About 1500 cc. of warm 10 per cent glucose normal salt solution is given during the day. If the rectum is irritable, 30 to 45 minims of deodorized tincture of opium may be added to the day's rectal feeding. When food by mouth is again resumed, white of egg water, cream and Vichy, milk and lime water and barley water, clear or with milk about 3 ounces every two hours, form the basis of the diet. Sugar should be added in amount short of being unpalatable and salt in minimum quantity is allowed. When it is once shown that such food is satisfactory, a graded diet may be established such as is here indicated:

N.B. Butter, salt and sugar may be added to any or all of these foods as desired unless otherwise specified.

The food mentioned in this list is given only as a type of food allowable from time to time in increasing amounts. The length of time such a diet should be established depends entirely upon the condition and immediate results. In peptic ulcer when meats are allowable, only those easily digested should be given at first, and probably not for a year or more should heavy meats be allowed at all. The dietetic management of the peptic ulcer case is, of course, only a part of the treatment. If the results are not satisfactory after a faithful effort, it may be concluded that no dietetic treatment will of itself be sufficient and that surgical procedure is

necessary.

If the results are satisfactory, i.e., the diet established produces the desired result, an effort should be made to increase the patient's weight to the normal standard so that the patient may have sufficient reserve in case of threatened recurrences.

This plan is given in a rather specific or dogmatic way because there is scarcely any condition of the digestive system, acute or chronic, primary or secondary, for which a part of this regime or all of it may not be applicable.

Conditions of the digestive system associated with or secondary to disease elsewhere are for some unknown reason usually not given the same careful attention from the standpoint of diet as the primary diseases of the digestive system are. It is remarkable that the nausea and vomiting of the patient suffering from chronic pulmon

same consideration from a dietary standpoint, as the patient having nausea and vomiting from acute exacerbations of chronic cholecystitis, for example. A patient suffering from a cardiac decompensation, with enlarged liver and engorged portal circulation should have the same consideration from the standpoint of diet as the patient who has a peptic ulcer. Why should the epileptic with gastric aura go without gastric study and rational dietetic care?

Probably no conditions of the alimentary tract are treated with less activity of gray matter on the part of the physician than are constipation and diarrhea. This is probably so because such irregularity of the bowels is largely due to errors in diet and to a failure in establishing regular habits. The correction of the condition depends largely upon the adjustment of the diet and the instruction to the patient. A certain medication is, of course, also necessary in some cases.

Defecation is a normal physiological process and when it is disturbed the cause of such disturbance should first be determined. Whether the cause is due to some error in diet or to a certain pathological lesion, in the digestive system or elsewhere, the treatment involves a dietetic problem. It is always easier for the doctor to write a prescription than to outline a diet. The dietitian may be of great assistance in such cases but the doctor, who should know the actual condition, must specify the particular diet and

the proper and careful preparation of the food and in determining its caloric value and proper balance.

Such a diet is of no earthly use in its application unless the cause of the irregularity of the bowels is known.

There is a vast difference between a spastic constipation and constipation due to atony, or between a diarrhea of gastrogenous origin or one due to ulcerative colitis. The diet must be adapted accordingly. The physician, the dietitian and the patient, as well, must see the absurdity of having one set diet list for constipation and another for diarrhea. I submit a diet list which lends itself easily to indicating to the patient what foods may be constipating and what foods may have a laxative effect. (See diet of Clifton Springs Sanitarium and Clinic.)

The two diet lists submitted are neither of them intended for any specific or definite disease of the gastro-intestinal tract but they may be helpful in indicating a diet for any pathologic or physiologic disturbance which may happen in the individual

case.

In conclusion, I wish to say that it is my observation that the dietetic treatment of gastro-intestinal conditions too often means to the patient starvation, to the dietitian a hard and fast rule, and to the average physician something to be side-stepped and neglected. It is the purpose of this paper to call attention to such general principles as may lead to the correction of the existing conditions.

Ο

N REVIEWING the literature on the subject of thrombo-angiitis obliterans, one encounters a number of the theorizations and speculative suggestions based in some cases on an incorrect understanding of the pathology of the discase and on attaching too much importance to some data gathered from the family and past personal histories of the cases.

In the discussion of the disease in this paper I will attempt to present only those facts which are based on established clinical and pathological findings, refuting others that have no definite basis.

DEFINITION

Thrombo-angiitis obliterans is a chronic, progressive disease affecting the extremities, the etiology of which is not as yet definitely established. It is characterized by a thrombotic occlusion, associated with an inflammation of apparently healthy vessels, resulting in circulatory obstruction and great pain, making it difficult or impossible for the victim to use the affected limb or limbs, with the ultimate development of ulceration and gangrene.

ETIOLOGY

The disease is not as uncommon as it is generally thought. Many cases are seen in the big cities among in

dividuals whose struggle for existence is great and where sanitary conditions are not at their best. It is most common among Russian, Polish, Roumanian and Galician Jews, for which reason it was named the "Jewish disease." Other nationalities are, however, not exempt. Kogo reported a number of such cases among Japanese; Ochsner, among Swedes; Ludloe, among Chinese and Brooks, in an Irish-American woman. The disease is probably overlooked in many subjects belonging to other nationalities. The most common ages are twenty to forty years, though cases of sixty or over are seen. Occupation is no factor. It affects peculiarly the male, but the female is not exempt. Nearly all cases are inveterate cigarette smokers for which reason some authors, notably Willy Meyer, consider tobacco to be the exciting etiology. The fact that there are proportionately so few of the tobacco smokers that develop the disease and that occasionally a non-smoker develops it would contradict this assumption. It must be admitted though that tobacco is the most important predisposing cause, for the disease is often checked on stopping the habit of smoking and is lighted up again on its resumption.

In many cases the histories seem to link the disease with exposure to extreme cold or trauma years before the

onset of active symptoms, in the interval of which there was experienced uneasiness and occasional pain in the affected parts. In some cases a congenital hypoplasia and a deficient development of the blood-vessels is found and has been blamed for the onset of the disease.

Of purely theoretical assumptions as to the exciting etiology may be mentioned rye-bread as an article of diet and the occurrence of typhus in early life. Both of these have no basis other than historical data gathered from an occasional case.

The pathogenicity is apparently dependent upon certain predisposing and exciting factors acting together neither of which would accomplish the results independently. Some of the predisposing factors must be an instability of the vaso-motor mechanism, which is always encountered in these cases, exposure to extreme cold, overstrain, intoxications-particularly tobacco and possible abnormalities in the internal secretions. These factors produce a deterioration of the blood and a certain amount of devitalization of the blood-vessels, preparing the ground for some specific infectious microorganism which, no doubt, is the exciting cause.

Of late, there was isolated a microorganisma bacillus-from the blood of some cases, by Rabinowitz, which apparently meets with the postulates of Koch, and which will undoubtedly prove to be the offending agent.

The occurrence of the disease only in the extremities, especially so, in the lower, would tend to prove the necessity of the predisposing factors in the production of the pathology. The greater exposure and strain the ex

tremities are subject to, the longer course of the vessels there-giving more area for intoxications to act onand the greater trauma these vessels. are exposed to, added to the hydrostatic effect of the circulation, make the vessels of the extremities, particularly of the lower ones, suitable for devitalization and for blood to stagnate there, thus preparing the ground for the organism.

PATHOLOGY

The primary pathology is confined. to the vascular system of the extremities but incidentally the nervous structures found in the vascular sheaths or accompanying the vessels are also affected. The gangrene which supervenes is due mainly to the shutting off of the blood-supply as a result of vascular obstruction. There are indications, though that it is in part, at least, due to the direct action of the causative factor upon the tissues undergoing gangrene.

According to the excellent work of Buerger, the pathologic anatomy consists of a migrating thrombosis of the deep arteries and veins the same as in superficial thrombo-phlebitis. Small portions, 5 to 10 cm., of the arteries and veins become simultaneously or alternately thrombosed. Reactive arteritis and phlebitis sets in with the accompanying small round cell infiltration, vascularization and connective tissue formation. Organization involves the thrombus, the vessel walls and even the contents of the sheath, including the nerves-all of which form a single cord-like mass. Canalization may occur producing a microscopic appearance resembling endarteritis obliterans.