necessary. That the knowledge of the condition of the digestive functions constitutes, however, an important factor in the treatment of these cases as well, goes without saying,

Medical Society Notes.

NEW YORK ACADEMY OF MEDICINE. STATED MEETING, APRIL 21, 1892. ALFRED L. LOOMIS, M.D., PRESIDENT, IN THE CHAIR.

HYDROTHERAPY.

Dr. William H. Draper said that he included mineral waters in his subject because he regarded the chief benefit from these to be due to the waters. He classified mineral springs according to the ingredients which they contained, referring to several of the celebrated springs as examples.

Passing to a consideration of the physiological and theraupeutic effects of hydrotherapeutics, he believed it was generally accepted that so far as the temperature was concerned it did not matter whether the water was mineralized or not. The immediate effect of cold upon the cutaneous surface was to contract the cutaneous blood vessels. And if this were long continued the heart's action would become weakened and there would be an accumulation of the blood in the systemic veins with the usual signs of collapse. It was the reaction which was usually sought in applying cold water to the surface, a reaction consisting in dilatation of the cutaneous vessels, stimulation of the heart action, rapid re-establishment of the equilibrium in the circulation, even where it was desired to abstract heat from the body in hyperpyrexia. The good effects were probably due largely to the stimulating influence on the nervous system. Nothing was more striking than the influence of the cold bath on the function of the brain and in strengthening the heart's action in certain conditions of hyperpyrexia. Any one who had seen the application of cold for insolation, or high fever, with marked disturbance of the sensorial and spinal functions, must have recognized the startling effect of the cold bath. In emotional shock, spinal irritation, hysteria, and other nervous affections, the influence of cold in reviving the organic functions should be more widely recognized.

The administration of cold required much intelligence, and could hardly be accomplished without the advantages of a well-appointed establishment. There was almost no end to the variety of ways of applying cold in hydrotherapeutic institutions, but it was probable that the method of application was less important than the regulation of the temperature, the force, and wisely and strictly carrying out the discipline. Besides the great value of cold in nervous affections, reference was made to its advantages in arthritic conditions, etc.

The application of heat produced the opposit effect to that of cold upon the cutaneous circulation causing dilatation instead of contraction of the cutar ous capillaries, to be followed, however, by contr

tion. The warm bath had been much more commonly prescribed than the cold one. It was mainly indicated in weakly conditions, in muscular and rheumatic affections, sexual excesses, alcoholism, overwork, etc. The warm springs were the last resorts of invalids who had thrown drugs to the dogs. It was difficult to say how much the benefit was due to the baths alone, and how much to the repose, the diversion, the change of air, the hygienic rules enforced at the springs. There was no evidence that absorption through the skin played any important part in bathing with the mineral waters.

The value of water taken internally depended not alone upon the mineral ingredients which it might contain, but also upon the fact that the system called for a large amount of fluids for carrying on healthful function. The whole system of hydrotherapy is a system of scientific hygiene based on physiological principles.

Dr. S. Baruch regards hydrotherapy as one of the most potent remedies. In order to entitle a remedy to acceptance by the profession it should fulfill three conditions.

3.

1. Its action must be explicable upon a rational basis. 2. It must be adaptable to exact dosage. It must stand the test of clinical use at the bedside. All these qualifications, Dr. Baruch said, are possessed by hydrotherapy. Its influence upon the nervous system by an excitation of the peripheral nerves followed by a contraction or dilatation of the blood vessels, has been shown by experiments made by Dr. Max Schuller, who trephined a rabbit, thus exposing the pia mater. On putting a cold compress about the rabbit, the vessels of the pia mater were seen to dilate, while on the other hand, when a warm compress was used, the vessels contracted. Dr. Baruch stated that he has successfully treated a number of desperate cases of insomnia by carrying out the idea shown in this experiment, which furnishes a physiological explanation of the action of water.

The dosage of this remedy can be graduated from a minimum effect, by simply using a sponge, to a very severe effect by means of the douche; the thermic effect can be graded from 35 to 110° F. The duration may also be graded. Thus we may dose water better than any medicinal agent.

The clinical test has been again and again satisfactorily applied. In typhoid fever our own Peabody and Dr. Wilson of Philadelphia have confirmed the claims of Brand, Vogil and Zemmossen.

In nervous diseases we have the testimony of Erb and Nothnagel and many others in Germany, and Charcot in Paris. At the Montefiore Home in this city we have succeeded in restoring to their families individuals who have been sent there from other hospitals simply to die. Hydriatic treatment has accomplished this in Phthisis, Chronic Rheumatism, Hystero-Epilepsy and Hysteria.