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and children had to be made the same as the diagnosis in aborted types of the disease in adults, namely, by exclusion mainly.
Dr. Jacobi had made the diagnosis of typhoid fever under two years, and had seen a few autopsies. The diagnosis in most cases was made by exclusion. If he saw a case with a moderate amount of fever lasting some time, without any local symptoms to account for it, or if there were two temperature curves in twenty-four hours for some time, it was typhoid fever unless there was good reason to take it for intermittent duplex. If the fever was well tolerated it would lead to the suspicion of typhoid. When there was a roseola, and the spleen could be felt under the ribs it was typhoid fever.
Dr. Earle, in closing, had but a few remarks to offer: I was afraid of relapses and guarded against them, and the additional diet which was allowed at the end of two full days without fever was very bland and easily digested, and when the little patients were restricted to it no relapse took place. At first it would be a little milk or cream toast, then the following day a softly cooked egg, and the third day a baked potato with considerable butter, and always with the instructions that if flatulency or any discomfort was produced a return to fluid food must take place. This care and general increase in food was exercised for at least two weeks before they were taking what I believed was sufficient for their nutrition.
It is probably hardly worth while for me to try to make Dr. Northrup believe that children under two years of age have typhoid fever. have typhoid fever. I admit the value of his very extended pathological study and observation, but notwithstanding this a considerable number of our ablest practitioners believe they have seen this disease in children under the age specified. In my judgment it will be but a short time before we are in possession of as many facts regarding typhoid in infants as we now have concerning it in adults.
ANNUAL OF THE UNIVERSAL MEDICAL SCIENCES. A yearly report of the progress of the general sanitary sciences throughout the world. Edited by Chas. E. Sajous, M. D., and seventy associate editors, assisted by over 200 corresponding editors, collaborators and correspondents. Illustrated with chrome-lithographs, engravings and maps. The F. A. Davis Company, Publishers, Philadelphia, New York, Chicago and London.
The fifth appearance of this great cyclopaedic gatherer of medical information justifies the editor in the mild gratulation which he indulges. The editorial
staff consists of men whose names are a guarantee for a truthful reproduction of all that is of value in medical literature. In the present volume two editors have been added, Dr. John O. Droyer for “Intubation," and Dr. Simon Baruch for climatology and balneology, to which has been added a section in "Hydrotherapy." In these days of rapid progress, large works are often far behind the times after the lapse of
a few years. To the professional man whose means do not admit of the constant purchase of new books, the Annual brings the library abreast of the foremost progress every year at a comparatively small cost. It has the advantage, too, of covering every branch of medicine, which it would be impossible for any practitioner to obtain. In localities remote from the great medical libraries, such an annual compilation is a work that can only be appreciated by those who, like this writer, has lived for many years in such a locality and longed for just such communion with the whole. medical world as Sajou's Annual affords. PROF. BILLROTH'S CLINIC, is one of the series of pictures published by Wm. Wood & Co.
This large and life-like representation of a familiar scene must add greatly to the attractiveness of the office or library.
THE READY-REFERENCE HANDBOOK OF DISEASES
OF THE SKIN. By George Thomas Jackson, M.D., chief of clinic and instructor in dermatology, College of Physicians and Surgeons, New York, etc. With fifty illustrations, pp. 113. Philadelphia: Lea Bros. & Co., 1892.
This is essentially a book for the practitioner, who is but too often bewildered by the numerous divisions and subdivisions of dermatologists. As an earnest of what the reader may expect if he consults this excellent work, we quote from p. 41: At present a new remedy is brought out nearly every month that promises to be better than any of its predecessors and tried ones. It is better for the general practitioner to learn how to use a few drugs than to try every new thing. By practical experience he will be surprised to see how much he can accomplish with a very small assortment of drugs." "Some Dermatological Donts," on p. 49 to 52, is a feature of the book, whose observance will save the practitioner many regrets and the patient much annoyance.
This volume is practically a dictionary of skin diseases, but its reading is far more interesting and instructive than the terms would imply. Many of the words may well have been omitted, but as the author had the privilege of Dr. Foster's great work, he doubtless was anxious to let his readers share this privilege.
Altogether Dr. Jackson has given us the fruit of many years study, and of a knowledge required in intercourse with pupils, a real "Ready-Reference Book" on skin diseases.
REST AS A CURATIVE AGENT.
THE modern physician has reached the conviction that his most potent curative agents, the means by which he expects not only to alternate symptoms, but cure disease, are the so-called physical agencies, viz.: those which nature herself employs in restoring health. Among these rest stands preeminent. In the vegetable kingdom the most casual observer must be struck by the simplicity and thoroughness with which the vegetable organism repairs damage inflicted by accident or design. The partly broken limb of a tree is restored to its usefulness and resumes its function if the fracture is not too extensive to prevent rest and consequent reunion of the injured parts. The gardener observing nature's method, places a splint of wood, paper or cord around the young tree, which has been injured by the storm, thus maintaining the restorative powers residing within it. The circulation of sap being uninterrupted, repair goes on rapidly, and usefulness is restored.
The surgeon, recognizing that the human organism is perfectly competent to restore the broken ends of a bone to their previous integrity, even in enfeebled subjects, provided absolute rest is permitted to the limb, simply secures the latter, arranging his splints so as to overcome voluntary or involuntary muscular action, and thus aid nature in absolutely curing an irretrievable injury.
The physician has frequent occasion to observe the
effort of nature to place inflamed serous membranes at rest, by the effusions of coagulable lymph, which interferes with the friction of the inflamed surfaces upon each other. When the disease is removed the lymph is absorbed, the splint is removed.
The modern physicians, realizing that disease is in many cases but the manifestation of an effort of nature to repair certain damages from which the organism is suffering, no longer seeks to throttle the disease by powerful remedies. He has learned from the history of medicine that these are two edged swords whose blades may turn upon the patient the very edge which should be directed to the disease. He recognizes the fact that if he would succeed in overcoming the lethal tendencies of disease, he must watch nature and observe the direction in which she endeavors to reinstate normal conditions.
This is, indeed, a trite observation. Vis Medicatrix Naturae has long been a recognized power in therapeutics. But it is, alas, the most neglected of all the agencies presented by the latter. Brought forward. by the father of medicine himself, contending factions have buried it under technical love and polypharmacy, so that the student of medicine has caught only occasional glimpses of this most efficient of all his aids.
Among the most evident elements of this vis medicatrix we find rest to the diseased organs, enforced by their constant rebellion against activity and by the vicarious action imposed upon one organ when another is diseased.
In diseases of the stomach, for instance, is its mucous membrane inflamed, it rejects all food, thus manifesting its demand for rest. The judicious physician follows this natural pointing and refrains from giving the organs any work to do. Even the most bland articles of food are eschewed by him. Unlike his less prudent colleague, who, haunted by the ghost of starvation, continues to give nourishment only to see it rejected, he withholds food and drink absolutely, for hours and days if need be. How much more rational such a proceeding is than a blister to the epigastrium, or a mercurial purge or an anodyne mixture, clinical observation has rendered trite and commonplace. And yet there are physicians who, rendered anxious by the apprehension of friends and bystanders, obey their fears rather than their judgment and allow the patient to take just a little of this bland food, or that peptonized preparation or the other concentrated nutriment. In severe ulcer of the stomach, which is a chronic disease, and therefore demands abstinence, which may be fatal, the judicious physician utilizes the well-known absorbent capacity of the lower intestine, and endeavors to prevent starvation by nutritive clysmata.
The difficulty of placing other organs completely at
rest, is probably a reason why rest is not more frequently resorted to in the treatment of their diseases. We may reduce the labor of the heart by reducing its pulsations by physical and mental rest. The difference in the average pulsations of the heart between the horizontal and vertical position is about six per minute. This would give us a reduction of labor of about one-eighth.
Moreover, rest in bed saves much labor to the muscular and heat regulating systems, all of which make great demand upon the circulation. The disadvantages of rest in bed must be carefully guarded against, in chronic as well as acute diseases. The patient may lie quietly and well protected in the open air.
The exhilaration induced by pure air and the cheering influence of sunshine and communion with nature, the removal from the deprecating environments of the sick chamber-all these may accrue to the patient's benefit, while the great restorative, rest, is being
Another method of resting the ever active heart may be found in widening the peripheral stream bed. In arterio-sclerosis, for instance, we have in the resistance of the rigid peripheral vessels additional labor thrown upon the heart. Nitro-glycerine has been found useful in neutralizing it to a great extent.
In infectious fever the paresis of the peripheral vessels adds to the labor of the heart, because the latter is deprived of the propulsive agency of the coats of the smaller vessels. The cold baths, judiciously given with friction of the body, widens the cutaneous vessels, as is evidenced by their turgor; it removes the paretic state, and this is the reason why the patient's pulse is usually reduced 15 to 25 per cent. in frequency and increased in force. This affords actual rest to the heart for the time being, and must conduce to the cure of a disease which kills by exhaustion of the organs through their enfeeblement by toxic elements circulating in the blood.
In diseases of the lung the same principles apply. Although these organs are necessarily laboring without cessation, and although their own integrity depends upon their constant expansion and ventilation, it becomes evident to the clinical observer that in disease much labor is thrown upon them which may be spared by proper adjustment.
Avoidance of any movement of the body as far as possible; rest in the semi-recumbent position and disturbance and especially conversation, which makes great but not usually noticed demands upon the mobility of the diaphragm and respiratory muscles; these are measures by which the ever laboring lung may be enabled to lose 10 to 25 per cent. of its respiratory excursions.
The rest cure of Weir Mitchell has become a classical method of treatment, which has rescued from con
firmed and painful invalidism a horde of valued members of society. Its rationale is based upon judicious rest, accompanied by judicious feeding. If the same methodical rest were applied in other diseases, the results would be astonishing. Only recently the genial author of the rest cure has given the world an illustration of the value of this greatest element of the vis medicatrix in his lecture on sciatica, (International Clinics, Ap., 1891, p. 279). He advises to put the patient's leg into the old fashioned Physicks splint, extending from the axilla to beyond the foot; care being taken that the heel does not carry the weight of the leg and that the knee can be maintained in slight flexion to be changed a little at each dressing. This method has been successfully used by Dr. Mitchell and Dr. Osler, in many sciaticas, that have defied more elaborate treatment. Mitchell in explaining the rationale says: "All inflamed tissues do better at rest, a doctrine which nature is not slow to teach. I have taken one of the hints and carried it out." It would be a happy consummation if all physicians would follow this wise and successful man's course.
There is scarcely a malady, acute or chronic, in which it may not accrue to the sufferer's benefit. And yet, how rarely it is resorted to with systematic design, is easily gathered from the fact that rest is rarely treated in works on therapeutics. writer has before him at this moment the two most recent American works, in neither one of which it is even mentioned in the index. One of these is a text book in all our colleges, and the other is a noble work of three volumes, which was written, as the preface says, "with the object of providing the practitioner of medicine with reliable and helpful information concerning the best and most recent methods of curing disease." Both contain articles on Weir Mitchell's rest cure for neurasthenia and hysteria, but although they treat of exercise, climate, electricity, hydrotherapy, mineral springs, food and every other remedy, rest, which is surely as important as any of these and more universally applicable than these, receives not a single chapter.
THE FOLLY OF THE COLD COIL.
The merchant finds it needful to his prosperity to close his doors, at stated times, in order to take an inventory of his possessions. The medical profession may, with advantage, imitate the practice in order to ascertain the real value of some of his aids in curing disease. Among our most vaunted remedies are heat and cold. Properly applied these are probably our most universally applicable therapeutic resources. Their imperfect or perverted application, however, has worked more harm than most other remedial measures, because the effect is not so readily traceable as that of poisonous medicinal agents.
The cold coil has long been vaunted as a superior agent for reducing general temperature. Indeed, the writer baving had occasion to consult a leading teacher in a case of typhoid several years ago, was surprised to learn that he always succeeded in reducing temperature and diminishing complications by the application of an abdominal coil through which ice water was made to flow constantly. Although the writer doubted the correctness of the gentleman's observations and deductions, his theoretical objections could not be sustained by the same clinical experience which the consultant brought forward and he therefore yielded to his view.
In a recent lecture by Dr. W. Gilman Thompson, who, as professor of physiology in the University of New York, has certainly the means and opportunities for exact observations, and who, fortunately, has also the means and opportunities for clinical observations as physician to the New York and Presbyterian Hospital, the subject is well brought out. (The Reduction of Temperature in Typhoid Fever, International Clinics, January, 1892, p. 3). "I have always doubted," he says, "of the cold abdominal coil or a compress, whether it were possible in any way to affect deep seated vessels in this manner. I therefore etherized several dogs, shaved the abdominal wall, and made a small incision in one side of it, through which a long stemmed thermometer was passed to the opposite side of the abdomen. Where the thermometer was felt beneath the skin, an ice coil was applied for an hour. So long as the dog's circulation was maintained, the thermometer remained uninfluenced, but as soon as the dog was killed, the temperature of the abdominal cavity began to fall very rapidly. Heat applied by poultices showed a corresponding behavior. Hence, as long as the circulation is fairly good, it appears to be impossible to influence, materially, the deep seated vessels by external local contrasts of temperature, certainly impossible to control hæmorrhage by those means, and practically I have never seen any benefit from such attempts. If any exist it comes through very circuituous cutaneous reflex action."
Dr. H. C. Coe, who as pathologist to the Woman's Hospital in this city for many years, has had ample opportunity for observation and whose accuracy of statement and learning are beyond cavil, has informed the writer that he has seen the abdominal parietes almost frozen, without the slightest effect upon the subjacent inflamed peritoneum as observed in post mortem examination.
It would seem from these actual observations that the cold coil is a myth as a reducer of inflammatory conditions within the body, and certainly still more of a fallacy as a reducer of general tempera
It is an expensive apparatus which is doubtless use
ful in local superficial inflammation, but it should be relegated to innocuous desuetude as an anti-thermic agent, because it gives the physician a sense of false security which may preclude the application of more efficient agencies.
It is bad stock, as the merchant would say, and had better be so estimated in an inventory of our remedies.
CARBO HYDRATES IN VARIOUS FOODS. In reply to a correspondent, the following is given from Juergensen, (Copenhagen): Milk, 4.8; Cream, 3.5; Buttermilk, 3; Whey, 5; Butter, 0.8; Fresh Curd, 2.05; Rice, 76; Wheat flour, 73; Rye and Barley flour, 72; Oatmeal, 64; Peas, 53; Beans, 51; Sago, 82; Cane Sugar, 95; Potatoes, 20; Carrots, 9; Cauliflower, 11; Spinach, 3.5; Cabbage, 5.5; Fresh Apples, Pears and Cherries, 12; Fresh Plums, 8; Goose and Strawberries, 7.5; Turnips, 10; Asparagus, 2.5; String Beans, 7; Dried Apples, Pears, 58; Dried Cherries, 45; Prunes and Raisins, 62; Liver Sausage, 6.5; Pea Sausage, 29.5; Blood Sausage, 25; Frankfort Sausage, 2; Weissbier, 6.5; Porter, 7; Kumyss, 2; Rice Milk, 24; Scrambled Eggs, 1.5; Omelette Souffle, 25.5; Kefir, 2; Rye Bread, 48; Wheat Bread, 52; Zwieback, 77; Noodles, 77; Macaroni, 77; Cake Chocolate, 68.
DIET IN GOUT.
BY SIR WILLIAM ROBERTS ABSTRACT OF CROONIAN LECTURES BEFORE THE ROYAL COLLEGE
In dealing with the therapeutics of gout I shall confine myself to those points which have a clinical bearing, and which can be brought into touch with the results of the foregoing investigation. According to the views developed in these lectures, the mischief done by uric acid in gout is contingent on its precipitation as crystalline biurate in the tissues or in the fluids of the body. Within this limited scope the study of the treatment of gout resolves itself into a study of the means we possess of controlling the factors which promote or hinder this precipitation. These may be divided into those which belong to the domain of diet and regimen, and those which consist in the administration of medicinal substances. It has been shown that one of the main factors in determining uratic precipitation is the percentage of urates in the medium. Other things being equal, the larger the proportion of urates present the earlier and more abundant is the deposition of the chrystalline biurate. Our power of controlling this factor lies almost entirely in the direction of regulat
ing the diet. Numerous experiments have been made on the effect of diverse kinds of food on the production and excretion of uric acid. The chief point of therapeutical interest that has been clearly made out is this, that the ingestion of large quantities of proteid matter is attended with an increased production of uric acid, and vice versa. It does not appear clear that proteid substances derived from the animal kingdom differ in this respect from those derived from the vegetable kingdom. But inasmuch as the commonly used articles of food of animal origin, such as butchers' meat, poultry, game, fish, eggs and cheese are richer in proteid stuff than the commonly used articles of vegetable origin, such as bread, oatmeal, rice, potatoes, and garden products, it is true that a vegetable diet is less productive of uric acid than an animal diet. The most trustworthy experiments indicate that fat, starch and sugar have not the least direct influence on the production of uric acid; but as the free consumption of these articles naturally operates to restrict the intake of nitrogenous food, their use has indirectly the effect of diminishing the average production of uric acid. There may be, and, indeed, undoubtedly are, other differences between animal and vegetable articles of food, and between one article and another of the same class, which are highly important. They differ considerably among themselves in their indigestibility, and in their stimulating qualities, but in regard to the point under review, namely their direct influence on the uric acid, articles of diet must, as far as our present knowledge goes, be classified according to the percentage of albuminoid matters contained in them. As a rough guide As a rough guide in the choice of food for the gouty, the subjoined table may be useful.
Table showing the Average Percentage of Albuminoid Matters contained in diverse Articles of Food. Animal Food.
Albuminoid Matters. 19 per cent.
essary than in gout to consider the man as well as the ailment, and very often more the man than the ailment; but the general rule in reference to the point under notice is, I think, pretty clear. Gouty people should be advised to partake cautiously of butcher's meat, foul, game, and cheese, and to partake as freely as their digestion will permit of bread, rice, garden vegetables, salads and fruit. The advantage to be gained from an adjustment of the dietary on these lines may be inconsiderable or even inappreciable in cases of inveterate gout, but it may be of critical moment in the slighter cases. A diminution of one or two grains per day in the amount of uric acid thrown into the circulation may make all the difference between the occurrence or non-occurrence of an arthritic attack.
INFLUENCE OF SALT.
The solubility of sodium biurate is conspicuously influenced by the proportion of sodium salts in the medium. I observed, in my experiments on the maturation of blood serum, impregnated with uric acid, that the addition to the medium of small quantities of sodium chlorate (0.1 per cent., or even less) always appreciably hastens the precipitation of the crystalline biurate. It has also been shown that the topographical distribution of uratic deposits through the body, bears a close and striking relation to the percentage of sodium salts contained in the several organs and tissues. Indeed, it might apparently be said with truth that if we possessed the power of regulating the dosage of sodium salts in the fluids and tissues, we should be able effectively to control the occurrence of uratic depositions. Our power in this respect is, however limited. Sodium salts belong to the physiological constants of the blood, and their proportion therein can only be modified within a comparatively narrow range. These remarks apply especialy to the most abundant of them--the sodium chloride. It has been found in experiments on animals that when common salt is given in excess with the food, or injected in the veins, the surplus is, for the most part, quickly removed by the kidneys, and there is only a small and transient increase of its percentage in the blood; and, conversely, when animals are fed on food abnormally poor in salt there is only a slight falling off in its proportion in the blood, for it almost disappears from the urine. The blood clings with great tenacity to its proper percentage of sodium chloride, and the experimental evidence indicates that in case of a threatened salt famine within the economy the blood has the faculty of supplying its necessities by extracting salt from the less vital fluids and tissues; and, contrariwise, in case of a glut of salt in the blood, the overplus is temporarily passed over into the serous cavities until such time as the kidneys have succeeded