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the means of mechanical disintegration, the selection of additional substances (fats, sugar, spices, acids, etc.); as regards the latter the method of preparation (whether in the orginal form, in jellies, with addition of sugar, acids, etc.).

In the matter of fluid foods and beverages (soups, coffee, tea), the temperature demands especial consideration. As regards alcoholic drinks, it is important to bear in mind the quantity of alcohol and sugar, as regards mineral waters the amount of carbonic acid.

V. We must distinguish between prohibited articles of food and those admissible when properly prepared. The more specific and exhaustive our directions are on this point the greater will be the benefit derived by the patient, and the less frequent the reproach that something has been left unexplained. The quality of the aliment frequently plays an important, part, inasmuch as an admissible food, as for example mutton, may in consequence of its abnormal character (a large quantity of fat, for instance), become a quite indigestible one.

Reliable and useful data for prescribing the proper diet in individual cases, however, are only afforded by an exhaustive knowledge of the function of the digestive organs.

As regards the condition of the stomach we distinguish 1, secretory disturbances; 2, motor disturbances; 3, sensory disturbances; 4, disturbances in absorption; 5, a combination of all of the above.

Secretory Disturbances. The secretion of the gastric juice may be abnormally increased, completey absent or deficient.

If excessively augmented (superacidity) we find in the vast majority of cases that the digestion of albuminoids takes place normally, while that of fats and starches is considerably disturbed or retarded. The cause of the disturbance, with reference to carbohydrates, consists in that the ptyalin, through excess of acids, loses its effects; and the same is true of the pancreatic diastase. The digestion of fats suffers in a similar manner. As is well known, the excessive and continuous secretion of gastric juice causes a precipitation of the bile, in consequence of which its essential ingredients are thrown down, so that the characteristic function of the bile to aid in the digestion of fats, which is not yet understood, is impaired or arrested. The same applies to the pancreas, although the recent investigations of Minkowski have apparently demonstrated that by elimination of the pancreas, the digestion of fats is not interfered with to any marked extent. Inbrief, in the above described condition of excessive secretion, the digestion of albuminoids is excellent, while that of carbo-hydrates and fats is impaired.

From this the following dietetic regulations may be deduced: We should administer strong albuminous foods, such as the firmer layers of beef, mutton, veni

son, but less of white meats. The indigestion of meats having course muscular fibres has a direct curative influence, inasmuch as much larger quantities of gastric juice are required for their solution, and hence only a small amount of acid is left free to irritate the mucous membrane; for the same reason the digestion of starchy food may be greatly enhanced by such a diet. The latter, as well as the fats, are indispensable. We should give carbo-hydrates in an easily assimilable form, if possible in a condition where the conversion has been partially accomplished before ingestion. The substitution for cane sugar, which must be inverted, of grape sugar, which is capable of immediate absorption, is also to be recommended. For the above mentioned reasons we will restrict the consumption of carbo-hydrates to the quantity absolutely required. It is not necessary to explain that vegetables, rich in cellulose, such as cabbage, turnips, etc., as well as rye bread, are to be excluded as much as possible.

The same may be said of fats, but my experience has shown that moderate quantities of good fats (butter and cocoa butter) are as a rule well borne. I, therefore, do not prohibit gravies made of butter, if the latter is prime quality.

An entirely opposite regimen should be adopted in cases where the secretion of gastric juice is entirely or almost entirely exhausted. If we were to reason from a theoretical standpoint we would select here a vegetarian diet, while practically the subject assumes a different aspect. In these cases the digestion of albuminoids is chiefly accomplished in the duodenum, while both the stomach and intestines assist in the digestion of carbo-hydrates. The digestion of fats per se is not at all affected. The dietetic restrictions in such cases apply to the ingestion of albuminous substances. For, although the intestines functionize vicariously for the stomach, the solution of the ingested proteids, which pass into the duodenum almost unchanged, will require a considerable period of time. Aside from this, the stomach is filled for several hours with first compact masses, in consequence of which there are provoked sensations of weight, pressure and fullness. This condition can be considerably relieved by selecting meat that is not too fresh, but somewhat dry, and treating it in a steam kettle until the primi tive muscular fibres are as much disintegrated as possible, and if necessary chopping it fine or rubbing it.

In severe cases of this kind the use of meat powders or peptones is indicated, especially if duodinal indigestion be also suspected (as for example in cancer of the stomach, liver or gall bladder, or cancer of the stomach and pancreas).

Inasmuch as an albuminous diet necessitates a certain amount of caution and restriction, we may supplement it by the administration of leguminous substances rich in albumen (lentils, beans, peas, etc.) whenever it proves insufficient.

Another condition which must be taken into account in prescribing a dietary in these cases is the absence in consequence of the lack of hydrochloric acid-of that factor which exerts a regulating effect upon intestinal decomposition. A considerable formation of aromatic products takes place high up in the intestines as the result of this deficiency, and these may give rise to disturbances, both in consequence of their absorption or their abnormal action upon peristalsis.

This renders it necessary in these cases to restrict as much as possible the consumption of easily-fermenting foods or beverages. In addition, those fats which contain large quantities of fatty acids are to be excluded from the dietary. Good alcoholic drinks, however, on account of their antizymotic effect, are admissible in moderate quantities.

Contrary to what obtains in superacidity, the use of. condiments, especially table salt, is not only to be allowed but positively ordered. Even the more pungent condiments, such as pepper and moderate. quantities of mustard are not contraindicated, since they exert a stimulating effect.

Between these extreme departures from the normal there are found the frequent forms of chemical insufficiency, in which the secretion of gastric juice is not arrested, but more or less reduced. In these we have nearly the same conditions of digestion as in the above, except that a certain amount of albuminous digestion takes place in the stomach, and that the development of aromatic substances is not at all as great as in cases where there is an absolute arrest of glandular secretion. Hence there does not exist the least necessity for instituting stringent dietetic regulations and the chief stress should be laid upon the manner of preparing the food. Our chief attention should be paid to the proper mechanical disintegration of the ingesta, and the stimulation of the secretions by small quantities of spices.

(To be continued.)

Medical Society Notes.

NEW YORK ACADEMY OF MEDICINE, FEBRUARY 11, 1892.

DISCUSSION ON DIPHTHERIA.

Dr. Winters said :-The primary indication was not only to disinfect the parts, but also, so far as possible, to destroy the germs. If in an initial attack the parts could be kept clean and antiseptic the development of the germs would be impeded and blood poisoning to a great extent be prevented. One should avoid in treatment causing irritation at other points, otherwise the spread of the germs and diph

theritic deposit would be encouraged. Moreover, such measures should be employed as would add least to the depression caused by the disease. Whatever was done should permit throughout of the recumbent posture. He condemned without hesitation the practice of placing the child in the arms of an attendant, and then, during its struggles, attempting to make local applications.

The object of local treatment was to disinfect the site of the morbid process, and to prevent sepsis. This could be done effectually only by irrigation. The infant should never be placed in a large bed, but in a crib where it could easily be got at. Before treatment the patient should be placed at one side of the crib, clothes and bedding should be protected by a rubber sheet, there should be a vessel for the fluid to run into. The irrigation should be made with the child in the horizontal posture; it could be made more effectual, and less resistance would be encountered if the fluid were introduced into the nose instead of into the mouth. It would be discharged through the other nostril or mouth. In rare instances it might be necessary to syringe through the mouth, in which case the medium soft rubber tube should be carried alongside the cheek to behind the last molar tooth. The disinfection should be made every two hours, or in bad cases where the deposits reaccumulated rapidly, they should be made every hour day and night. He preferred a ten per cent. solution of peroxide of hydrogen, or a saturated solution of boracic acid. As a syringe he preferred the Davidson with a proper tip for introduction into the nose, and for mouthsyringing he put on the end a suitable piece of rubber tubing. The first syringing at least should always be done by the physician. Mention was made of the steam atomizer, of the spray, of vapors of oil of eucalyptus and turpentine in the room, but the author laid principal stress on nasal or mouth irrigation, and on another measure which he proceeded to mention. Some years ago he had read a paper in which he spoke of the value of sulphurous acid gas in the room of one sick with diphtheria, stating that it relieved the feeling of dryness and swelling much more than any other agent. His own experience while suffering with diphtheria had proven this, and recently he had had corroborative evidence of a physician in Newark, who had made use of it while suffering from this disPatients experienced comfort when the strength of the gas was so great that attendants had to leave the room because of the irritating effect.

ease.

The gas was more efficient in causing exfoliation of the diphtheritic membrane than any other agent. It was generated by burning sulphur candles.

Quarantine and Disinfection in Tenements and Small Apartments; precautions for other members of the family.-Dr. H. D. Chapin read a paper on this subject. The parlor he said, was usually the only

room unoccupied by other members of the family. The child should be placed in this room in a crib which could be destroyed or readily disinfected; not in a bed or on the sofa. A sheet wet in some disinfectant might be hung across the door opening into other rooms, which would act as a danger signal if it did not kill or prevent, the spread of germs. The mother should wear a loose wrap in the sick-room, cast it aside on going into the other rooms. The room should be kept warm enough to permit of lowering a window somewhat. Some authorities thought they had seen benefit from a vapor of oil of eucalyptus, turpentine, etc., in the room. Recognizing the Klebs-Loeffler bacillus as the cause, which was local, care should be exercised to prevent exposure of an unnecessary number of articles to which the disease germs might adhere, such as pictures, books, clothes, etc. The disease, it should be remembered, was both infectious and contagious, although contagious only in a restricted degree. Cheese-cloth or old clean linen should be used instead of handkerchiefs, and be immediately burnt. A local disinfectant should be employed, but not strong enough to be irritating. Bichloride of mercury or boracic acid in solution was recommended. Bed clothing and other clothing should be soaked in zinc solution, and exposed to the sunlight and air on the roof of the house, for sunlight and air were the best and most harmless disinfectants known. Furniture and walls should be washed with carbolic acid, 1 to 20, or corrosive sublimate solution, 1 to 2000. The same might be used to flush the sinks. While bacteriologists doubted whether sul phur fumigation destroyed germs, it tended to sweeten. the room and caused subsequent free ventilation. If possible, the remaining children in a small apartment should be taken away temporarily, and he recommended that the city build houses of refuge. Children remaining in the house should have the nose and mouth irrigated with a solution of bichloride or boracic acid, and should take tincture of bichloride of iron.

Methods of Forced Feeding.— Dr. L. Emmett Holt said: In a disease like diphtheria, where the principal cause of death is asthenia, or exhaustion, no question can exceed in importance that of nutrition and. stimulation.

We may not be able to quell the storm, but in a very large number of cases we may act the part of the intelligent pilot who guides the ship through the storm safely into the harbor.

The greatest difficulties were met in children under three years of age. The most common mistake which he had seen made, and which he believed he had sometimes made himself, was that of overdoing the matter, both of feeding and stimulation in the first few days of the disease. As a consequence it happened only too frequently that when the critical period of

the illness came the overburdened stomach struck and refused to do anything.

The points which he wished to make might be grouped under three heads (1) Character of food and stimulants; (2) Frequency of administration ; (3) Forced feeding.

As to the character of the food, little need be said except in condemnation of two articles often allowed, namely: ice cream and jellies. In his experience. these interfered with taking more valuable food. The main reliance must be upon milk. The addition of a little cocoa was not objectionable if the child preferred. Next to milk were beef broth, mutton broth, expressed beef juice, soft-boiled eggs, milk toast, wine whey, oatmeal or barley gruel, junketwhich might be given cold with a little wine addedkumyss, for children who took it well; but most did not.

Brandy was the best stimulant, but one should be guided by the child's whims and use whatever it would take best. Stimulants should be well diluted, best with mineral waters. If stimulants were badly taken, it was a mistake to mix them with food, since, although this might succeed a few times, the child would soon refuse everything.

As to quantity and frequency, extensive experiments in stomach-washings had proven to him conclusively that a child's stomach was rarely empty sooner than two hours after feeding. He thought we should not give food requiring digestion at shorter intervals than this. But stimulants and predigested foods might be allowed at shorter intervals. The quantity should be less usually than what the same child would take in health.

Regarding stimulants, in his experience one should not begin with them until it was indicated by the pulse and prostration. Then they should be pushed until the desired effect was produced, the only other limit being the tolerance of the stomach. Unlike food, they were best given in frequently repeated doses. He thought it best to decide on the amount to be taken in the twenty-four hours, and let the nurse give it when she could rather than give a definite quantity at definite intervals.

A careful record should always be kept of the amount of food taken and retained.

Forced feeding.-It happened that in quite a large number of severe cases after the fourth or fifth day, sometimes not before the tenth day, that the child absolutely refused all nourishment and stimulants. An immense amount of strength was wasted and little was accomplished in trying to feed such a child by the spoon. It was at this juncture that the question of forced feeding arose. That which most physicians had resorted to was rectal feeding, but in Dr. Holt's hands this had been very unsuccessful, and in young children he now never thought of resorting to it. The slightest amount of rectal irritation was

sufficient to cause the child to relax the sphincter and allow the whole quantity to come away. Rarely could the second, and almost never could the third injection be retained.

nose.

Much more efficacious and with far less disturbance to the patient, was forced feeding by the mouth or The difficulties in the way were surprisingly small. The ordinary apparatus for stomach-washing was all that was required. The preferable position was on the back. In his experience the milk or other food had rarely been vomited; the mouth was to be chosen instead of the nose in most cases, unless there was much resistance. A trained nurse could with little practice do the feeding, with the assistance of one person to hold the head. Completely peptonized milk or kumyss had been used most by him. If repeated once in four hours a proper amount of nutriment could be introduced with far less worry and disturbance than attended spoon-feeding. Stimulants could be mixed with the food.

Constitutional Treatment in Diphtheria.-The remarks of Dr. Winters on the local treatment of diphtheria met with his full approval. Corrosive sublimate was used by himself internally, and also by many other physicians, and in children suffering with diphtheria it showed very little tendency to produce any stomatitis or diarrhea. It was administered in very small doses, largely diluted, at frequent intervals.

Where sepsis had developed, it. could be got rid of only by elimination, and it was necessary here to keep up the child's strength. Too often the case was allowed to run along until the pulse had gone up very high, and prostration had become marked. Then it was too late to give one's remedies.

Do not waste time for results to follow administration by the stomach in severe cases, but resort to hypodermic medication.

Sub-membranous Injections.--Dr. A. Seibert had the past year and a half treated diphtheria when limited to accessible spots by sub-membranous injections of chlorine water, stronger than the officinal chlorine water. He had lost only one case of diphtheria in a year; patient had already pronounced constitutional symptoms.

Dr. J. Lewis Smith had observed treatment by peroxide of hydrogen in the hands of several physicians, and advised its dilution one-half with water for the mouth, two parts water when used in the nose. Personally had found ten per cent. strength irritating and quite disagreeable. Dr. J. Lewis Smith said regarding the vapors of oil of eucalyptus, turpentine, and carbolic acid, that in his experience this tended to prevent further infection, was protective to the attendants, and in harmony with the observations of an Australian physician, he had found that where used, the patients were less likely subsequently to

have diphtheritic paralysis. He had not had a patient with diphtheria show diphtheritic paralysis in five years.

Dr. Smith also cautioned against standing in front of the child when examining the throat. As a like precaution Dr. Allen recommended the interposition of plain glass between doctor and nurse, as was employed in Vienna. Dr. Stowell spoke of the efficacy of peroxide of hydrogen in dissolving the diphtheritic membrane. Dr. Berg thought a chief cause of spread of diphtheria was failure on the part of the Board of Health to notify schools soon after the physician had sent in his report.

Dr. Fischer had collected germs in the air of rooms where diphtheria existed, and in adjoining rooms, some of which were the Klebs-Loeffler bacilli, others of a different nature. Culture tests were made, and the animals had died with the usual symptoms.

Literary Notes.

A System of Practical Therapeutics. Edited by Hobart Amory Hare, M. D., Prof. of Therapeutics in Jefferson Medical College, Philadelphia, assisted by Walter Chrystie, M. D. Vol. I.: General Therapeu

tic Considerations-Prescription Writing-Remedial Measures other than Drugs-Preventive MedicineDiathetic Diseases and Diseases of Nutrition. With illustrations. Philadelphia: Lea Bros. & Co., 1891.

Distinctly American in scope and treatment, although containing some valuable contributions from English authors, this volume forms a practical addition to our therapeutical knowledge which is a monument of interesting and original research.

The articles contained in it are: General Therapeutic Consideration, by Prof. Horatio C. Wood; Prescription Writing, by Prof. Remington; Electro-Therapeutics, by Dr. A. D. Rockwell; The Rest Cure, by Dr. John K. Mitchell; Swedish Movements and Massage, by Dr. Benjamin Lee; General Exercise, by Dr. E. M. Hartwell; Climate, by Dr. S. E. Lolly; Hydrotherapy and Mineral Springs, by Dr. Simon Baruch; General Sanitation, by Dr. II. B. Baker; Disinfection, by Dr. George Sternberg; Antisepsis and Asepsis, by Dr. J. William White; Nutrition and Foods, by Dr. J. Burney Yeo; Tuberculosis, by Dr. Solomon Solis Cohen; Scurvy, by Dr. John B. Hamilton; Diabetes Mellitus, by Dr. Frederick A. Packard.

The volume being intended as a companion to Pepper's System, it will probably attain a popularity equal to the latter work, as it contains a perfect mine of information on the subjects treated, and the selection of the matter and the author's best fitted to treat it does great credit to the skill of the editor. The mechanical execution is like all books bearing the imprint of this staunch house, unexceptionable.

THE

short his allotted existence. The prevention of such interference is at once the crowning duty and triumph

Dietetic and Hygienic Gazette; of our art; the striving after this end the 'Highest

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THE HIGHER FUNCTIONS OF MEDICINE. Upon this subject the Jenkins Medical Association of Yonkers had the privilege of being addressed by one of the few true orators of which the medical profession in this country may boast.

Dr. T. Gaillard Thomas, the man who most truly represents the profession, inasmuch as he is a specialist who for a long time previously to his becoming a gynecologist,stood high as a general practitioner in this city, is peculiarly fitted to tell the profession in what the higher functions of medicine consist.

He says: "Time was when one would have been deemed sacreligious who dared maintain that any higher functions could attach to the science and art of medicine than that of healing the sick; who asserted that a nobler, loftier sphere existed than that of going from house to house, from village to village, carrying comfort and cure to the suffering and afflicted. But times have changed and we have changed with them.' A higher duty of medicine is recognized to-day in the medical education of mankind; the instruction of the masses of the world in those means and methods by which disease may be prevented and death deprived of its supremacy and its power."

After describing the natural method of dying he says: "Man dies at an earlier period only when some accidental interference with the plan of nature cuts

Function of Medicine."" Dr. Thomas well foresees that he will be charged with enthusiasm when his optimistic views of the future of medicine shall be known. He claims that in one hundred years the contagious diseases-scarlet fever, measles, vericular, whooping cough, typhus fever, cholera and yellow fever-will be as effectually stamped out as smallpox is to-day; that the deaths from phthisis will be diminished by three-fourths, and the mortality of cancer can be greatly altered for the better. The author sustains his proposition by the simple reference to the feats accomplished; the diminution of puerperal fever, hospital gangrene, trismus nascentum tetanus, hydrophobia, cholera and yellow fever.

He justly lays stress upon the great promise that lies hidden in the present agitation in hygiene, experimental physiology and dietetics. To day a few men out of every generation live to a hundred years of age; in fifty years many more may reach that age, and a century hence it may be a common occurrence. Even with all the drawbacks of to-day the age of 80 is not rarely arrived at. The men who reach it now have been damaged by diseases of early youth and mature manhood; have depreciated their tissue by impure drink, by unhealthy food and by vitiated atmospheric condition; all of which it is the function of the next century to greatly improve.

Dr. Thomas feels justified in his optimistic predictions, by the realization of events, once thought as improbable as his prediction seems to-day, such as the surprising feat of Tanner, who fasted forty consecutive days and nights, without dying; the feat of horses trotting a mile in two minutes and nine seconds; the passage of steamships across the Atlantic in less than six days and the power of whispering into each other's ears between New York and Chicago.

That there is cogency in this argument cannot be denied. These marvellous feats have become realizations only by the application of scientific principles based upon physical laws. The further study of the possibilities of the latter must, in the course of evolution, accomplish results that may seem more astounding to our successors than are those we witness today.

As we have repeatedly said in these columns, it is our firm belief that the recognition of simple cleanliness as the chief preserver of beauty and life, will accomplish marvels in the prevention of disease. Whenever men, women and children shall appreciate the lessen to eschew dirt as they would sin, that the one contaminates the body, as they are now taught the other contaminates the soul, a broad vista of health, comfort and happiness will be opened to the human The cleanliness referred to here is not simply

race.

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