ical men. It has long been known that a very severe burn, covering a large extent of skin, has as one of its secondary dangers a peculiar form of disease of the kidneys, and this has been traced to the increased work placed on these organs by the destruction of so many millions of the little vessels we call pores in the skin. In other words, precisely the same action is set up after such a burn as that which takes place when nature closes the pores, but in the former is more or less permanent. Increased effort is thrown on the kidneys to eliminate from the blood the waste matter and this increased effort being abnormal, brings disease with it in time. For, while the parts of the body may be trained to do that which nature never intended they should, it is impossible to interfere with the balance of the organs which together carry on the processes of life without disturbing them and inducing that injury to them we call disease.

In "railroad kidney" we discover cognate symptoms to those found in these organs after any very extensive burn. Reasoning, therefore, from results, we say that "railroad kidney" is caused by an artificial stoppage of the pores of the skin, the dirt of the railroads being responsible for such stoppage. If any person will examine his hand after riding for two or three hours in a car-and this is especially true if he be perspiring he will find the hand is dirty. But a closer examination will show the existence of a fine grime, the particles of which, so soon as the perspiration ceases, act as minute corks stopping up the orifices of the pores. How deeply this grime works into the skin is shown by the fact that after a railroad trip one washes one's hands and face two or three times before they become clean. It is this grime which It is this grime which produces railroad kidney. The sufferers from it are members of that class in the community ordinarily known as railroad men and in the cases of some engineers, conductors or brakemen the effects become very marked. Of course, it is not to be supposed that an ordinarily healthy person will contract this disease in any trip of a day or two. But where a person is already a sufferer from chronic disease of the kidneys, it is possible that a week on railroad trains would aggravate his malady to an appreciable extent. Still, for all practical purposes, the travelling public need not fear kidney diseases.

But persons travelling on a railroad are exposed to many things which may bring sickness of one kind or another to them. First and foremost among these are the draughts inseparable from railroad cars. These may come from an open door, window or ventilator, and will act on the person exposed to them just as any other draughts might. More particularly is this true in summer when for the most part it is very hot in the cars and when people suffering from the heat open the windows for relief. It is not strange that when a draught is turned on to one in a violent per

spiration, checking this suddenly, there should result a severe cold; and the danger from this is greatest at night. Personally I have never seen a sleeping car in which draughts did not make themselves felt. In order then to escape from the ills these will bring with them we must prepare ourselves for them.

Persons who travel should see to it that flannel or wool in some shape is worn next to the skin. These flannel underclothes should not, unless the trip be long, be changed while the wearers are on the road. Important as they are for grown people they are even more necessary for children, for the latter being much more apt to take cold, protection becomes more imperative. Nowadays we are much given to laughter over the nightcaps our forefathers and foremothers wore, but beyond question these nightcaps were not without their use in times when every window poured a draught of cold air into the room. In travellingthe conditions being the same-we should go back to them and should not sleep without some soft clinging cap over the head. Again, this is peculiarly necessary for children and for women who are weak, while men with the fashionable baldness of these days will find great comfort and not a little safety from some covering for the head.

Warm socks for sleeping in are almost as necessary as the caps, and should form a part of every traveller's outfit. For women and children nothing is better to sleep in than warm blanket wrappers. These should be of a good length, button up high in the neck and be loose enough to be comfortable.

Comfort on the railroad may be secured at a small outlay, and comfort has, in travelling as in every other experience in life, a distinct hygienic value. First and foremost among the appliances for comfort I rank the sponge in the rubber bag. This is carried in the travelling satchel and kept damp. At any time. when the face is hot and dirty it can be used, and if you then have a thick, soft towel with which to wipe. the face perfectly dry, you will be surprised at finding yourself so much refreshed. I have never known a person who had tried this simple little addition to the traps, willing to be without it. The cost is as nothing compared with the actual pleasure resulting from its use. And in travelling one wants to be able to assume that position at any time which is the most pleasant. Consequently the clothes should be loose and should be those in which a wrinkle or two causes no uneasiness. Old clothes, therefore, are much better than new and old shoes or slippers will add not a little to one's enjoyment of the trip. For women as well as men a soft travelling cap, preferably one that may be slept in, should never be left behind.

In this country as in othe. it often happens that it becomes necessary to travel with the sick. Those things which diminish pain or add to the comfort of persons who are ill are doubly needful under such cir

cumstances. The strain on the sick when travelling is very severe and no precaution is too great to take which will lessen this in any way. A travelling bag should be especially fitted up for the journey. In it must be placed a sponge in a bag, two or three soft towels, plenty of clean handkerchiefs, one of these little alcohol stoves or lamps with cups of tin in which fluids may be heated, a bottle or flask of alcohol, another with strong home-made beef stock out of which to make beef tea, lemons and sugar and salt-the latter two in covered tin boxes-and possibly a bottle of effervescing fruit salts with which to make cooling drinks. Nowadays drinking water can be obtained in any car. In shawl straps should be carried one or two rugs, folding boards and not less than two pil lows. These folding boards were the invention of a lady I knew who suffered from lameness, and they are the best things I have seen for any person who wishes to rest the legs. In order to make one a piece of wood eight inches wide and three-quarters of an inch thick is taken. It must be three feet, four inches long, or long enough to rest about an inch and a half to two inches on each seat when it is placed across from one seat to another in a railway car. It is sawn in two in the middle and two strap hinges are firmly screwed on one side. Folded, it goes in the shawl straps perfectly, and when it is opened out with the hinges on the under side and placed from one seat to the other it forms a perfect support for the leg. One, two or three of these boards may be carried when for any reason it is impossible for a sick person to lie down, and with their aid a very respectable couch can be male out of two seats in a car and the rugs, or in default of them, the blankets will make the sufferer fairly comfortable.

The reason why home-made beef stock is better for invalids than the many beef extracts on the market is very simple. As a rule they like it better, and other things being equal we should always give the sick that which they like to eat. To make this stock pur chase a shin of beef, cut all the meat off carefully and into pieces about the size of walnuts. Put these into an agate lined saucepan or pot, cover them with not less than three quarts of water and boil them very slowly for six hours. It is impossible to boil them too slowly. Strain out all the meat and put the soup away to cool. When cold skim off all the fat, put the soup on the fire and boil it slowly down to one pint. Warm the glass jar or bottle in which it is to be carried (tne jar is the better of the two as being more convenient), pour in the stock and let it get cold. It will then become jelly. A tablespoonful of this put into the cup over the lamp can be heated with half a pint of water, and the result will be a very good cup of beef tea.

It often happens that a person who is sick is intensely annoyed by the light and noise in the ear.

Giving them cotton wool to put in the ears will greatly lessen the latter, and for the former a most simple expedient will give relief. This is to hang up on the side of the car on which the patients eyes naturally rest, a dark shawl. If this be a dark green color, so much the better, but if not, it should be gray or brown. Do not use one in which there is a flaring pattern of any kind, or in which bright colors have been employed for it would be worse than useless.

As a matter of course when travelling with the sick, medicines are carried. These are not only those precribed by the physician for that particular case, but they should also include remedies for emergencies.

The full list of these would include a flask of good whiskey, a dozen cathartic pills, a bottle of Squibbs or of the Sun cholera mixture, quinine pills (2 grains), compressed tablets of phenactine (5 grain) for headache or fever, a menthol point, six ounces of soap liniment, a sufficient quantity of adhesive plaster, a box of absorbent cotton, a roll of inch and a half bandage, a dozen safety pins, and a measuring glass. This list contains all that could be needed for emergencies in the great majority of cases. As, however, every case of sickness has its especial needs, the list of emergency remedies should be submitted to the attending physician for revision. He may add to it or may declare that some things mentioned above are useless, and his advice should always be followed.

When travelling with children, especially very young children, full preparation should be made to meet those ailments which are immediate in their demand for treatment. For colic, five or six drops of the Sun or Squibbs cholera remedy in water and given every half hour will bring relief. Of course in giving this or any other remedy to a little child allowance must be made for the child's age and its physical condition. For croup nothing is better than syrup of ipecac, ten drops every hour until relief is obtained.

With this latter disease great care must be taken to keep the child wrapped up and protected from draughts.

These various remedies must be packed in one of the satchels by themselves. Everything must be plainly marked and the dose must be written or printed on the label. The satchel should be carried by one person, preferably a girl of about twelve years old, and she should be made responsible for it for no matter what may be forgotten this must not be left behind.

RESUMÉ OF THE TREATMENT OF
OBESITY.

DR. PAUL CHERON, PARIS.

Experiments carefully made show that the three great classes of food yield fat, in some degree; that alimentary fat may be fixed in the tissues; and that

bydrocarbons favor the deposition of adipose either directly or indirectly.

Fat may disappear with great rapidity under certain conditions as in many maladies. Therefore, as fat never passes into the secretions, at least not in appreciable quantities, it probably undergoes transformation, perhaps by oxidation or a form of fermentation, the final results of which are, directly or indirectly, water and cadaveric acid. It is certain that oxidation favors the destruction of adipose, and that everything which inhibits such destruction tends to fat-accumulation.

The following methods have been in vogue. Their careful study may enable the physician to adapt them to individual cases:

The Banting System.-Dr. Harvey decreased the weight of Mr. Banting 40 pounds by the following diet:

Breakfast.-Broiled fish, smoked bacon (veal and pork forbidden), a cup of tea or coffee without milk or sugar, one ounce of toast or dry crackers.

Dinner.-Five to six ounces of lean meat or fishexcluding eel, salmon and herring; a small quantity of vegetables but no potatoes, parsnips, carrots, beets, peas or beans; one ounce of toast, fruit or fowl; two glasses of red wine-beer, champagne and port forbidden.

Breakfast.—At 6 A. м. in summer, 7:30 in winter. -Eight ounces of black tea without either milk or sugar; two ounces of white bread or toast, with a copious layer of butter.

Dinner.2 P. M.-A modicum of beef marrow soup; four ounces of meat, preferably of fatty character; moderate quantity of vegetables, especially the legumines, but no potatoes or anything containing starch; raw fruits in season, and cooked fruits (stewed without sugar); two or three glasses of light wine as a beverage, and, after eating, a cup of black tea without

sugar.

Supper-7:30 P. M.-An egg, bit of fat roast, ham or bacon; a slice of white bread well buttered; a large cup of black tea without milk or sugar; from time to time cheese and fresh fruits.

Ebstein's System, which has afforded most excellent results to Unna and others, certainly exposes the patient to dyspepsia, when the routine must needs be interrupted or modified; hence it is not always to be depended upon.

Denneth's System has acquired celebrity. It has for its aim the reduction as far as possible of alimentary hydrocarbons while permitting a certain portion of fat which resembles closely that of Ebstein.

Oertel's System is based upon a series of measures withdrawing from both circulation and the economy at large as much fluid as possible. It is especially adapted for the relief of those obese who are suffer

At bed-time.-Grog without sugar (whisky and water or rum and water), and one or two glasses of Bordeaux.

"Bantingism," to be effective, must be most closely followed, when, unfortunately also, it proves extreme ly debilitating; it is suitable only for sturdy, hardriding gluttons of the Squire Western type. The patient rapidly loses strength as well as flesh, and speedily acquires an unconquerable repugnance to the dietary. Further, from a strictly physiological point of view, the quantity of meat is greatly in excess, while with the cessation of the régimen, the fat quickly disappears.

Ebstein's Method.-Ebstein formulated a dietary that is certainly much better than that of Harvey and yields as good, or even better, results. He allows patients to take a definite quantity-two to two and a half ounces of fat daily, in the form of bacon or butter which, theoretically at least, offers several advantages: It diminishes the sensations of hunger and thirst, and plays a special rôle with respect to the albuminoids; the latter may thus be assimilated by the economy without being resolved into fat, and thus the adipose of the organism at this period is drawn upon without subsequent renewal. The following is the outline :

follows:

Breakfast.-Four or five ounces of tea or coffee with a little milk; two to two and a half ounces of bread.

Dinner.-Three or four ounces of roast or boiled meat, or moderately fat food; fish, slightly fat; salads and vegetables at pleasure; one and a half ounces of bread (in certain cases as much as three ounces of farinaceous food may be permitted); three to six ounces of fruit; at times a little pastry for dessert. In summer, if fruit is not obtainable, six to eight ounces of light wine may be allowed.

Tea.-A cupful (four or five ounces) of tea or coffee, with a trifle of milk, as at breakfast; one and three-fourths ounces of bread; and (exceptionally) six ounces of water.

Supper. One to two soft boiled eggs; four or five ounces of meat; one and three-fourths ounces of bread; a trifle of cheese, salad or fruit; six to eight ounces of light wine diluted with an eighth volume of water. The quantity of beverage may be slightly augmented at each meal if necessary, especially if there is no morbid heart trouble.

Schwenninger's System-Schwenninger, who opened a large sanitarium near Berlin a few years since for the treatment of the obese, employs Oertel's treatment, modified in that an abundance of beverage is permit

ted, providing that it is not indulged in at meals; it is forbidden until two hours after eating. He is celebrated as Bismarck's physician.

Both Oërtel's and Schwenninger's methods have produced grave dyspepsias, and fatal albuminarias as well, according to Meyer and Rosenfield.

Thus, it will be observed, that while some forbid beverage, others rather insist upon its employment in greater or less quantities. Under such circumstances it would seem but rational, before undertaking to relieve obesity, to establish its exact nature, and also the rôle taken by fluids in the phenomena of nutrition.

Physiologists generally admit that water facilitates nutritive changes, which is explained by the elimination of a large quantity of urine; the experiments of Genth and Robin in this direction appear conclusive.

Bischoff, Voit and Hermann have shown that water increases, not alone in the elimination of urine, but also of sodium chloride, phosphoric acid, etc. Oppenheim, Fräenkel and Débove, while believing that water has but little influence upon the exchanges, admit it does not diminish the latter. Débove and Flament, after administering water in quantities varying from two to eight pints per diem, concluded that urine was diminished below the former figure, while above the latter it increased somewhat, being dependent upon the amount ingested.

These results were immediately challenged by Germain Sée. It seems certain, to say the least, that water taken during the repast does not tend to augment the quantity, and facilitate the elimination of urine. Abundance of beverage, moreover, presents other advantages, in that it facilitates digestion by reason of its diluent action, a fact well worth bearing in mind when treating the obese who are possessed of gouty diathesis, and whose kidneys are accordingly encumbered with uric and oxalic acids. The foregoing presents the ground upon which Germain Sée permits an abundance of beverage; but he also expresses strong reservation as regards beer and alcohol, either of which (more especially the former) tends to the production of adipose. In his opinion, the only beverage of the alcoholic class that is at all permissible, and then only for cases suffering from fatty heart, is a little liqueur or diluted wine. Coffee and tea he commends highly, and recommends the ingestion of large quantities at high temperature, both during the repasts and their intervals. Coffee in large doses is undoubtedly a means of de-nutrition, and so, too, in no less extent, is tea; both act vigorously owing to the contained alkaloids, though, to be sure, they sometimes, at first, tend to insomnia and palpitation, to which no attention need be paid, however.

METHOD OF GERMAIN SEES.

1. A physiological régime comprising four or five ounces of nitrogenous principles as derived from

eight to ten ounces animal muscle and albuminates; three to six ounces of fat; eight to ten ounces of hydrocarbons as yielded by ten to twelve ounces of sugar or starch food.

These proportions to be modified in such manner that the musculo-albuminates shall not sensibly exceed the normal ratio, for meat in excess, itself furnishes fat during transformation. The fatty substances of easy digestion may, without inconvenience, be utilized in doses of two to three ounces. The hydrocarbons should be reduced to a minimum. As for the herbaceous elements, they contain nothing nutritive.

2. Beverage, far from being suppressed, should be augmented, in order to facilitate stomachal digestion and promote general nutrition, though alcoholic liquids must be inhibited; likewise mineral waters, except, perhaps, for occasional use. Both should be replaced by infusions of coffee or tea, taken as hot as can be drunk.

METHOD OF KISCH OF MARIENBAD.

Rapid and marked decrease of adipose, per se, is objectionable, even if not positively injurious, since it tends to provoke general troubles of nutrition. He suggests that first the fats and hydrocarbons be reduced as little as possible; that a moderate mixed régimen is required, containing a preponderance of albumen, small quantities of hydrocarbons and gelatinous matters, with but very little fat. Certain fatty meats, however, should be generally interdicted, such as pork sausage, smoked beef tongue, goose breast, smoked ham, fat salmon and herring in any form. Eggs, however, may be taken of in moderation, giving preference to the albumen over the yelk. Farinaceous foods, in the main, should be rejected, even bread being allowed only in small quantities, and then preferably in the form of toast. Cheese likewise contains too much fat; and mushrooms are so rich in hydrocarbons that they should be rejected. Condiments, water, vegetable acids (vinegars excepted) may be permitted; especially pernicious is vinegar when there is any tendency to gout or gravel. All fatty beverages-bouillon, unskimmed milk, chocolate or cocoa-and all alcoholics are hurtful; breakfast tea is undoubtedly the best beverage, but, after a little, is advantageously replaced by light white wine diluted with water.

Kisch believes in a free and abundant use of water by the obese, especially where there is a tendency to plethora, since this fluid facilitates oxidation as the result of absorption; thus he advocates the inhibition. of large quantities of cold water by all, save those presenting evidence of cardiac insufficiency. In short, his régimen is based upon the administration of a large quantity of albumen, like that of Harvey-Banting.

E. Munk recommends an almost identical dietary, save thas he prefers great moderation in fluids employed as beverage.

(To be continued.)

THE SUCCESSFUL TREATMENT OF CHRONIC DISEASES. A PLEA FOR THEIR MORE METHODICAL MANAGEMENT.

BY SIMON BARUCH, M.D.

Prof. Semmola of the Naples University says: "The methodical, internal and external, use of water, together with climate, exercise, etc., are the means by which hydropathy stimulates cutaneous activity, and, with it all, functions of tissue change and organic purification, so that often real marvels of recovery are obtained in serious and desperate forms of disease. Unfortunately these wonderful effects are more rare to-day than they were in the time of Priessnitz, and of which I was a personal witness. It is to be regretted that physicians in general do not give to hydratic treatment that attention which its great value deserves, for with the exception of the cold-water treatment of nervous diseases, which is often used in the most irrational manner, very little and bad very use is made of it in diathetic diseases. Those who were in a position to follow the cures of Priessnitz will readily remember what wonderful and unhoped for recoveries were obtained in Graefenberg by the water treatment. Let me impress deeply upon you this classical method of evoking and furthering a natural therapy which powerfully contributes to rejuvenate the organism and best secures therapeutic

success. In all those cases which are united under the common term of retardation of tissue-change activity, hydropathy forms a truly rational etiological treatment, and it is therefore of certain and unfailing effect unless the local processes have advanced to atheroma, visceral arterio-sclerosis, etc."

II. FUNCTIONAL DISEASES

These offer a wide scope for the inculcation of the principles which this essay aims to advocate.

Rarely do we have an opportunity to treat such maladies methodically, for even where they are far advanced the patient is often allowed to pursue his avocations or pleasures. Under the erroneous idea that diversion of the mind is an important factor in the management of these cases, they are permitted to escape the discipline which is the only true means of proper treatment. In recent years a flagrant illustration of the value of systematic treatment of some cases of functional nervous trouble, hitherto regarded as the opprobria of medicine, has been observed in the rest cure introduced by Dr. Weir Mitchell. Volumes have been written upon this ingeniously constructed method of our talented countryman, who has thus immortalized himself by simply

applying the principles I would now urge upon your adoption in other diseases-viz., a more methodical application of our remedial measures chiefly dietetic, hygienic and psychical.

ΑΝΑΜΙΑ.

A faulty hæmatosis is frequently of functional origin. When it is a manifestation of organic disease, the latter must receive the chief attention.

Observation has taught me that these cases are rarely subjected to any but desultory treatment. Exercise in the open air, change of scene, a nutritious diet and iron in some form are the main elements of treatment. The patient is allowed to drift along as best he may. Fortunately, many recover under this treatment.

That our average results would be more favorable under a carefully planned and punctiliously executed management, every physician of experience will readily grant. Weir Mitchell has given us some beautiful illustrations upon this subject. Dr. Laache, of Christiana, has also recently demonstrated that absolute rest in bed is in many cases essential. Dr. Scholz of Bremen, treats obstinate cases successfully in his institution. He has found small venesections of great value, together with hot air baths. This treatment has a rational basis, it having been demonstrated by Dogiel's experiments on dogs that bleeding with ten to fifteen leeches does not alter the tension unless it raises it slightly. If the bleedings are repeated every three or four weeks, the dog gains weight, sometimes considerably, and the number of red corpuscles increases, unless the bleeding is carried to excess or repeated too many times. Vogt also confirmed these experiments and states that the hæmaglobin is positively increased by small bleedings. This depletion, accompanied by proper diet, etc., probably induces increased tissue metamorphosis. I refer to these reliable clinical and physiological experiments for the purpose of calling attention to the fact that the usual slipshod iron treatment of anæmia is by no means the ultimate resort of the physician, and that in desperate cases we have many other resources. But my chief object is to ask attention to the necessity of promoting and encouraging tissue change in all diseases, in which there is a faulty hæmatosis. Here again I am able to furnish abundant testimony of the auxiliary value of hydrotherapy. Again and again have I observed cases of anæmia and chlorosis which had defied prolonged iron treatment under my own care as well as under the advice of colleagues yield readily, when a suitable hydriatic method was added.

The most simple means for this purpose is the cold ablution taken every morning while still warm from bed, not with a wash-rag however, but by pouring water at 70% abundantly from a sponge or pitcher