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or in certain essential ingredients.-The follow milk. If, however, these predigested foods are ing are the chief errors in this respect:

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(a) Insufficient Gross Amount of Nutritive Material. For instance, a child is found unable to digest any mixture of cows' milk stronger than 1 in 4, and it is kept upon this. But the capacity of the stomach is limited, and it is impossible for it to take a sufficient quantity of this mixture to supply the material required for growth and full nutrition. Thus I found the other day an illnourished child of five months' old kept by medical advice upon a mixture of milk and water which afforded twelve ounces of milk only in twenty-four hours. It was impossible for a child of this age to grow and thrive upon this gross amount. It was unable to digest a stronger mixture. The difficulty was easily overcome by the addition of some Valentine's meat-juice and cream, pending a very slow and gradual increase in milk as the child's digestive power developed.

(b) Food Deficient in Fat.-This element is of especial importance in the food of children. And yet they are constantly brought up on a diet sadly wanting in it-as, for instance, most of the artificial foods, whether purely farinaceous or containing desiccated animal matter. Some condensed milks are deficient in cream, while skimmilk, upon which I have known children to be fed, is practically destitute of fat.

(c) Food Deficient in Proteid.-The same thing may be said with regard to deficiency in proteid. Children, especially those with whom cows' milk does not agree, are frequently placed solely upon some artificial food which does not supply the necessary quantity of nitrogenous matter without the addition of milk.

The removal of a portion of casein by rennet in "artificial human" milk is sometimes carried to excess and continued too long. I have just been consulted about a child fourteen months old who has become soft, sweats about the head, has attacks of laryngismus, and has had two attacks of general convulsions. It is rickety, and has been fed to this age solely upon "humanized" milk, from which one-half of the casein has been removed. Children starved of these two elements are often large and fat, but flabby, anæmic and rachitic. Indeed, this defect in food is one of the chief causes of rickets.

(d) Prolonged Use of Artificially-digested Foods.-Another error, now growing common, has arisen from the discovery of the value of predigested foods. I refer to the practice of maintaining children on peptonized or pancreatized foods for too long a time. These preparations do excellent service in the case of children just weaned or with small power of digesting cows'

continued for months nutrition falls off, the child becomes flabby, soft in bone and in the end strikingly anæmic. Moreover, the power of digesting curd is seriously impaired, so that there is often great difficulty in changing afterwards to ordinary milk foods.

I have now under care three children of from ten to fourteen months, brought up entirely on pancreatized food. In condition they bear a singular resemblance to each other. They are all full-sized, plump, but soft and white, and show signs of commencing rickets. One has profuse sweatings, and has had repeated convulsions during teething. In all the anæmia is marked. In all the improvement on raw meat juice and fresh milk has been immediate and decided. And further, I have noted three cases of scurvy arising on a sole diet of peptonized condensed milk. This diet should be gradually replaced by ordinary milk.

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The Treatment of Infantile Diarrhoea.-There is a belief current amongst mothers and nurses, and held also by many medical practitioners, that a moderate amount of diarrhoea is rather beneficial to a child than otherwise, especially during the time of teething. It appears to be regarded as a means of discharge for various undefined and peccant humors" of evil tendency, escaping, as by an open safety-valve, to the great relief and advantage of the patient, and especially useful as a safeguard against convulsions. Upon this assumption, a looseness of the bowels is often allowed to run on unchecked until it has assumed dangerous proportions. I believe that this view of infantile diarrhoea is entirely erroneous, and I am sure that the practice based upon it is most mischievous, often disastrous.

The diarrhoea of young children is most commonly due to the irritation of the mucous lining of the intestine by undigested and decomposing articles of food, aided, perhaps, by the influence of ptomaine poisons in causing paresis of the splanchnic nerves, undue stimulation of the vagus, or derangement of secretion of digestive juices. It is also caused apparently by irritation reflected from the dental nerves in teething, setting up increased peristalsis in the same way.

Now, in the first case, it cannot be wise to acquiesce in the condition by which nutriment is passed out, some of it partially digested, and what is digested hurried on too rapidly to permit of absorption. There can be nothing curative or of absorption. beneficial in the process.

In the second case, when the flux is due to reflected irritation in teething, there can be no advantage in the nutrient drain which the increased

peristalsis involves. Many, although not all, of these attacks of diarrhoea during the period of teething, and attributed to reflex dental irritation, are in reality due to direct irritation of the alimentary canal, the dentition being merely a coincidence, or only subsidiary by rendering the mucous membrane more excitable. So far from diarrhoea being a safeguard against convulsions, it is precisely those children who have been drained by diarrhoea and vomiting who are most liable to them.

Little children bear continued purging badly. Metabolism is active, and the loss of nutrient material tells heavily upon them. The mere drain of fluid is in itself alone a grave matter. Look how, in choleraic diarrhoea, they dwindle and wither rapidly, and, with pinched face and sunken eyes, shrink to half their former size almost. Although the diarrhoea may not be severe-three or four loose stools a day only, perhaps the risk of permitting such flux to run on uncontrolled in a young child is a serious one. A diarrhoea which begins moderately, and which excites no apprehension, but is viewed perhaps with satisfaction, is apt to develop dangerous proportions within a very short period, and to reach a point beyond the control of medicine. It is easy to keep it within limits if it is held in check from the first. But when it rages with full violence drugs may have little or no effect. I have, in many instances, seen fatal consequences result from neglect of this precaution, from a fatuous inaction in the early stages until the disorder passes beyond control, and leads to profound collapse beyond the influence of remedies.

In every case of diarrhoea in a young child, however slight, it is wise to get it under control at

once.

It is not necessary to induce absolute constipation, but to bring the action of the bowels to natural limits. The younger the child the more important this becomes, the risk being in inverse proportion to age. An infant is very easily killed by vomiting and diarrhoea during the first few months of life.

Having drawn your attention to the mischievous practice of letting this disorder run on unchecked, I have a word to say upon certain common mistakes made in treating the condition by drugs and diet.

In the first place as to food. Usually, if the child is on cows' milk, it is stopped absolutelyso far so good. If milk is given at all it should be peptonized, and diluted with a little barley water. Give nothing which is not sterilized, nothing but what is pre-digested or easily digested. Do not, however, commit the mistake often made of giving nothing but barley

water or veal broth. These supply fluid, but little else-they do not yield sufficient nutriment. In the tendency to collapse a meat essence is of great service, and ten drops of Valentine's juice should be given in a dessert-spoonful of water every four hours. I must not, however, go further into details. It is not my object in this lecture to lay down a complete plan of treatment, but to point out errors in treatment.

I have a word to say with regard to the use of drugs. As a rule astringents are given and opium carefully avoided as being dangerous in the case of little children. In my experience astringents such as hematoxylum or catechu are useless in the acute stage, and opium in some form essential in anything like a severe case. Gray powder with Dover's powder in small but frequently repeated doses should be given if there is much vomiting. Bismuth, the insoluble nitrate, in doses of five to ten grains with chalk, and or ora minim of liquor opii sedativus, according to age, are the most efficient remedies.

Chronic Constipation.-Every medical man, I imagine, thinks he knows how to treat constipation; but my experience hardly warrants the assumption. I have been surprised to find what a narrow routine practice prevails. Three devices only appear to be adopted as a rule.

(1) The administration of more or less active purgatives from time to time, sometimes once or twice a week, the remedy being repeated as often as the bowels become confined again.

(2) The use of enemata, sometimes regularly every few days for lengthened periods.

(3) The inclusion in the diet of coarse foods and fruits, oatmeal, cabbage, prunes, figs and the like.

Adults are generally treated more sensibly than children. They are given, perhaps, a daily dinner pill, or sent to drink laxative waters at some spa. But with children treatment is almost invariably limited to the three stock measures I have named.

Now, if the constipation is only occasional, an exceptional difficulty, a free purge or enema may end the trouble and cure the complaint. And if the constipation is slight only, the use of stimulating foods containing insoluble débris may be sufficient to keep the bowels acting. But if they are not successful, remember that they do positive harm by favoring hard accumulations and excretions.

If, however, the constipation is recurrent or habitual, and obstinate-chronic, in a wordnone of these measures will be adequate to effect a cure. The relief given by a brisk purgative, if frequently repeated, tends to defeat its own end, and to retard, not hasten, the ultimate cure.

The purgatives lose their effect after a time;

the frequent stimulation of the bowel renders it less and less sensitive. Stronger and stronger purgatives are required, the constipation grows more difficult to overcome; at last the bowels, rendered callous to stimuli, refuse to act, except in response to powerful irritant purgatives or enemata. The colon, its muscular wall in a condition of atony from over-stimulation, habitually distended by fecal accumulation and evolved gases, and not unfrequently by repeated copious enemata, becomes largely dilated and utterly inert. The last state of the patient is apt to be worse than the first. The attempts to cure have in reality aggravated the condition.

Now, this state of chronic constipation in children requires treatment-and treatment by drugs. Treatment to be effective must be continuousnot intermittent. The constant daily use of some mild laxative is essential to ultimate success.

Night Terrors.-Children from two or three years old up to five or six, or even older, are liable to what are called "night terrors." They wake out of sleep, or, rather, do not fully wake, but start up in a condition of great distress, calling out, screaming or crying. They seem dazed, half conscious, cannot be aroused so as to take rational notice of the mother or nurse, and cannot be pacified. The state of screaming, crying, terror may last for hours. This form of disturbance varies in degree from mere restlessness and crying in sleep to almost maniacal delirium.

Such cases occur usually, but not invariably, in delicate, sensitive, neurotic children, and they are, in most instances, cachetic or ill-nourished. The parents are filled with apprehension that some serious brain disease is at the bottom of the trouble. The doctor, recognizing the neurotic element, and going no deeper, usually prescribes bromides, often with good effect for the time. Now, these attacks are simply childish nightmare. There is, as I have said, usually, but not invariably, a neurotic disposition underlying the disturbance. The actual disturbance itself is directly due to some superadded source of irritation, central or reflex, most commonly the latter. The administration of sedatives, such as bromide and chloral, only subdues the manifestationsdoes not cure the complaint.

The direct sources of irritation are undue stimulation of the brain: as of the imagination, by exciting stories; the rough treatment and terrorizing of an unscrupulous nurse; a visit to the Zoological Gardens, and dreams of bears and lions; or over-pressure of work in school.

More frequently, however, the irritation is reflex-sometimes, but not often, a round worm in the intestine; sometimes indigestion of food at

night. But by far the most common cause is constipation, often slight but persistent, the stools being hard, dry and often light-colored.

The point which I wish especially to enforce is, the futility of the mere sedative treatment almost invariably relied upon; as a rule nothing else is done; "it is all nervous," doctor and parents agree.

Now, the great object should be to discover the cause of irritation, and to remove it. If the cause lie in over-stimulation of the brain by exciting stories, or overwork, or terrifying threats, or other fears, these must be stopped. In such cases the bromides are, indeed, most useful aids. They do not suffice alone.

If the cause, as by far most often happens, is constipation, the daily administration of laxatives with strychnine will cure the affection, bromides being administered for a short period at first until the exciting cause is removed.

Drug Treatment of Debility, Anaemia and Rickets. One of the most universal mistakes, although, perhaps, not one of the most serious, is that of relying largely or chiefly upon drugs in the treatment of diseases of defective nutrition. Children are apt to be dosed with cod-liver oil and preparations of iron and phosphates indiscriminately, without regard to the condition of their digestive functions and their fitness for the reception of these materials at the moment.

Thus a delicate child, with feeble appetite, is drenched with cod-liver oil and syrup of phosphates because it is flabby, ill-nourished, and anæmic. The tongue is coated, the bowels confined. The child is, perhaps, overfed already by rich foods. The chief cause of the anæmia and defective nutrition and want of appetite is the disordered state of the functions of digestion, absorption and fecal excretion. A few doses of calomel, or gray powder, followed by a tonic, with some saline laxative and judicious feeding, will do far more to remedy the anæmia and debility than cod-liver oil and syrups of iron. These are excellent remedies in their proper place; but, in these conditions of disordered function, they do more harm than good. They intensify the digestive difficulty, and take away appetite. When the disorder is rectified they may find their place again.

This habit of giving syrup of phosphates, or codliver oil, or both indiscriminately, whenever a child looks pale, or seems languid, or deficient in flesh, has spread from medical men to the mothers and nurses, so that these drugs have become almost regular articles of diet in many families, to the detriment rather than advantage of health.

In the case of rickets, again, far too much reliance is placed upon treatment by drugs. Rickets

is a diet disease-at any rate in the main. Milk or cream, raw meat juice, sunlight and fresh air, are better medicines than any to be found in the Pharmacopoeia.

Local Treatment of the Throat in Diphtheria. -The cruel and useless practice of swabbing out the throat with caustic applications in diphtheria of the fauces has, I think, died out; but this method of applying astringents, such as perchloride of iron, or antiseptics and solvents, still survives.

The diphtheria wards in this hospital afford exceptional opportunities for observing the effects of various methods of local treatment; and, from long observation, I have no hesitation in condemning as injurious the system of brushing out. And this for several reasons. In the first place, on account of the distress it causes to the patient. In the case of a young child it involves a severe struggle; sometimes the help of two or three persons is required to overcome the fierce resistance, and to open the mouth and reach the fauces. It causes terror, excitement, heart strain and physical exhaustion-conditions most inimical in a disease tending to death by asthenia-and the distressing process has to be repeated frequently if it is to be effectual. Moreover, apart from this matter of the wear and tear involved, the rough treatment of the fauces probably does harm by causing abrasions of the surface, and thus favoring absorption of the local poison. We know how readily fresh raw surfaces of all kinds take up poisons which come in contact with them. Witness, for example, the communication of scarlet fever in surgical operations, the absorption of morphine from a blistered surface. If the diphtherial poison is rendered more available for circulation by the application of solvents, the infective absorption is liable to be still greater. The most rapidly fatal case of diphtheria from profound general systemic poisoning I have ever seen was one in which the throat was cleared of membrane by brushing out with papain.

I am sure that not only are the patients saved great distress, and doctors and nurses much trouble and anxiety by the abandonment of the brushing-out process, but the results generally have been more satisfactory. Insufflation with iodoform or sulphur, or spraying with boric acid or corrosive sublimate solutions, are far more easy of application, and more effectual in antiseptic action.

There are other errors in treatment of which I should like to say something, such as oppressive poulticing of the chest in pneumonia, obstructive to respiratory movement, and tending to increase the body heat; the administration of emetics in

diphtheritic croup, which is utterly ineffectual except to depress and exhaust the patient; their frequent repetition in bronchitis and whooping-cough when there is no extreme mucous obstruction of the air-passages to justify it; the too free purging of rickety children suffering from laryngismus and convulsions, under the belief that irritant matter in the alimentary canal is the sole cause of evil.

But time forbids me to do more than allude to these things. I will merely add this word of advice. In treatment, consider as carefully what not to do as what to do. To avoid doing harm is as important as to effect positive good.-- The Practitioner.

Medical Society Notes.

SOCIÉTÉ D'HYDROLOGIE.

September, 1891.

Dr. Laussedat read a paper on "The Advantages and Disadvantages of Hot-Water Therapeutics in Cardiac Disease." He claimed that cardiac stimulation by means of baths and warm or tepid douches was a rational procedure in the following conditions: 1. If the patient is young and not nervous, and suffers from functional or organic cardiac trouble of moderate intensity or recent date, hydrotherapy is advantageous in cases of anæmia, rheumatism, dyspepsia, gout, or albuminuria, and we may hope to cure the heart trouble, or at least exert a favorable effect upon it. 2. When a cardiac affection has gone through all its phases of development, and when a compensating hypertrophy has taken place, thermal measures can be of little service. If, however, the patient is not of an excitable disposition, we may resort with caution to hot-water treatment for complicating diseases, such as dyspepsia. This is contraindicated, however, in cases of aortic lesions, which are much more dangerous than those of the mitral valve. It is necessary to determine carefully to what extent the myocardium and arterial system are implicated; if the patient is above fifty years of age, the degree of atheroma will govern us in the choice of treatment. Finally, it should not be forgotten that syncope, angina pectoris and rupture of vessels may be the result of an untimely resort to hydro-thermal measures, which are always contraindicated during periods of blood stasis and as soon as symptoms of asystole make their appearance.

M. de Lavarenne said that a good deal of discrimination should be employed in the treatment of cardiac disease, especially endocarditis, which is frequently of infectious origin, and chronic lesions

of the heart. He admitted the possibility of rheumatic affections of the heart being cured by mineral waters. In chronic cardiac troubles, before resorting to thermal treatment the physician should inquire into the integrity of the heart muscle. In aortic insufficiency hot sulphur baths should be used with great caution.

M. Cazeau thinks that mineral-water medication may be employed without fear in cardiac cases. He permits baths in cases of mitral lesions, but is more careful in aortic insufficiency. He believes that the use of thermal mineral-water baths is able to effect the resolution of exudations in infectious cardiopathies. If the myocardium and blood-vessels are healthy, mineral waters may be employed with advantage in cardiac disease, and too much attention need not be paid to the vascular condition.

M. Caulet said that M. Laussedat had not spoken with sufficient precision. It is necessary to know before commencing treatment whether the patient is suffering from an active disease of the heart or from an inactive and chronic one. At St. Sauveur, where the waters have no excitant effects, patients suffering from chronic cardiac disease are subjected to the same treatment as the other cases-that is, baths and douches, the latter sometimes of fifteen minutes' duration. If the cardiac lesion is not progressing this treatment is entirely free from risk, but it is best to discard the ascending douche, which has a tendency to produce syncope. M. Caulet also differed from M. Laussedat, in that he believed the douche to be less dangerous in these cases than the bath. frequently employs the tepid rain-douche, of eight to ten minutes' duration, directed against the cardiac region, in cases of false angina pectoris, and has in this way cured or relieved twenty patients who suffered from this painful affection.

He

M. Labat remembered having seen, many years ago, patients drinking the waters and taking the baths at Homburg, Wildbad and Schlangenbad for the treatment of heart disease. From his own observations he concluded that such patients should resort to springs which have sedative properties. Waters having excitant or irritating effects have been almost universally proscribed in these cases, and the tendency now is to administer smaller amounts of water and abridge the duration of the baths, by which the possibility of dangerous effects is greatly diminished.

M. Frémont thought that in all cases of aortic disease mineral-water cures are contraindicated; other cardiac affections are sometimes relieved, but never cured.

M. Senac-Lagrange believed that angina pectoris might sometimes result from these baths. It

is therefore better to employ the douche-not the strong interrupted douche, but the gentle and continuous spray, in heart affections. The spray is preferable to the douche, and attacks of suffocation are less to be feared from its use. There are cases where the alternating douche gives good results for instance, where the heart is dilated and very feeble. The speaker had seen persons who could not move about on account of the great cardiac oppression greatly relieved by the use of the douche, so that they were able to walk long distances.

PHILADELPHIA POLYCLINIC MEDICAL SOCIETY.

Dr. Thomas J. Mays read a paper on "SweetOil in the Treatment of Gall-Stones," which embodied the results of a collective investigation undertaken by the Therapeutic Section of the abovenamed society, with the view of determining the clinical value of this drug in biliary colic. In response to circulars sent to a number of physicians nineteen replies were received, and thirty-seven cases of gall-stone colic treated with olive-oil were reported. Records of seventeen additional cases were collected, making a total of fifty-four cases. An analysis of these cases demonstrated the positive value of olive-oil in this condition, 98 per cent. of the patients being greatly relieved. These figures, moreover, do not furnish a true estimate of the favorable action of olive-oil; for two of the observers stated that they had treated forty other cases of biliary colic without a failure, but of which no record had been kept. As regards the manner of action of the drug, Rosenberg's experiments have shown that olive-oil largely increases the quantity of bile secreted, while at the same time it diminishes its consistency. The manner in which it accomplishes this is not yet understood, but Dr. Mays thinks the hypothesis formulated by Virchow the most rational, which is that the oil is absorbed from the intestinal canal, excreted by the liver, and thrown again into the bowel through the biliary passages. It may therefore be conceived that the beneficial action of oil consists not so much in dissolving biliary concrements, as it does in increasing the excretion of bile, in flushing and in lubricating and washing out the passages of the liver. As to the dose of the oil, the author thought that the large quantities administered in most of the cases were not required, for eight of the cases received only dessertspoonful doses every three or four hours, and apparently with the same prompt and positive relief as that which was afforded by doses of from five ounces to one and two pints. If this should

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