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upon successive parts of the patient, who stands in a tub of hot water to prevent chilling. Gradually we may advance to the dripping sheet and wet pack. Several years ago our talented colleague, Dr. Mary Putnam Jacobi, wrote an able essay on the wet pack and massage in anæmia in which she furnished so exhaustive a description of the method and physiological action of the treatment that I refer you to the original for valuable data. Suffice it here to state that in no type of disease does this systematic treatment evince more brilliant effects, than in anæmia and chlorosis.

FUNCTIONAL DISEASES OF THE STOMACH

are a fruitful field for methodical treatment. How

rarely these are subjected to systematic descipline, we have abundant daily testimony. These maladies have become so common, that we rarely encounter a student or professional man or woman who has not at some time suffered from "dyspepsia."

In these affections I regard the application of cold water externally by various procedures and the lavage by warm water, as may be indicated in each case, as probably of greater therapeutic value than all other treatment combined. A single brief history may serve to illustrate the value of systematic treatment in which hydrotherapy and electricity played a promi

nent rôle.

Miss W., daughter of an Ohio physician, aged 23, was sent to me by Dr. Francke Bosworth, the wellknown rhinologist, on May 15, 1889. Pale, emaciated, despondent, the picture of woe and despair, she was brought into my office by her sister. She had been ill three years; suffering first from fainting fits at the menstrual period; afterward from violent pains in the right hand, traversing the body and concentrating in the epigastrium. For these her father and brother had been compelled to administer morphia for a month. Her stomach became irritable, and has continued so up to the present time; she vomited and spat up nearly all her food, mostly the solids. Seabaths did not improve her. She studied hard and grew worse. In the Fall of 1888 she lived on milk and farinaceous mush, and her stomach was regularly irrigated, without improvement.

She grew worse, became emaciated; she took peptonized milk for a month, but vomited it; meat produced the same effect. Last Fall she lived on grapes, which agreed with her. Now she had tonics, pepsin, and all possible medication which her father and brother could muster, without avail. She was sent to Dr. Bosworth, who is a friend of her brother. After being in the city for three weeks without improvement, the doctor sent her to me. She now vomits every day; she traces her ailments to painting lessons, but I drew from her the history of a potent pyschical factor a cause of the sudden violent insanity of the

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favored nurse of her childrood. My diagnosis was nervous dyspepsia. The stomach was washed out twice a week to remove mucus and fermenting material. She had general faradization daily. Every morning she received the dripping-sheet at 60° F., while standing in warm water. Under this system

atic management she improved slowly, vomiting ceased entirely; she went to the seaside improved in July. On her homeward journey she called to tell me that she had grown stout and felt perfectly well. Last year I received a letter from her informing me that despite family troubles, the death of her father, which necessitated her adopting teaching as a means of livelihood, her health had been perfect. would not know me," she wrote, as the same gir you treated."

CONSTIPATION.

"You

Constipation is one of those minor functional ailments which give us much trouble. After failure of medicinal agents I have obtained excellent results from systematic treatment. Witness the following obstinate case, for whose history I am indebted to Dr. Leo. Ettinger, formerly resident physician of the Montefiore Home : M. G., a painter, has a history of lead poisoning; complains of marked abdominal distension, undefinable pains; is sallow and anæmic, anorexia and severe constipation are the symptoms that drove him from work to seek a last refuge in this home for incurables. Being regarded as a hopeless invalid by all his previous attendants, he was admitted, leaving his family to spend his remaining days in the Home.

March 15, 1889, he weighed 139 pounds. He received a dry pack, followed by an ablution at 65° daily. On the 15th of March hot fomentations were applied to his abdomen, while he lay wrapped in the blanket pack, until his entire body perspired freely. He now received a rapid but gradual ablution with water at 65°, was dried and rubbed. An enema of

5 ounces of water at 45° was administered before the pack and retained. This treatment was continued daily, the bowels being emptied daily by large, warm April 3.-Pil aloes and mastich before each meal without effect for three days, enemata being suspended.

enemata.

April 10.-Abdominal swelling has disappeared; under one pill of aloes and mastich at bedtime.

May 1.-He was discharged, cured, at his own request, weighing 149 pounds, a gain of ten pounds in six weeks.

He has remained well since that time.

FUNCTIONAL NERVOUS DISEASES.

This class of diseases is the plague of our lives, simply because the patient is rarely sufficiently ill to require constant attendance. I am satisfied that in

all these cases we may imitate Weir Mitchell with advantage, without resorting to the extreme methods which he judiciously advises for some of them.

Methodical Management is the sine qua non of success. Constant observation is required; punctilious reports and submission to dietetic, hygienic and medicinal directions alone will enable us to accomplish the best results. Without fatiguing you with histories, I insist that in cases of neurasthenia, hysteria, chorea and allied troubles, I have derived great advantage from the systematic and judicious application of medicinal and non-medicinal remedies, especially from hydrotherapy. My essay having already exceeded the limits I had designed, I must be content with the following confirmation of my personal experience in these maladies from a source whose authority all will respect and honor.

In his able work in Ziemmesen's Cyclopædia, Prof. Erb, of Heidelberg, says: "Cold and cool baths, in various forms, belong to the most important therapeutically active agents in the field. This method has, since it has been more carefully studied and more rationally pursued, made notable advances. sults in all possible forms of chronic nerve troubles are extraordinarily favorable. There are few remedies which have an equally powerful influence upon the nervous system."

Its re

This indorsement may be accepted as of far greater value than the clinical histories which I am able to furnish in large numbers.

In conclusion, I beg to emphasize the following points:

1. A systematic methodical management which includes all known therapeutic agencies accomplishes results in chronic diseases which must surprise those who treat these cases in the usual desultory manner.

2. It would inure to the interest of both patient and physician, if chronic diseases were treated with the same regard to detail and precision as acute diseases, and if the medical attendant would prefer to dismiss the case to permitting the patient to follow his inclinations and neglect the advice of his physicians.

3. Hydrotherapy is an important and much neglected auxiliary in the treatment of chronic diseases.

"In many chronic diseases it has proved so successful, after failure of medicinal agents, that no case should be yielded up as hopeless until hydrotherapy in some form has been tried. My experience at the Montefiore Home, which receives only incurable cases, demonstrates this fact.

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precision in their application and their perfect adaptation to the constitutional peculiarities of each case-i. e., not treating disease but the patient.

"For this reason the best consultants in Germany, in Italy and France-men like Leyden, Charcot, Senator, Semmola, Ziemmessen, Northnagel, Binswanger and Erb, send their patients to hyrotherapeutic establishments, which are under the direction of educated physicians who have studied the subject, with their diagnosis and general suggestions, rather than with specific directions for the method to be employed. Finally, so much depends upon the reactive capacity of each patient that only systematic observations can determine the most useful hydriatic procedure in each case." (American System of Therapeutics, Edited by H. A. Hare, M.D., Vol. I, p. 514).

Medical Society Notes.

SUFFOLK DISTRICT MEDICAL SOCIETY.

In an interesting paper on "Some of the Uses of the Stomach Tube," Dr. E. M. Buckingham stated that he had employed this instrument in a limited number of cases during the past few years, and with fair results. He had found its introduction easy, if care was taken to hold the tube in one vertical plane and in the median line as it passed behind the tongue. The only curve should be from above, downward, and there should be none from side to side, in which latter case the tube was very apt to catch. In his opinion, milk, which was sometimes used as a lubricant, was not as good as something more tenacious— oil for instance. The operation was somewhat facilitated if the patient was made to swallow, but time could be gained and discomfort saved to the patient by pushing gently at the same time. Although it had been stated that some patients become accustomed to this procedure, or even object very little to it at first, he had never met with such a case, and regarded it as extremely disagreeable. For this reason he thought it advisable not to resort to this treatment except where its use was imperative, and this rule would exclude it in some cases where recovery might be hastened by its use, but where other methods, although slower, promised to be effectual. The tube was commonly introduced with the patient sitting, the head being thrown back to straighten the passage from mouth to stomach; but in some cases it is equally easy to use it with the patient flat on the back. Unless the patient was deeply narcotized this

position was net attended with danger from water flowing toward the mouth in sufficient quantity to enter the glottis. In his practice a few cases of nervous dyspepsia had been relieved, although he thought that an equally good result might have been obtained by electricity or any other treatment which appealed strongly to the imagination. Cases of catarrh of the stomach, with or without constriction of the pylorus, were, however, capable of much benefit from systematic lavage. The author's experience was certainly not favorable to a more extended use of this method, for in his opinion its advantages were usually counterbalanced by its annoyances.

Dr. T. A. De Blois did not doubt the usefulness of the stomach tube in certain gastric disorders, especially in chronic gastric catarrh. He had employed it to dilate strictures of the esophagus, but had found that small rectal bougies were equally efficient. He remarked upon the ease with which the stiff tube could be passed, especially if the head were thrown well back and the hand was placed upon the epiglottis. He thought the soft tube was passed more slowly, although the stiff one had the advantage of not being constricted by spasm of the œsophagus.

pylorus. In washing out the stomach we were able to remove matter concealed in the folds of the stomach and the curds which had formed and kept up a catarrhal or dyspeptic condition. Dr. Jacobi had expressed an opinion of this kind and Dr. Koplik had reported a number of interesting cases. The technique of the proceeding in young infants consisted in the use of a soft catheter about nine inches long, or, if necessary, the length of the instrument could be increased by insertion of a glass tube. Care must be taken not to distend the stomach too forcibly. An infant's stomach was easily distended; and hence instead of the use of a fountain syringe it was better, perhaps, to substitute the method of Epstein-of attaching a simple funnel to the catheter.

Dr. T. M. Rotch said that the stomach could probably be washed at any age without danger to the patient. Dr. Seibert had performed the operation on his own child when it was but thirty-six hours old. The child was seized with obstinate vomiting threatening its life, and one or two washings out with sterilized water arrested the vomiting. This method was employed much more abroad than in this country, and in view of its advantages it had not been given a fair trial. It was well known that drugs were frequently of little service in the vomiting of children and in the different forms of gastric catarrh. The reports of Dr. Seibert and of Dr. Bocker, of the Wilson Sanitarium at Baltimore, had demonstrated the efficiency of stomach washing. We should recognize, however, that it is not merely by washing out the stomach that we could effect a cure in these cases. Some physicians seemed to think that all that was necessary was to distend the stomach with water and the catarrhal condition would pass away. probable that the water did not enter the small intestines, and yet the duodenum might be the seat of the disease in these catarrhal conditions. In obstinate cases of this kind stomach washing should be part of the treatment employed, and the speaker knew of very few cases where it had been followed by dangerous symptoms. He thought that in these catarrhal conditions it was impossible to put an antiseptic in the stomach which would kill the germs. In the first place it was improbable that the antiseptic would reach the whole of the stomach, and this applied especially to the upper part of the greater curvature. The drug was either absorbed or it passed into the

It was

Dr. G. Liebmann said that he had had considerable experience with the stomach tube during the last two or three years, and especially in catarrh of the stomach. He had been somewhat disappointed in the effect of stomach washing in ordinary chronic gastric catarrh. Improvement had followed the first two or three washings, but it failed to continue. He thought that in these cases the moral effect did as much as the lavage. In dilatation of the stomach, however, it was the remedy par excellence. With regard to the introduction of the soft tube he had found it useful to insert a stilet or mandrin made of rattan, in cases where the patients were nervous. This method had been employed lately in Europe, especially by Leube, and was of great service in the hands of the physician. Before he had adopted the use of the stilet he had failed in a number of cases, having to depend on the co-operation of the patient. If the patient did not swallow, we could not push the soft tube through the pharynx into the œsophagus, and had to give up the attempt; but the use of the mandrin did away with the difficulty. The speaker also referred to the value of the stomach tube in the diagnosis of diseases of the stomach, by enabling us to evacuate and examine the contents of the stomach.

Dr. Charles P. Putnam had employed the stomach pump for washing and feeding in a child about eight months old, and could testify to the great ease with which the procedure was performed and to the good results of the treatment. The child had been unable to retain food and was extremely restless, but after washing out the stomach it was able to retain food administered in the ordinary way. He had also observed a case of diphtheritic paralysis where the child. was starving to death because unable to swallow food, and where, by the administration of food through a large catheter, which was passed without difficulty, the child was kept alive and recovery brought about. The age at which it was difficult to introduce the tube was between two years and the time when the child could be reasoned with. Up to two years it was easy to perform this operation.

Literary Notes.

The Dietetic Value of Bread, by John Goodfellow, F. R. M. S., Lecturer on Physiology and Hygiene at the Burr and Bromley Institute, etc. Pp. 328.

This book is unique in its scope and aims, inasmuch as there is no other work extant upon the subject.

We congratulate our readers upon this addition to works on hygienic subjects, which but too often are simply a rehash of trite and well worn themes. Its pages are bright and entertaining, scientific yet not pedantic, intended for "the masses, yet valuable to the doctor." The author gives us a substantial contribution to the material for food reform, because he dose not only lay down rules but gives the reasons for them.

The important fact is brought out, which is too much lost sight of, that bread is really the staff of life, for it is proven statistically that among 20,000 children among the poorer classes they had other food beside bread only once or twice a week, receiving it for breakfast, dinner and tea. Among the better situated the use of bread is not so exclusive.

Section 1 of the work deals with bread from a physiological standpoint. After giving a succinct account of the physiology of digestion, the essential nature and function of food, tables of diet are given showing the deficiencies, etc.

Section 2 deals with the structure of the wheat grain, and the composition of various qualities of flour, and continues with articles upon the price of bread compared with other foods, the composition of bread, the amount and nature of its salts, the digestibility of bread as compared with other foods; the amount of waste present; whether bread allows full action of the digestive juices; its flavor, staleness, sourness and other points; whether it is adapted to infants, and lastly its common adulterations and their effects. After giving the actual nutrient value of various foods, and their comparative cost, the author says (p.106): It will be perfectly clear, from a study of these facts that bread is, one of the cheapest foods, not only with regard to the actual weight and nourishment obtained, but also with regard to the variety of the nutrient constituents; and the purchaser who expends his modest 24d. in a 2lb. loaf may rest assured that he could not spend his money to better advantage except, perhaps, in the purchase of oatmeal, which contains slightly more nourishing nutriment than bread. Section, 3, deals with whole-meal bread. No bread is entitled to be thus designated unless it is made from meal obtained by grinding or pulverizing the entire wheat grain. Formerly whole-meal bread was a mixture of white flour and bran, which resulted in a loaf of inferior nutritious quality.

Ordinary whole-meal bread is not regarded by the author as a desirable food; it is deficient in actual

nourishment. Fine whole-meal bread, on the contrary, is not objectionable. "It must not be concluded, however, that it is a panacea for every disease under the sun,as many food reformers would have us believe."

We have quoted enough to give an idea of the author's style of treatment. The reader who desires to know more of his principal food will doubtless refer to the original, which is printed in the style which the house of Macmillan is noted.

Flint's Condensed Complete Encyclopædia of Medcine and Surgery by various writers arranged upon a new system which embodies the methods of treatment employed by many eminent practitioners of medicine (45 wood cuts). Complete in two volumes. 1892. J. B. Flint & Co., New York. Cloth, $6.

The old time practitioner who looks over these pages is forcibly reminded of his old favorite Copeland's Dictionary of Medicine. This book is built upon the same lines but it bears the impress of a more progressive time. Strict utiliarianism beams from every one of its bright pages. The practitioner who is in search of information, comfort and guidance, will surely find them in these pages, for the publishers have here furnished him a veritable vade mecum of medicine, and surgery. A novel feature is in the statement of homeopathic after the regular method of treatment of each disease. This is the first book in which such extremely broad therapeusis has been ventured upon. For instance, in the treatment of fever we find an excellent statement of the value of aconite in minim doses, quinine in 10 to 20 grain doses, sylicylic acid in 20 gr. doses every three or four hours, Antifebrin Antipyrin, etc., and a most judicious brief enposition of baths and of the chemical antipyretics, signed by David McAllister. The article is followed by "Symptomatic Indications" under which the most hide-bound follower of Hahnemann will find comfort in Aconite, veratrum, gelsemum, Arsenicum, and Belladonna. This striking departure from the customary methods of medical bookmaking renders the book doubly interesting. The mechanical execution of the work excellent. is printed on heavy paper in clear type.

It

A System of Gynecology, based upon a translation from the French of Samuel Pozzi, M. D. Revised by Curtis M. Beebee, M. D. Complete in one volume, 359 illustrations. Price, cloth, $6.00; sheep or half morocco, $7.00. J. B. Flint & Co., New York.

This excellent work having been reviewed in our January, 1892, number, we can only add that its value must be very great in the eyes of publishers since two firms have undertaken to produce its translation. Dr. Pozzi's practical treatment of his subjects fits the book eminently for every day practice.

It will prove a boon to the plodding doctor in town and country.

H

We have such a substitute in the fine whole-meal

Dietetic and Hygienic Gazette; bread, which may be mixed or not with gluten or

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BREAD AS A REMEDIAL AGENT.

In a recent work on bread, published by the Macmillans, a chapter is devoted to its use "as a medicinal agent." The author, John Goodfellow, F. R. M. S., discusses the uses of bread in disease in so practical a manner that we take it for a text.

The action of bread depends on the presence of fine particles of bran, its quantity of phosphoric acid and iron, the relative digestibility of its constituents and the relative properties of the latter.

We have practically tested the application of bread in obesity, for instance. In the disease of tissue change it is important to divert the nutrient elements from the faulty channel into which they seem to tend. This may be best accomplished by certain hygienic measures, hot air baths, cold douches to increase tissue change by encouraging fluxion exercise, etc. The most important element, however, being diet, the latter must be well chosen to satisfy the patient who, not being really sick, must satisfy his appetite as well as his palate.

This is the rock upon which we are apt to split. In order not to make the diet monotonous, the writer has been in the habit not to exclude any article of food except sugar. For this he substitutes sac

charine.

Bread is the staff of life. To deprive the patient of a food to which his palate and stomach have long become habituated is objectionable. We must compromise by giving him a bread which satisfies both.

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finely ground bran. The object in view is to satiate the appetite without adding to the fat-producing elements of food. By utilizing this variety of bread and minimizing its use, we may attain results more slowly but we may rely upon a longer endurance of the treatment by the patient.

In extreme cases gluten bread may be used for brief periods.

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In constipation, the use of coarse breads has long found favor. Here again it is necessary to exercise care that the whole-meal is well ground in order that we may not load the intestinal canal with a quantity of detritus that would absorb its fluids and thus frustrate the very object in view.

In diarrhoea, on the contrary, a bread made from the finest white flour is useful. Freed from all bran particles by careful bolting, bread made from such a flour becomes a valuable adjunct to other treatment, provided the baking is thoroughly done to adapt it to the gastric digestive powers of the patient.

The value of toasted bread may here be referred to as preventing fermentation which often is a gastric manifestation in chronic diarrhoea.

The author makes a good point in applying bread to the indigestions, which could only have occurred to one so thoroughly versed in the entire subject.

Diastase or malted breads, and bread made from dough which has been treated by special fermentable substances to quicken fermentation are very beneficial in many cases of indigestion, because of the considerable quantities of dextrine, sugar and, in some cases, soluble albumenoids which they contain. Aerated bread and bread made with salt or acid should be avoided in indigestions due to atonic conditions of the stomach. These kinds of bread would be useful, however, in fermentative dyspepsia.

In anæmia whole-meal bread is a useful adjunct to other treatment, medicinal and hygienic.

To adapt bread to the gustatory condition of the patient, is a problem often difficult to meet. A good understanding of the various kinds of flour and bread may aid the physician materially in meeting therapeutic indications in their common manifestations.

It would seem superogatory to refer to gluten bread in this connection, but this is really the best known and most valuable application of bread to disease. The difficulty has been to prepare from gluten a bread that would satisfy the patient's craving for the staff of life and be palatable. Thus far this has not been accomplished. All the dibetic flour preparations now in the market contair a large proportion of starch, varying from 66 to 70 per cent., the percentage being in converse ratio to the claims made that they are free from starch. A mixture of gluten with whole-meal in proportion adapted to each case would

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