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be an exceedingly useful method of applying bread as a remedial agent. In the book referred to a new claimant for gluten bread appears which has the indorsement of Dr. Pavy that it is far more eatable than anything of the kind he has ever met with. The bread is moist and will keep good for abou tten days. It seems to increase the variety of foods at the command of the diabetic; and, independently of this, possesses the advantages of presenting an approach to the condition of ordinary bread, It would be a great boon to diabetics to obtain bread made by this process. But since it is a secret preparation, diabetics in this country are debarred from its use.

In considering bread as a remedial agent, regard must be had to the fact that if we can adapt it to the case in hand the results will be far in excess of those obtained by medicinal agents, provided we apply it with precision and insist upon the exact execution of our directions. This is the great fault of all therapeutics outside of medicinal agents. There exists an indefinite loose method of prescribing dietetic and hygienic measures, which, if applied to medicinal agents, would at once condemn the prescriber.

There is room for improvement. We may begin profitably with the staff of life.

OBESITY.

Among the ailments to which flesh is heir there are few which render an individual more uncomfortable and anxious for relief than a superabundance of fat. Not being accompanied by the usual manifes tations of disease, such as pain, loss of sleep and appetite, and not depriving the individual of the customary means of enjoyment, this trouble is, as a rule, not regarded as a subject for treatment until it threatens to destroy the symmetry of the body, or becomes an impediment to comfortable locomotion. As is the case in all other ailments, an early resort to treatment would not necessitate the radical measures which become imperative when the condition is well advanced.

Especially in young people steps should be taken to divert the abnormal nutritive condition into the proper channel.

The article in this issue by Dr. Paul Cheron is timely and judicious. It presents a fair resume of the best methods of managing this troublesome condition, and will enable the physician to cull the method best adapted to each case. The hot air bath, especially box bath, in which the air inhaled is not expanded by heat and rendered impure by lack of ventilators, as is the case in the Turkish bath establishments, followed by gradually cooling douches under good pressure, 20 to 30 pounds and terminated by a spray or jet douche of low temperature, 50 to 60o, has proved an effective auxiliary in increasing tissue change in the right direction.

The arm exercises, as described by Cheron, while standing erect against a straight wall, are another valuable measure, too little practiced. It should be executed in a well ventilated room or in the open air.

The consumption of large quantities of green vegetables acts as a fodder to satisfy the palate and satiate the appetite without furnishing nutritive material.

The use of tea and coffee, as advised by Germain See, proved an excellent denutritive agent, which must, however be avoided in the erethetic, excitable obese. It is invaluable in sluggish and plethoric individuals, who are fond ofand indulge in siestas, because it counteracts the latter tendency. Except in the obese suffering from certain cardiac troubles the deprivation of water, which has become so empirically universal since Oertel's treatment was published, is a needless cruelty. Indeed, in some subjects, such as the rheumatic and gouty, the free use of water is an absolute advantage because it assists the exchanges and aids in freeing the patient of uric acid deposits that impair his movements and render him unfit or disinclined to exercise. A careful study of all the elements of each case, an insistance upon the methodical execution of the physician's directions will amply compensate the doctor and patient. To advise a patient to abstain from starchy and farinaceous food, to exercise a great deal and drink no water, without minutely entering upon methodical directions invariably leads to failure and dissatisfaction. If we expect the patient to obey directions, the latter must be made as little irksome as is consistent with through

treatment.

There is no reason why the obese may not be made comfortable and content, if their predelictions are regarded, and the restrictions placed upon their habits and customary mode of life are ordered with care, judgment and sympathy. The physician needs to learn the maxim "Put yourself in his place," when prescribing for an individual who is not bedridden but as capable of enjoying the pleasures and comforts of life as himself.

Annotations.

ON THE DIETETICS OF THE SENILE HEART. BY G. W. BALFOUR, M.D.

Cases of senile heart may be grouped for dietetic purposes under two distinct heads: First, those who are over their normal weight, who are breathless with occasional irregularity of the heart, and with or without marked signs of cardiac dilatation; and, secondly, those who are at or below their normal weight, and who suffer very considerably from cardiac dis

turbances of various characters, also with or without very evident signs of dilatation of the heart. The first class of cases are usually dubbed cases of fatty heart, and are probably told to expect a sudden death; or if the view taken is not quite so serious, they are sent to Marienbad to be fined down. The second class are grouped under the ordinary heading of cardiac disease, and treated accordingly. I have already pointed out that a fatty heart is a comparative rarity, and that its diagnosis is perfectly impossible. Hearts set down as fatty are weak, dilated, or dilatable, and some of them are oppressed with fat, though not themselves in any respect fattily degenerated. To send such cases to Marienbad is a practice not without danger, as the saturation of the vessels with acidulous water often precipitates the cardiac dilatation it is our object to ward off. The danger of this treatment is now distinctly recognized, and is very distinctly warned against by some of the ablest of the modern German physicians. Fortunately it is not necessary; we can easily and comfortably relieve such patients of their dangerous and wearisome burden without taking them from their own firesides, if they will only be obedient and trustful; if they will not, by all means let them take the risks of Marienbad-if they choose.

The first point of importance in regard to all cases where dieting and dietary come into question is to divide the day properly, so that there may be a sufficient interval between each meal. In health the stomach empties itself three or four hours after a meal, and requires a rest before more food is ingested. In those having weak heart and feeble circulations the digestion is bound to be somewhat slower, hence the first rule to lay down is not less than five hours between each meal. This allows of three statutory meals of the day, with a sufficient interval for the digestion of the last meal to be pretty well advanced before retiring to rest, which tends to insure a quiet and restful night. The next matter of importance to remember is, that the ingestion of solid food into a stomach still digesting a former meal arrests that process and provokes flatulence, hence the second rule to be laid down is no solid food of any kind is to be taken between meals. This rule must be absolute; not even a morsel of cake or biscuit, or any similar trifle, is to be ingested between meals. There is nothing so destructive of gastric comfort as the continual pecking induced by gouty bulimia. This prohibition does not extend to water, which should be taken hot rather than cold; and of this hot water half a pint may be sipped if desired about two or three hours after a meal. Taken in this way it does not disturb the digestion; it washes out the stomach, and passes speedily through the kidneys without raising the blood-pressure. But as little fluid as possible should be taken with meals.

The third important rule is that all invalids should have their most important meal in the middle of the day, and should only have a light meal in the evening. All those with weak hearts have feeble digestions from the gastric juice being deficient in quantity and defective in quality; it is needful, therefore, for their own comfort, to restrict the quantity of their food, and to see that it is not diluted with too much fluid. A model dietary for a patient with a weak, irregular heart would be: Breakfast, 8:30, small slice of dry toast, weighing about an ounce and a half, with butter; one egg, or half a haddock, or a similar quantity of any fresh whitefish, with a small cup of good coffee or of tea, not infused longer than four minutes, with cream and sugar if desired. The next meal is dinner at 1:30 or 2 P. M. This may consist of two courses-fish and meat, or meat and pudding, or fish and pudding-never any soup. Individual idiosyncrasies must be inquired into and attended to, but certain things must be absolutely forbidden-soups, pastry, pickles and cheese being the most prominent of these. Fish of every kind may be taken, and also meat of every kind; though at the commencement of the treatment the choice had better be restricted to white fish boiled in milk or grilled, sweetbreads, chicken, rabbit, game or tripe, but ere long, any variety of meat may be taken in moderation. vegetable a single potato, if desired, may be freely allowed, if care be taken that it is thoroughly disintegrated by teeth or fork before being swallowed. Spinach is always a safe vegetable, as there is not at particle of flatulence in it, and its chlorophyll has the credit of acting as a cholagogue; probably it is slightly laxative. Tomatoes, onions, leeks or celery, either stewed or raw, are safe enough. Green peas

For

or beans must be used sparingly, if at all, but all other vegetables must be wholly shunned. While this list of safe vegetables is given, it is merely intended as an alternative list, the model allowance being the single potato or an alternative. The puddings must be restricted to stewed fruit or any form of milk pudding.

A single cup of tea, infused only four minutes, may be taken at five o'clock, or from four to five, if desired, or a tumblerful of hot water if preferred or the tea disagrees; and if any stimulation is thought needful, a teaspoonful of Liebig's extract of beef may be stirred into the hot water, but not a morsel of biscuit or cake must be taken with it.

Between half-past six and half-past seven comes the final meal of the day, and this may be a bit of whitefish and a potato, a bit of milk pudding, porridge and milk, or cold bread with hot milk poured over it. At bedtime a small tumblerful of hot water will soothe the stomach, promote sleep, and pave the way for a comfortable breakfast next morning.

On some such dietary as this, which is given merely

as a sample, to be modified according to idiosyncrasy, but which must be adhered to in its main lines, a weak digestion from a feeble heart will gradually recover its tone, and the patient will feel comfortable, instead of being puffy and oppressed after meals, with an irregular and trembling heart. The patient should be weighed from week to week, and if the declension is too rapid the dietary must be altered or varied according to idiosyncrasy or circumstances. As a rule, a patient who has been wasting gains flesh from improved digestion, while an obese patient gets thinner, and in most an equilibrium is established as soon as the average normal weight is reached. Care must always be exercised to prevent the loss of weight from being too rapid, and to arrest it by modifying the diet if the declension persists too long. A mixed diet is always best for the maintenance of health, and if animal fats are not much indulged in the carbohydrates in the diet indicated will not be found to be too much. Those accustomed to live fully require to exercise a considerable amount of self-denial to keep within due bounds, and nothing but self-denial will ever reduce obesity with comfort and perfect safety. -Braithwaite's Retrospect.

Hydrotherapy

in Croupous Pneumonia.-Dr. A. Baginsky reports thirty cases of children (17 males and 13 females) treated by hydriatic measures. The majority of the cases were characterized by high fever, the temperature not infrequently rising to 41° C. The results were: 24 patients were completely cured, 2 were convalescing at the time of the report, and the others who developed complications (pleuritis, tuberculosis) were more or less restored to health. It will thus be seen that all of the genuine cases of fibrinous pneumonia made perfect recoveries. Baginsky states that the indiscriminate reduction of all elevations of temperature is not called for in the treatment of these cases although practically high temperatures are as likely to act as injuriously on children as in adults, it must not be forgotten:

1. That it is highly probable that in febrile temperatures the organism has a weapon for combatting the disinctive effects of bacteria or the toxic substances produced by them. 2. That the more powerful antipyretics have an injurious action upon the heart muscle or the blood corpuscles. For this reason great care is demanded in the use of antipyretics in pneumonia when the preservation of the cardiac power is urgently required. The author formulates the following axioms on this subject :

1. Antipyretic treatment in children should only be utilized to the extent of effecting reductions of temperature without depressing the heart action.

2. Extreme care should be exercised in the employment of these antipyretic measures which have

an injurious influence upon the heart muscle or blood.

3. If antipyretic remedies are resorted to, cardiac stimulants should be simultaneously administered to counteract their noxious effects.

In brief, a mild and careful antipyresis together with exhibition of tonics and excitants is, in the author's opinion, the best means of treating pneumonia and all analogous infectious diseases. Of all antipyretic measures he thinks cold water is least likely to be attended with dangerous effects. In children in whom the cutaneous surface is extensive compared to the mass of the body and the cutaneous vessels abundantly developed a loss of heat by way of the skin takes place far more readily than in adults, and hence in them antipyresis by application of cold water is the most suitable. In the employment of this measure we should carefully consider the effect of cold upon the nervous system of the child. Intense and sudden impressions by cold, such as are produced by cold ablutions in a warm bath, should only be employed in exceptional cases, because the effect upon the nervous system is too powerful, and by the fear inspired may give rise to dangerous sequelæ. The same may be said of baths having low temperature (54°-65° F.); but the cool bath may be considered as an effective antipyretic, especially in cases where it is desired to stimulate the nervous system which has been depressed in its energy by the febrile process. As antipyretics of medium grade we may regard the tepid bath of a temperature of 76°-86° F. and the cold pack. The last named are the best and most effective means of reducing temperature to any desired extent in children, without disturbance of the general functions. Of the two procedures the author expresses his preference for the cold pack, on account of vivifying effect upon the nervous system and the convenience and ease with which it can be employed. Its antipyretic effect, if employed in the proper cases, is undoubted and any depressant influence it may exert upon the heart muscle may be counteracted by intercurrent doses of stimulants.

The cold pack is applied by Bagnisky in the following manner: The child is stripped naked, and then covered over the head (leaving free the face), shoulders, arms and legs with cold wet cloths having a temperature of 58-66° or 72° F., and enveloped in woolen blankets. After remaining thus for ten minutes the moist sheet is removed and a second one applied, Frequently this measure is repeated for the third time, so that the entire procedure occupies about one half hour. In the last cold pack the child may remain half an hour, and is then dried, and lightly covered. If necessary the cold pack is renewed twice or three times daily. In the intervals between its application the children receive small doses of strong wines (port or sherry) in doses propor

tioned to the age. The antipyretic effect of the cod pack is not identical in all cases and may be entirely absent in special conditions. In the majority of cases, however, it is sufficient to effect reductions of temperature of 1°-1, 4°-2° C.

Bagnisky does not make use of the cold pack in all cases of pneumonia even when attended with high fever, but rather in cases where the elevation of temperature is associated with severe general symptoms especially marked implication of the nervous system Occasionally it may be necessary to administer in addition other antipyretics, but this applies always to serious cases, and the non-appearance of antipyretic effects after the cold pack is of importance in a prognostic sense as enabling us to estimate the severity of the disease. In general, in such cases internal antipyretics are insufficient or their effect is nullified by the occurrence of attacks of collapse. It should not be concluded from this that the author is opposed to all remedial antipyretics. In protracted febrile conditions like typhoid fever, he is in the habit of combining hem with the cold pack, but regards the latter measure as by far the most efficient. Archiv fur Kinderheilkunde, Bd, 13, 1891.

Hygiene and Dietetics of the Arthritic.-Dr. Lucas Champonnière, in the course of an able article upon this subject, deduces the following rules as to the best diet to be ordered for the patient. The author says that for those suffering from pronounced arthritis who are very lithomic preference should be given to white meats, veal and young animals, mutton and lastly beef. In some cases, however, game or venison should be denied. If fish be ordered, the white-meated is best, as we find it in the

sole, haddock or codfish, while such colored or oily

flesh as in the salmon, eel, mackerel or sturgeon had best be avoided. Shellfish and crustacea, while nutri tious, the author considers as too compact in their tissues, and hence indigestible, and on this account inadvisable for the arthritic.

Peas and beans yield a considerable amount of nitrogenous matter, but, strange to say, do not seem to form uric acid. The fruit acids become alkaline in the system, and these two classes the author advises in the diet table.

As to liquids Dr. Champonnière considers water especially good for the gouty. Some writers have gone so far as to say that this article alone is sufficient for a cure. Water increases the excretion of urea, and it is proven that the production of uric acid is in indirect ratio to the formation of urea, hence the more water the patient consumes the less uric acid is formed. Finally, water aids in the elimination of all waste organic products, and in the dissolution of the fatty acids which constitute gall stones. A dry diet, it is thus seen, is rather a dangerous one for the arthritic.

As to wines the author advises very light varieties.

Alcoholic wines and champagne especially are most injurious.

The following rules are held to be applicable to every case:

See that the arthritic patient produces and absorbs the least possible amount of organic poison which, by irritating the less resisting connecting tissue, would cause arthritic manifestations.

Modify the arthritic diathesis as far as possible by means of exercise, gymnastics, hydrotherapy, massage, etc.

Attend to the amount and quality of the food; hasten nutritive changes; facilitate elimination of all organic waste and toxines by stimulation of the emunctories, which are usually unreliable in arthritic patients.

The Treatment of Chlorosis by Bleeding and Diaphoretics. In the Revue de Therapeutique Generale et Thermale for 1891, Schubert has contributed a paper upon the treatment of chlorosis by bleeding and diaphoresis. Although this treatment seems at first sight to be paradoxical, it is, nevertheless, one which has been tried by other physicians, and which Schubert believes to be distinctly

beneficial in many cases.

The fact that it was of benefit was discovered

through the improvement which took place in those epistaxis or of hemorrhage from the stomach. From his experience with it, Schubert is convinced that the method is worthy of general adoption by physicians. The amount of blood which is to be taken away varies from a few minims to several ounces. The results are

cases of chlorosis which suffered from an attack of

generally very rapidly produced, so that after five

re

weeks' treatment the patient becomes very much improved. The author quotes Wilhelm, who has ported thirty cases of chlorosis treated by bleeding,

and who reaches a similar conclusion as to its value. Closely allied to the treatment of chlorosis by bleeding is that of Schultz, of Bremen, who has employed diaphoretics for the same purpose, combined with laxatives and sometimes with bleedings. Schultz claims that under the influence of this combination of methods, the symptoms of the disease disappear with great rapidity. The amount of blood which is taken by Wilhelm is eight to ten drops for each two pounds of body-weight. Schubert, on the other hand, withdraws but fifteen or twenty drops. After the bleeding, the patient should rest in bed for twenty-four or forty-eight hours, and should receive acidulous drinks and liquid diet.-L' Union Medicale, December 3, 1891.

Hydrotherapy in Spinal Diseases.-Dr. R. Von Hoesslin urges the use of cold water applications in spinal diseases. Although he has observed unfavorable effects from hydrotherapy in some cases,

his results from cold water applications have, in the main, been excellent. He is especially impressed with the value of cold affusion to the lower extremities, after previous heating of these parts by the hot pack or by steam baths. The cold applications should not be made for more than a minute at a time, after which the parts are dried and covered with blankets for half an hour to one hour. In some instances, the reaction following the cold bath was no longer perceptible after daily employment of the bath for two or three weeks. When this occurred other hydropatic measures were resorted to, such as cool sitz-baths or full baths, cold affusion to the back, the sittings being of the same duration as the above. Later the above described method was again practised, when the re. action could be obtained as at first. This treatment proved especially efficacio us in tabes dorsalis, multiple and lateral spinal sclerosis. Many of the cases reported by Hoelein were seen also by Prof. V. Ziemmssen. These results confirm the view expressed by Leyden in the addendum to the Realency clopædia that Hydrotherapy is only really valuable therapeutic agent in tabes.

Multiple Neuritis Cured by the Cold Douche.-Dr. J. Dubrisay reports the case of a married woman, aged twenty-six, who first suffered from cardiac trouble and began to emaciate in November of 1890. Attacks of diarrhoea and vomiting occurred frequently; amenorrhea, anorexia, and continuous thirst, sleeplessness, apathy were also present. The patient was unable to maintain an upright position on account of the extreme pain and weakness. She was so weak that she could not hold the spoon when eating. On the forearms the paresis affected to an equal extent the flexors and extensors. On the legs the flexors were more involved, the toes were bent, but the foot flexed in such a way that the patient always walked on the heel, Romberg's symptom and the patellar reflex were wanting. The patient had a constant feeling of cold, was analgesic and anæsthetic over the entire surface of the body, and complained of intense paroxysmal pains over the ends of the fingers and plantar surface of the foot which were increased by pressure on the plantar

nerves.

There was also a feeling of burning and tearing in the feet, with some oedema; and painful formication in the hands. The patient was addicted to alcohol. The treatment consisted of tonics, opium, and chloral to produce sleep, and paregoric against the diarrhoea. The chief means of cure were cold douches of 25 to 30 seconds' duration and once or twice daily. Alcohol was permitted in moderate quantities, the thirst relieved by a decoction of wild chicory or cinchona, and two litres of milk givis per day. Under this treatment the patient was perfectly restored.-Deut. Medizinal Zeitung, No. 122, 1892.

Treatment of Cholera Nostras of Adults with Large Quantities of Water.-Dr. K. Fiedler says he had the opportunity to observe, in Dresden, in 1890, several cases of cholera nostras in adults. In the first case, a woman 54 years old, when in her usual good health, ate of cabbage with zest at dinner. In the evening she went out, and after her return she was suddenly taken ill, about eight o'clock in the evening, having felt dizzy when on the steps. Sweating first appeared, then diarrhoea, pain in the belly, with nausea and vomiting. Diarrhoea and vomiting quickly increased in frequency, oppression and anxiety appeared, then cramps in the calves of the legs. Subsequently there was transient faintness. When seen by Fiedler, the patient was in collapse, with pale cyanotic face, cold sweat upon the face and brow, deeply sunken eyes, passages without interruption, retching constantly, etc.

Tincture of opium was prescribed, and pieces of ice to allay the thirst. Efforts were made to keep the body warm, and direction was given to apply a wash if general sweating should occur. The next day the patient complained that the ice had made her abdominal pain and diarrhea worse, but that several cups of tea had made her feel better. In general her condition was unchanged. Dr. Meinert, who then saw the patient, ordered the opium stopped, and directed the patient to drink freely of ordinary tap waters. On the following morning there was a very pronounced improvement. During eight hours the patient drank a quart of water every hour. All the symptoms had improved, and the next day the patient was dismissed from treatment.

Two other cases received the same treatment, and also recovered very promptly and satisfactorily.— Therapeutische Monatshefte, December, 1891.

The Treatment of Neurasthenia by Transfusion of Nervous Matter.-In a report made before the Paris Academy of Medicine, M. Constantin Paul described a new method of treat

ing neurasthenia by transfusion of brain substance prepared as follows: 15 grms. of gray substance from a sheep's brain are chopped fine, and macerated for twenty-four hours in 75 grms. of glycerine; to this 75 grms. of water are added and the mixture filtered through D'Arosonval's apparatus under a pressure of forty to fifty atmospheres produced by carbonic acid. In this way 150 grms. of a 10 per cent. solution of brain subfluid, having a spec. gr. of 1080-1090, and may be stance are obtained. This forms a colorless transparent preserved unchanged for ten days. The injections are made in the flank or lumbar region, and their immediate effect is practically nil, no signs of local inflammation being produced, except in a few instances a transient swelling of the lymphatic glands. The author has treated eleven cases by this method, 3 of neurasthenic chlorosis, 3 of typical neurasthenia, 1 of

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