selecting quarters for the patient; but, if this is not available, a bed room with windows on two sides, allowing a cross ventilation is very good. The room should be selected, so that, in summer, it will get the morning sun and afternoon shade, the reverse during the winter. Freedom from dust, smoke and the noise of traffic, is essential to good air; but these conditions are met a short distance from the business district in most of our Iowa towns and cities.

A few years ago we kept our patients outside (or at least, we tried to) day and night, during the severest zero weather and winds, paying little attention to their comfort or discomfort so long as they received plenty of fresh air. In a large percentage of cases, such a rigid rule is wrong, and often harmful. Much better results will be attained, and the patient be more contented, by instructing him to remain outside as much as possible in calm weather, even though it be quite cold, but on windy days to remain inside, in a well ventilated room. Cold winds blow the heat from

the body, and so draw heavily upon the vital energy. The physician should endeavor to utilize all of the advantages of the climate, and to avoid. the disadvantages as much as possible.

Patients often have their own ideas regarding breathing; one of which, is breathing deeply. Some of them have the air-cure so deeply rooted in their minds, that they will expand their lungs to the fullest extent, a counted number of times, both morning and evening, hoping by this means, to accelerate their cure. Such a procedure defeats the very object for which we are seeking, viz: Rest to the injured organ. As this occurs quite frequently, the doctor should advise against it as a matter of routine.

Quiet, natural breathing should be advised, and, as the patient improves and is allowed some exercise and light work in gradually increasing amounts, the lung will be called upon gradually for greater expansion and activity, which is all that he should attempt until firm healing is estab

lished.

Elimination—Elimination by bowels, kidney and skin is an important factor in the treatment, and one that is often left largely to the patient's own judgment. Man, through bad habits, has gradually arrived at the conclusion that one bowel movement per day is sufficient; but he is the only animal that appears to think so. To maintain good health, at least two evacuations per day are necessary; and this is the more so in a disease, the treatment of which calls for a copious, rich diet, and enforced rest. It is necessary first, to instruct the patient, how to acquire good habits

in this respect, such as going to stool at stated intervals every day; copious water drinking with meals, and between meals, and the selection of a diet containing sufficient residue.

Where artificial stimulation of the bowel is needed, and this is usually the case, Hinkel's pill, morning and evening, or bitter extract of cascara, in small doses three times a day, I have found very useful.

One must not forget that these patients with sluggish bowels, often suffer from a degree of stasis. The patient may have one or two fairly good bowel movements per day, and still suffer from faulty elimination, by reason of the fact that the movement is always anywhere from a few hours to seventy-two hours late; thus permitting putrefaction of the intestinal contents, and absorption of the products thereof.

In cases where this seems to occur, the patient becoming depressed and losing his appetite, I find that a smart dose of epsom salts or Pluto water an hour before breakfast, followed by a glass of hot water and copious water drinking, will usually restore him in a day or so. Copious water drinking should be encouraged, because most of these patients are poor water drinkers, many of them seldom use it as such. It will aid greatly in digestion, which is, as you know, simply a process of reducing solid foods to a solution. It aids greatly in the absorption, especially of fats, and increases the activity of the kidneys and skin; all of which is necessary in aiding nutrition.

To promote elimination from the skin, one or two cleansing baths per week should be advised.

Drugs-It is true that the less drugging a tuberculous patient receives, the better he will get along; for many reasons, chief of which is the long duration of the treatment, and the liability to depend upon them for a cure instead of pinning his faith to a rigid routine of living. A good rule to follow, is to give a drug only where such is clearly indicated. Teach the patient to subdue the cough, much of which is purely bad habit. Then, if a drug is needed, a combination of codiene, gr. 4, dilute hydro-cynic acid, minims 1 to 3, in a drachm of peppermint water, given three or four

times per day between meals, and continued for a few days or a week, will usually suffice.

A simple stomachic may be used for a short period for the appetite and digestion, and a soft Blaud's pill, containing a small dose of arsenic, during the period of anæmia. A patient who will rest and will follow out his routine conscientiously, will call for very little medication. Any medicine aimed at the direct destruction of the

The busy practitioner will do well to leave serums and vaccines to those specially schooled in their use.

Exercise-There remains to discuss the question of exercise; and it is difficult to lay down any rules that are applicable to most cases. Exercise should be looked upon as a powerful drug, capable of doing great good, or harm, accordingly, as it is properly used or misused. Most cases must be treated strictly on their own merits, but a good rule to follow is to keep the patient pretty well at rest until he has gained his normal. weight, and until the temperature has been normal for a week or two, and the pulse under ninety, taken at rest. Exercise should begin by allowing him to come to the table for meals, and walking around the house for a few days before venturing to walk out of doors. He may then start out on a fifteen minutes walk morning and afternoon, this to be taken after complete rest until 10:30 A. M. and 3:30 P. M. He should walk slowly, and when he returns, he should lie down for a little while before coming to his meal. It is at this time, that the patient should be carefully watched, and cautioned against taking more exercise than is allowed; for, if he does, he will probably have a return of his fever and digestive disturbances. A careful record of the temperature and pulse, taken four times a day, between 7:00 A. M., and 8:00 P. M. should be kept, and the exercise increased accordingly as these continue to remain about normal. It should not be increased more than

fifteen minutes at a time, and a week to ten days should elapse between the periods of increase. After he is able to take three-fourths of an hour without symptoms, a little light work can be added, which brings into play the muscles of the arms, chest, back and abdomen.

Some difficulty is usually encountered at this stage of the treatment, in holding the patient down to this routine. It is, perhaps, the most critical of the whole treatment, because he usually feels so well that he thinks things are not moving along fast enough; consequently he tries one or two new moves on his own account, each day, until, at the end of a week or two, he is living about as any normal individual would live. Trouble now commences, and he seldom blaims himself, but his doctor. This can be avoided by questioning the patient each time that he is visited, regarding his hour of arising in the morning, and retiring in the evening; when he takes his exercise; when he rests, etc., because very few patients are bold enough to deliberately falsify. He

asked, and finally admit that he wandered off the path, which gives the doctor the opportunity to correct his false steps.

The treatment during convalescence simply resolves itself into a question of managing the patient; of knowing in advance just about what mistakes the patient is likely to make, and continually cautioning him on these points.

802 Leavitt & Johnson Bank Bldg., Waterloo.

REPORT OF A CASE OF CARDIO-SPASM WITH ENORMOUS DILATATION OF THE ESOPHAGUS*

THOMAS J. SNODGRASS, B.S., M.D.,
Pember-Nuzum Clinic, Janesville, Wisconsin

of the oesophagus were collected by von Ziemssen The first cases of so-called idiopathic dilatation and Zenker in 1878. In 1904 Mikulicz reported one hundred cases collected from the literature.. Since that time Sippy, Lerche and Erdman in this country have reported a number of cases, and in 1908 H. S. Plummer of Rochester wrote a very excellent paper on the subject and reported forty cases of cardio-spasm which he had treated up to that date. Many more cases could be reported at this time, but the diagnostic methods and the treatment have not changed materially since that time. The interest in the subject lies in the fact that cardio-spasm is a condition which the average practitioner seldom sees.

The following is a brief summary of Plumattributed first, to cardio-spasm; second, to atony mer's work on the subject. The disease has been of the œsophagus; third to simultaneous presence of cardio-spasm and paralysis of the vagus; fourth, to congenital disposition; fifth, to primary cesophagitis, and sixth, to kinking of the hiatus. esophagi. In all probability the atony seldom occurs. Cardio-spasm may be associated with gross lesions as ulcer or cancer.

The cardia is normally closed and the food is pushed through by the peristalsis of the oesophagus. After dilatation takes place the bolus of food is carried forward in the usual manner as far as the upper end of the dilatation. At this point the peristaltic contraction ring ceases to exert any di

rect force on the bolus, but sweeps around it. The food is then propelled by gravity and increased three stages are recognized. In the first stage the pressure. In the development of cardio-spasm peristaltic contraction is sufficient to force the food through the spastic cardia.

*Read before annual assembly, Tri-State District Medical Society, Waterloo, Iowa, October 4, 5, 6, 7, 1920.

This stage is characterized by discomfort, pain, and a choking sensation. Second, the peristaltic force is insufficient and the food is immediately regurgitated. This may be due to the increased cardio-spasm or decreased muscular power of the œsophagus. At first the spasm is periodic, later continuous. At first, there is a hypertrophy of the muscles of the œsophagus and later a stretching. Third, once the oesophagus begins to give away the dilatation is rapid. This stage is characterized by retention of food and its regurgitation at irregular intervals after injestion. The symptom complex is therefore, first, cardiospasm without food regurgitation; second, cardiospasm, with immediate regurgitation, and third, cardio-spasm with dilated oesophagus, retention, and irregular regurgitation. After dilatation has taken place the sac never completely empties and the amount of retention may vary from two to sixteen ounces and can be withdrawn twenty-four hours after fasting.

Some of the points in diagnosis are: food regurgitation from the œsophagus and not the stomach; the existence and character of the obstruction at the cardia; the presence or absence of œsophageal dilatation, its shape and size; radiographing of the bismuth in the dilating œsophagus; determination of the size of the dilatation by means of a rubber balloon distended within the œsophagus; and the cesophaguscopic examination.

One of the suggestive symptoms is failure to pass the stomach tube although an olive passes readily into the cardia. Immediate regurgitation of undigested food upon passing the stomach tube is suggestive of dilatation of the oesophagus. One cannot always make a diagnosis by the use of olives because if an olive strikes the cardia at its center it passes very readily through the cardia without offering much resistance. This will distinguish it from an organic stricture.

The old style of treatment such as the use of fluids, non-irritating diet, effervescent drinks, bromides, frequent passage of sounds, is very ineffective. A few cases have been operated upon and the cardia dilated through the gastrostomy wound. This is effective but not necessary. The development of the apparatus for stretching the cardio-spasm by means of hydro-static pressure in a strong, silk bag has made the more radical treatment unnecessary. With such an apparatus it is possible to stretch the cardia enough to paralyze the sphincter without tearing the opening itself. If pressure of 500 m.m. will not accomplish this, pain is disregarded as a guide and dilatation is carried out, gradually increasing the size. In

the cases treated in this way the most gratifying results are reported.

The case which I wish to report is that of T. P. W., age sixty-six, married farmer; weight 142; weight several years ago 172; family history negative. He gave a history of having had trouble in swallowing since he was fourteen years of age. He said that food would stay in his oesophagus several hours and then he would have to spit it out. He gave no history of any trouble before the age of fourteen, except that he was subject to croup. He was taken to one doctor who recommended smoking and this did him. some good. A year later he was taken to another doctor who recommended an operation, but his people were poor, and did not favor such a procedure. This continued without treatment for forty years. Seven years ago, he had the flu, and from that time he grew steadily worse in regard to his swallowing. It required enormous pressure to force food into the stomach. He found that he could eat practically a whole meal before swallowing it. It would then be necessary for him to leave the table, throw his arms back, grasp something firmly, take a drink of water, throw his head back and thus, with enormous pressure, force the food into his stomach. It would shoot in with a very audible whistling sound.

The oesophagus, however, was never entirely emptied and every morning he would throw out a large amount of food that had been taken the night before. The patient's appetite was good; he belched practically not at all, but was continually troubled with a large amount of gas which passed out through the bowel. He had no particular distress after eating; he never vomited, but simply regurgitated the food out of the œsophagus, which he was unable to swallow. His bowels were regular; he had a slight brassy cough; no pain; was somewhat nervous and ill-nourished. His general physical condition was fair for a man of his age.

An x-ray examination was made. Upon giving him a bismuth meal it was found that no food passed into his stomach; that the oesophagus was enormously dilated, was narrowed down by a small stricture in the region of the cardia about one inch and a half long and one-eighth of an inch wide. On the first examination we were unable to fill the stomach, but upon attempting to pass the stomach tube, a large amount of undigested food was regurgitated from the œsophagus. Considerably over a quart of residue was thrown out at this attempt. We were also unable to pass the olivary bougie as it seemed to stick in the sac.

The patient was given a spool of silk thread with two bebee shot attached and instructed to swallow the shot and keep the spool of silk in his pocket. After several days the thread had passed down into the intestine far enough so that it could not be pulled back. With perforated olive bougies we followed the silk thread down through the stricture and by increasing the size of the bougies, gradually stretched the stricture. We found, however, that the stricture

would close down immediately after stretching and the patient was given anti-spasmodics for a few days and this treatment continued. Later it was possible to pass the stomach tube along down the thread and into the stomach. After this had been accomplished he was fed through the stomach tube a large amount of milk and cream and given only very soft food and liquids. By this means his general physical condition was improved very greatly. Later, we were able to pass a rubber bag with a silk covering into the narnowing. With ordinary bulb pressure we stretched the stricture enough to give him considerable relief. These stretchings were continued and at the same time, the œsophagus was kept empty and food was introduced into the stomach by means of the stomach tube. The patient's condition improved rapidly and the œsophagus regained its tone somewhat. The analysis of the stomach contents showed a considerably lowered acidity. He was given little diluted hydro-chloric acid to assist in the digestion of his food.

An x-ray examination several months after treatment showed very normal function of the gastrointestinal tract. The six hour breakfast had advanced to the cæcum; there was no residue in the œsophagus or the stomach. Examination under the fleuroscope showed still some delay in the food passing from the oesophagus into the stomach. He was able to swallow food with very little difficulty, his weight increased, he never regurgitated food, he belched freely, and was thereby relieved of the distressing bowel symptoms.

The bulb pressure apparatus is one that can be made by anybody and will give fairly good results from the start if the dilatation is repeated often. However, by means of the hydro-static dilator which we later obtained and used on this case, it was possible to accomplish more with one or two dilatations than we accomplished with many treatments of the milder type. In the first treatment with the hydrostatic apparatus the pressure is ordinarily run up to three or four on the gauge. In this case pressure up to twelve was used. With the second treatment an attempt is made to increase this pressure enough to accomplish the desired results. Even with this apparatus it is sometimes necessary to repeat these dilatations a good many times, and if a recurrence occurs within a year or two the spasm can usually be overcome with one or two treatments.

The second case which I wish to report is a case of a young woman, age twenty-three, who was referred to me by a nose and throat man whom she had consulted with the idea that she had throat trouble. This young woman gave a history of having had difficulty in swallowing for the past two years. She first noticed that food would stick in her throat at times and she could often feel the food as it passed down through the oesophagus. A year ago she became much worse. She consulted several physicians but obtained no relief. Since that time she has been regurgitating small portions of food and liquid immediately after swallowing.

When first examined her trouble had become so severe that she was suffering from a very distressing thirst which she was unable to relieve because of her inability to swallow water. She was in good physical condition and showed no evidence of malnutrition. Under the fleuroscope the barium meal seemed to lag in the oesophagus. Liquids went down fairly easily. Twenty minutes after giving her a motor meal, the œsophagus was still filled with barium and slightly dilated just above the cardia. The stomach tube failed to pass and upon withdrawing it from the œsophagus, some of the meal was regurgitated. The olivary bougies passed with only slight resistance at the cardia, which slight resistance was about fourteen centimeters down from the teeth. The hydrostatic dilating bag was passed but upon filling the bag it was found difficult to hold the dilator in proper position as the inflation seemed to press the bag into the stomach. It has been found that in these early cases where the oesophagus is not much dilated, it is necessary to hold the dilating instrument very firmly against the teeth and not allow it to slip down if one is to accomplish the desired result. Three stretchings were used in the case of this woman, pressure was used up to twelve in the first, fifteen in the second, and twenty in the third, as is shown on the pressure gauge. Since the first stretching she has had no difficulty in swallowing and aside from the little discomfort which she had about forty-eight hours after the treatment, she has had complete relief from the symptoms.

In conclusion I would say that if one is not able to obtain a hydro-static dilator, the bulb-pressure apparatus can be made with just a blood-pressure bulb, a stomach tube, a galvanized telephone wire, and an olivary bougie. The olive is soldered on to the end of the wire. The wire is placed in the lumen of the stomach tube to act as a stillet, and over the olive and attacked to the lower end of the stomach tube, is placed the rubber balloon and on the outside of this there is a silk bag or an animal membrane to keep it in shape. This is then pushed into the contracted cardia and as much pressure as the patient can bear is used, repeating this as often as necessary to accomplish results.

Plummer, H. S.-Cardio-spasm. Report of forty cases. J. Amer. M. A., 1908, Vol. 1, No. 7. Further progress in Treatment of Chronic Cardio-spasm. G. Gottstein Archive Five. Klinische Chirgie, Berlin. Vol. lxxxvii, No. 3, pp. 497. Wilson, Hugh-Personal communication.

The most available therapeutic agent in the acute paroxysm of asthma is the original adrenalin chloride solution supplied for many years by Parke, Davis & Co. A hypodermic injection of a few minims of adrenalin solution promptly relaxes the bronchial spasm, supports the heart, stabilizes the vasomotor mechanism, and produces a calm, restful respite from the tumultuous, exhausting efforts of nature to maintain the respiratory function.

The Journal of the

the individual, his life or his limb, the old domestic relation could not thus be restored, al

It is sometimes said that familiarity breeds contempt. This may be true, but the saying has its limitations and should have an application only to questionable things. The important things in life should escape such an implication, we have in mind now, danger and dangerous conditions. The reasonable and sensible man will never acquire a contempt for danger or dangerous things but will on the contrary, gain in respect for conditions that are dangerous for himself and others.

Employment has always been dangerous even when industry and transportation was conducted in a primitive fashion but in later years, the powerful, complicated and rapidly moving machinery and the corresponding development of transportation has immensely increased the hazard to life and limb. When the casualties of a great industrial or transportation corporation are for a period of years, or even one year, added together they are certainly not pleasant to contemplate.

There was an appeal in this to R. C. Richards, general claim agent of the C. & N. W. Ry. Co., who for twenty years had the story of loss and suffering spread before him. Was there not some way of escape from this horror? The remedy would look on its face simple enough, but in fact involved a most difficult problem; it required the cooperation of so many factors. It was easy enough to pay the bill in money as had been the accepted custom but this did not restore

wheels of machinery and transportation revolved. It was said that the ways of providence were inscrutible, but Mr. Richards did not believe this and ten years more of study was the result. Unthinkable problems had to be met and overcome. It required an immense amount of work in checking and studying the records to find the line of cleavage, who and what was responsible; it was a work of great difficulty, a correlation of facts. were essential, reason and logic were necessary, the argument must be convincing. After ten years of reviewing and revising, Mr. Richards is able now to lay before the world a mass of statistics of the most impressionable character. The forty years of service entitles this man to a place in public esteem earned but by few great public benefactors. It is not the value of Mr. Richards' services to his company, we are considering, but his services to the public, to the men, women, and children, he has benefited.

Railroads have not always enjoyed the highest public favor. Selfish interests have not always been confined to countries ruled by kings and emperors, we might find some of it even at our own doors.

There are many observed welfare measures scarcely noticed, because not dramatic, which have passed silently so far as public notice is concerned.

There are men in industrial and transportation corporations who are not killed, but more or less seriously injured, some so badly that a slight error in treatment they will die, others who may be crippled for life, or whose recovery may be greatly delayed if unskillful treatment is employed. If this is true, and undoubtedly it is, may not the work of surgical treatment be supervised on the same lines of prevention of accidents? Most railways appoint some surgeon in whom they have confidence as the chief who coordinates the surgical work and others who serve in an advisory capacity. The chief surgeons call the local surgeons together once a year to consider if some of the seriously injured who die of their injuries may not be saved and some suffering crippling injuries may not be made whole, and if others may not have their period of disability made shorter.

Who shall measure the welfare service these corporations are carrying on with scarcely a public notice? We cannot measure the service in terms of dollars.

A long chapter could be written on the activities of a similar character being inaugurated by