"cured" in its fullest sense. And in curable cases the X-Ray is as nearly specific as any therapeutic agent in use to-day.

Taking for granted that in the majority of surgically recurrent cases the return of the trouble is due to a proliferation of epithelial cells from the original or primarily affected area, every surgical case should be placed under X-Ray treatment within from one to three weeks after operation. Only by the early and vigorous use of this method can we hope to forestall more serious trouble. We have not exhausted this subject. The praises due the X-Ray could be prolonged almost

Χ.

NUTRITION IN FEVERS AND OTHER CONDITIONS, WHEN FOOD IS NOT READILY ADMINISTERED.

For the sake of convenience, it has thus far been assumed that there has been no notable failure of digestive power and no considerable degree of nausea. If undigested food appears in the feces, without marked failure of appetite or vomiting, the problem is fairly simple, as the digestive power can be reinforced by the simultaneous administration of digestants, preferably of pawpaw extracts, or by first pancreatinizing milk and similar foods. So-called predigested foods should be viewed with suspicion and untried "digestive" preparations should be tested. For example, a "digestive" wine prepared from pine apple, which certainly contains a valuable ferment, was found to be absolutely inert and many of the so-called peptones fail to show the characteristic lilac band with an alkaline copper sulphate solution. practical purposes, artificial peptones are objectionable on account of their bitter taste and the accompanying toxins and we can, at most, administer albumoses. Predigested carbohydrate means, according to the degree of digestion, dextrin, maltose or glucose and it seems probable that cane sugar is as easily transformed as maltose by inverting into glucose. Yet, on account of cloying the appetite and irritating the mucous membrane, we cannot administer clear sugars in any amount and, for practical purposes, predigested carbohydrate simply means cooked and finely divided starch, partly dextrinized and with only small quantities actually digested into either maltose or glucose. Predigested fat, literally means glycerin plus soaps. There is much dispute as to the practical food value of the former while the impracticability of using the latter, is universally recognized. Thus, we can go on farther than the emulsification of a fatty food and there is no proprietary or other artificial emulsion superior to good cream.

Thus, for practical purposes, the methods of predigestion at our command are very limited. If there is failure of hydrochloric acid, without marked deficiency of ferments-the usual condition in fevers-we may add the official dilute

HCI (10 per cent of the gaseous acid) to milk, milk and egg, etc., drop by drop till 3.5 per cent is present, the amount necessary to combine fully with the proteid.

While, in theory, almost any form of animal or vegetable digestion may be imitated artificially, the only one at all commonly employed is the pancreatic, using a dry, alkalinized extract. Approximately, 1,000 parts of milk require 1 part of extract or "pancreatin" and about an equal amount of sodium bicarbonate. However, different extracts differ much in digestive power and a moderate excess does no harm. The most convenient preparation is the "peptonizing tubes," one of which is sufficient for a stated quantity of milk. The digestive process is carried on at body temperature for about 20 minutes, a further digestion producing bitter peptones. The digestive process is then stopped by cold or heat, scalding to about 150 F. or cooling to 40 F. being sufficient.

In case of violent nausea and vomiting, persistent psychic objection to food, mechanic obstacles to swallowing or to the onward passage of food from the stomach, as in cancer of the pylorus, or any other condition which persists and prevents the taking of food in the normal way, we are relieved of considerable responsibility, as the indication in favor of nutrition by fistula, rectal injection, inunction, etc., is plain. The details of all such methods will be discussed in a separate chapter. It is the intermediate cases which neither present absolute obstacles to natural alimentation nor submit to an adequate ration, which cause the physician the most anxiety and subject him to the greatest responsibility. cases may be febrile, or otherwise, the stomach may be irritable from local lesion, such as cancer or catarrh, or from a reflex disturbance, as uterine disease, movable kidney, renal or biliary calculus or some vague disturbance of metabolism; or, as the result of some primary condition, there may be an abortion or premature delivery and an irritable stomach as a result of both the primary and the secondary condition. Sometimes there is no obvious cause for the lack of appetite or unrest of the stomach. Again, there may be an esophageal stricture that is not absolute. All of these and analogous cases present the same general indica

Such

tions from the dietetic standpoint: to introduce sufficient nourishment, to keep it down and to have it digested and absorbed.

This group of cases may be considered in three categories:

1. Those in which the first indication is the principal one, and in which the problem is practically solved if we can introduce sufficient nutriment. Among the insane, gavage or feeding at the hands of an attendant must occasionally or, in certain cases, regularly be practiced. Sometimes the patient resists the introduction of food; sometimes the resistance is merely nominal or the patient may even report voluntarily for nourishment, but will not feed himself. The writer has seen a neurasthenic case also syphilitic and showing signs of gastric catarrh, but with neither organic disease of marked degree-in which no food of any importance was taken for over a week. Treatment was almost wholly by moral suasion. Many patients will tolerate nourishment introduced by the tube in amounts which they can not or will not swallow. In other cases, the direct management of the case devolves upon a tactful nurse who is also a good cook and expert in preparing dainty dishes.

2. Cases in which attention must be paid both to the introduction and digestion of the food. Along with the administration of food, artificial digestants or predigestion must be considered and the condition of the digestive organs requires active treatment, local or medicinal. While it is beyond the scope of dietetics to discuss the latter indication in detail, it may be pointed out that the two or three hours immediately following the administration of food is the time to force digestion and to use measures directed at the retention of food, while the interval remaining till the next meal should be used in treating the underlying digestive disturbance.

3. Cases in which absorption or assimilation fails, in the absence of direct failure of digestion itself, or in which the food leaves the body, imperfectly digested, in spite of every effort at securing predigestion or at adding artificial digestants and spurs to the digestive functions. These cases are usually malignant, or due to essential disease of the pancreas, or to functional failure of innervation, as in Addison's disease, pernicious anemia and other states not understood. Normally, the filtrate or watery extract of the feces should contain practically no carbohydrate nor proteid and neither fat, milk curds nor other wasted nutriment should appear macroscopically, except in tenden ends, tough meat and in vegetable foods having tough cellulose inclosures. In all doubtful cases, thorough chemic investigation of the feces, which are beyond the scope of clinical medicine, should be ordered. While the demonstration of such conditions should cause redoubled efforts to secure digestion and absorption, intrinsic and continued failure of these functions is beyond control, nor can even digestion alone be carried on artificially to a successful issue.

While the general principles of feeding in fever are readily adapted to special infections, it may be well to consider briefly, certain indications and contraindications commonly considered to exist in the various infectious processes.

Rocky Mountain Fever; Continued Fever (of

doubtful nature), Dengue-Diet same as in typhoid.

Malarial Fevers, Exanthemata, Pertussis, Influenza, Febricula, Erysipelas. From light, house diet, to that of typhoid, according to the severity, there being usually no local nor metabolic factors to demand special precautions.

Typhus, Bubonic Plague, Anthrax, Equinia.— On account of the grave disturbance of the system these require practically the same care as typhoid, while there is even greater need of supporting the strength by an abundance of nourishment. Eggnog is a staple ingredient of the diet. If possible, 2,000 Cc. of milk and 4-10 eggs should be given in twenty-four hours.

Relapsing Fever.-Same as for typhoid, there being less urgency as to feeding on account of the brief course before the intermission, during which feeding should be forced so far as practicable.

Septicemia, Pyemia, Miliary Tuberculosis, require an abundance of easily digested food, not necessarily liquid unless the temperature is high.

Cholera and Yellow Fever often present considerable irritability of the stomach and upper intestine. Even nutrient enemata may not be retained. Enemata and subcutaneous injections of saline solutions must be relied upon to a large degree and, theoretically, we have in these diseases, an urgent indication for subcutaneous injections. of glucose. As soon as the rectum or stomach becomes tolerant, predigested foods should be administered.

Dysentery. In tropical dysentery, the advocates of the ipecac treatment, emphasize the importance of avoiding all foods for at least three hours after administering the drug, although ice may be allowed. For the first day or two, milk alone should be given. Beef extracts, eggs, bread and other "light" foods, are said to be prejudicial to the action of the ipecac. After a few days, these may be given but solid foods are commonly interdicted for a week or more, or until the condition of the bowel is considerably improved. Many authorities prohibit solid food till the patient is convalescent.

The milder forms of dysentery, such as are seen in this country and perhaps including cholera nostras and infantum demand somewhat less arbitrary restrictions, as regards the kind of food. In the choleras, it is well to give no food for a day or two, unless the patient is threatened with inanition. Water and salt, preferably by enema or through the skin, may be employed to advantage. In infants who have been fed upon milk, many authorities regard the condition as essentially a milk poisoning, which probably is to be explained as due to the excessive virulence of certain bacteria, on account of the pabulum afforded by the milk. Thus, the indication is to administer egg albumin, beef juice, toast water and other vegetable gelatinous solutions, such as are obtained from barley. The prepared foods may also be employed temporarily. It is only fair to state that many authorities are sceptic as to the existence of anything that deserves the term milk poisoning and that, even when infection has apparently been due to milk from a certain source, they see no objection to feeding with milk, provided that it be of good quality. While the bacillus dysenteriæ has been isolated from the stools of typic cases of cholera infantum, we are not yet justified in con

sidering all cases of cholera nostras-including cholera infántum-as genuinely dysenteric or as belonging to the group of specific fevers.

Mumps. The inflammation of the parotid usually requires feeding with liquids, through a curved or bent tube.

Hydrophobia, and Tetanus.-The attempt at deglutition or even the reflex from intubation of the oesophagus or the insertion of a rectal tube, may excite a convulsion. The comparative rarity of both these diseases renders it impossible to formulate any definite rule as to the conflicting indications for absolute rest and for nourishment nor as to the best means for introducing nourishment. Sometimes, especially when there is a notable degree of spasm of the jaw, feeding by a nasal tube is preferable. In all cases, the nourishment should be bland, liquid or semiliquid and of the body temperature in order to excite as little reflex response as possible. Usually, the food should be predigested.

Cerebrospinal Fever.-Reflex convulsions may interfere with nutrition, as in the preceeding diseases. Tyson advises rectal nutrition for the first few days, using not over 120 Cc. at once. Heubner, on the contrary, advocates gavage.

Diphtheria. To prevent the swallowing of infectious material, nourishment should be given immediately after a local treatment of the throat. The throat should be again cleansed immediately after the meal. The patient should then be allowed to rest as long as possible, considering the urgency of the local lesion, and should rarely be fed oftener than once in four hours. The nature of the food should be in accordance with general principles and rectal or other special modes of introducing nourishment should be used when indicated.

Beriberi. While undoubtedly a parasitic disease, certain groups of cases have been ascribed, respectively, to fish and rice diet and it is well to avoid such articles of food, not only on account of the possibility of introducing fresh infectious material but because the limited diet may, very probably, have caused a relative deficiency of certain food materials. In general, the indication is for a simple, digestible but fairly varied diet.

Chronic infections, such as tuberculosis, syphilis, possibly the malignant neoplasms, actinomycosis, etc., require no particular limitation of diet, excepting during febrile exacerbations, if such exist. Local lesions of any of these processes, in the alimentary canal, may indicate various restrictions of diet, in accordance with principles already discussed. Certain authorities consider that the parasite of cancer-whose very identity and existence is still questioned-is introduced in raw vegetable food, which should, therefore, be avoided after early middle life. In general, the possibility of the introduction of specific microorganisms by food, is a matter of prophylaxis, rather than of diet. Febrile processes connected with inflammations of various organs, whether due to specific, microorganismic cause, as pneumonia or gonorrhea, or to ordinary, non-parasitic irritants, require no special discussion, so far as diet is concerned.

MINIMUM RATION.

In attempting to feed patients who can retain and digest only small quantities of nourishment,

it becomes of the utmost importance to determine on how little food life can be maintained and how much the patient is actually ingesting and absorbing.

The standard physiologic man, exercising actively, weighs 70 kilograms, excretes about 35 grams of urea by the kidneys (including as urea, about 2 grams of uric acid and other nitrogenous matter decomposed by hypobromite solution and calculated as urea) and about 5 grams additional of nitrogenous waste by the feces, the excretion of nitrogen by the skin and lungs being too small to be measured. Thus, empirically and by comparison of molecular and atomic weights, we have the following progressive ratio: 70 kilograms weight of body: 40 grams total daily nitrogenous waste, calculated as urea and including both metabolic waste and wasted nutriment: 18 grams waste N: 110 proteid food: 550 grams lean meat. While 125 grams of proteid is usually allowed in diet tables, 110 grams is probably a full allowance, if an abundance of fuel foods are given. In sedentary individuals of fair health, we find the urinary nitrogenous waste, calculated as urea, reduced to 15-20 grams. Adding 1-7 for fecal nitrogenous waste, the total is raised to about 1723 or approximately 50 per cent of the standard and this total may be still further reduced, if the patient is notably under weight, though we must estimate what the patient would weigh if carrying an average amount of fat, for the latter, in reasonable amount, has no influence on nitrogenous metabolism. Allowance must also be made for deprivation of limbs and unusual heaviness or lightness of bones, weight of tumors, etc. No accurate means are available for these allowances. Granting that the patient, as standarized, is comparable to the physiologic man of 70 kilograms, we may conclude that, in a resting condition, with plenty of fuel foods, he may subsist on about half the normal amount of proteid, or approximately 50 grams. In any given case, however, the proteid ingested should correspond to the total nitrogen eliminated, either as the result of metabolism or of failure of digestion. Bernert and Steyskal (Archiv für Experimentalle Pathologie und Pharmacologie, Vol. 48), have investigated the minimum albumin required for nitrogen-equilibrium in pernicious anemia and place it at 0.48 grams per kilo of body weight, corresponding to 30-35 grams for a person of average size. But this estimate is extremely low and scarcely applies to the nutritive demands of disease in general because, in pernicious anemia, the red blood cells, or rather, for present purposes, their power of carrying oxygen, is greatly reduced, much more so than in ordinary secondary anemia. In this connection, allusion may be made to a point that is often overlooked, namely the importance of administering a portion of the proteid in the form of meat or of such meat juices and extracts as contain notable proportions of hemoglobin. Expressed meat juice contains very little, as is indicated by its color and beef teas, prepared by heat, contain less than appears to be the case. Except for the psychic element which may often be overcome, fresh blood is an excellent food, while bovinine is practically a preserved blood. It is commonly stated that the hypobromite test as applied to urine, includes practically all nitrogen as urea but Dr. J. H. A.

Clowes of the N. Y. State Cancer Laboratory at Buffalo, states that he has found the Kjehldahl estimation of total N to be almost exactly equal to the sum of the N obtained by hypobromite, and that contained in uric acid. Unless the patient is taking some preparation of ammonium, inorganic N may usually be disregarded. An excess of N in the feces usually indicates failure of digestion and absorption. Still, the trouble and expense of full determinations of N are often prohibitive and we may usually depend upon the hypobromite method as applied to the urine with the arbitrary addition of 1-7, provided that proteids are absent in the fecal filtrate or extract.

That a full proteid ration is not sufficient without an abundance of fuel foods, is well shown by two observations of Harley and Goodbody on persons confined to bed. A rather fat woman of 72 kilograms-corresponding to a standardized body of 50-60 kilograms-was placed for a week on a daily ration of a pound of mutton, containing 12.16 grams of N or about 75. of proteid and about 25 grams of fat. The total daily elimination was 13.51 of N, only 0.48 of which was by the feces, indicating a full utilization of the food and probably a deficient hepatic eliminative function. In the week she lost 9.45 grams of N, corresponding to 283.50 of lean muscle, the total loss of weight being 2,000 grams. A male patient lost, in four days, on the same diet, 32 grams of N, corresponding to 960 of lean muscle, with a total loss of weight of 2,000 grams; the difference between nitrogenous and total loss being, of course, mainly due to combustion of fat.

While the estimation of N, for a patient, simply involves trouble for the attendants and expense, that of C, is impracticable, for 90 per cent of CO, is eliminated by the lungs and this cannot be collected without subjecting the patient to an environment which is out of the question except for animal experiments and those voluntarily submitted to by healthy persons. In health, the total elimination of C is about 280 grams, that of N, 18, the ratio being easily remembered as 16:1. It is calculated from molecular weights that the ratio of C to starch is 2:4.5, of C to cane sugar, 2:4.75, of C to glucose 2:5. 51.5-54.5 per cent of proteids, is C. Tripalmitin contains 75 per cent of C; tristearin, 78 per cent minus; triolein, 78 per cent plus. The various fats consist mainly of these three substances, more or less mixed.

It is not possible to calculate mathematically, the ration of fat and carbohydrate, on account of the fact that one may replace the other to a large degree. Then too, in disease, the combustion of fuel foods may be increased or decreased from the normal and, even in fevers, in which oxidation is theoretically increased, we can be by no means sure that the elevation of temperature really means an increase of heat units formed by oxidation. Moreover, the body has a store of fat which may be drawn upon and it is doubtful whether the indication is to provide for increased oxidation or to diminish temperature by withholding the ultimate source of heat, even if emaciation does occur more rapidly.

By making certain arbitrary assumptions, which are supported, to some degree, by experience, we may estimate the carbohydrate necessary. It has

been shown that a minimum of 50 grams of proteid is required. An equal amount of fat may usually be administered, half being introduced by inunction, if necessary and part of the remainder being contained in meat, cereals, eggs, etc., ordinarily used as the source of proteid, or, if milk is used as the source of proteid, the patient receives approximately equal amounts of both fat and carbohydrate. Thus, in general, 50 grams of fat may be administered without the realization on the part of the patient, that he is receiving any fat at all. Fifty grams each of proteid and fat, represent 27 and 38 grams respectively, of carbon -a total of 65. In health, we have an additional demand for 215 grams of carbon, corresponding to 483.75 grams of starch. In a quiescent state, life may be maintained on half this allowance without drawing to any degree upon the store of fat. A loss of weight of 2 pounds a week, allowing for equilibrium of nitrogenous and watery intake and outgo, signifies the daily utilization of about 100 grams of body fat. Such a loss, which can be sustained for ten weeks by most patients, supplies about 76 grams of carbon additional and supplants about 170 grams of starch, so that if from 70-100 grams of starch or other carbohydrate can be given daily, the patient may be considered as free from any immediate danger of starving, always provided that the nutriment administered is actually assimilated.

Thus, we may place the minimum emergent ration, for a quiescent patient, at 50 grams of proteid and fat, each, and 70-100 of carbohydrate. This corresponds to a quart of milk and five soda crackers daily, with a considerable margin in the way of carbohydrate or, still more closely, to a quart of egg nog, including two eggs and an ounce of sugar. Less than this ration is plainly inadequate and we can only comfort ourselves with the empiric knowledge that fairly healthy men. have fasted forty days and have recovered and that under stimulation, by strychnine or similar drugs, and the use of hot saline solutions, even a very sick patient may vegetate for several days or a week or two, and still recover.

The plan of administering a teaspoonful or two of nourishment every half hour or hour, interrupts digestion, breaks the rest of the patient and tends to maintain a state of gastric irritability, even though the stomach may not immediately be able to relieve itself of such minute amounts. Two teaspoonfuls of milk an hour, represents 240 Cc. a day, if no vomiting occurs and it usually does occur several times. This quantity contains only about ten grams of each kind of organic food. The same amount of 6 per cent solutions of meat extract-the full proportion usually containedrepresents about 14 grams of proteid but practically nothing else. It certainly is reasonable to suppose that patients recover in spite of, not on account of, such dietetic management.

K. Worel (Phot. Cor.) describes a process of producing colored photographs by means of red, yellow and blue dye materials rendered sensitive to light by certain essential oils and the print finally fixed with a solution of copper sulfate. Prints are taken through a stained glass picture or a colored positive.

Ladies and Gentlemen: In order that you may be able to better understand the subject which I am about to present to you, I will preface the presentation of this case by a few remarks on static electricity, the variety of current we will use in the treatment of this case of chronic nephritis. This form of electrical energy is probably the most peculiar of all the manifestations of electricity and the apparatus used in its production is one of the most peculiar of all forms of electricity generators. We oftentimes liken the

voltage of a current of electricity to the height of a column of water in a tube. If we used that method of estimation in static electricity we would have to liken it to a pipe of water five hundred feet high, with a pinhole opening at the bottom. That would give us a very small outflow of water, but one having a tremendous force. Static electricity is nearly all voltage and little or no amperage.

You will understand this more readily when I say to you that it requires fifty thousand volts of pressure to cause this spark to arch across one inch of air space. Yet, while the voltage is so enormous, the amount of current carried by the spark is less than one five thousandth of a milliampere. So that it will be apparent to you that the therapeutic force of static electricity is not from conduction, because there is nothing to conduct. Its therapeutic action resides in the vibrations set up in the current which is conveyed to the nerves.

A simple illustration will probably elucidate that. Take three tuning forks, A, B and C, and set them upright in a board. I take another tuning fork, strike it on the table and set it in the board next to the other three, and it is the only one of the four which will vibrate. The vibration which will affect this fork is not the same as is required to set the other three vibrating. The same is true of each of the others. Each fork will respond to its own peculiar vibrations. The same thing is true of static electricity when we are treating the nervous system.

There is no one, I believe, today who would doubt, after the elaborate and conclusive experiments of Schiff, Dubois-Raymond, Darsenvahl and others, that we have electrical currents traversing the body in every direction, and that the nerves are the carriers of this current. It is also true, as I have repeatedly informed you, that everything that acts as a carrier of an electrical current vibrates. Then, it is manifest that if the nerves carry this current of electricity they must vibrate, and in the state of perfect health the nerves are constantly vibrating. Each nerve vibrates in a different way from every other nerve because they all carry different kinds of currents. The rate of vibration is peculiar to the kind of cur

*Clinical lecture especially reported for the Medical Standard.

rent carried by the nerve. Whenever a nerve loses its normal vibratory tone, its function is destroyed. But if I place this person on the platform of the static machine and include him in the static circuit he is made subject to a series of vibrations, from a few to many millions per second, so that every nerve in the body will find a current to which it will respond, and they will vibrate accordingly. If a nerve is vibrating normally, it will continue to do so. But if it is not vibrating normally, it will choose its vibratory tone from the currents generated by the static machine and vibrate in a normal way. Every nerve in the body is taking the vibrations which are peculiar to it and they are all normal for the time being. Of course if degenerative changes have taken place in the nerve, so that there is no longer any substance to act as a carrier for the current, the nerve will not vibrate. It is dead.

We have many beautiful illustrations of this fact, some of which you have seen demonstrated in this clinic. I recall very vividly one case, that of a man who fell from a street car and injured the nerve that supplies the left internal rectus muscle of the eye. In consequence of this injury he had diplopia or double vision. When we held up a ball before him, before the machine was in action, he always saw two balls, one about four or five inches above the other and a few inches to one side. Then, when the machine was started he would, after five or ten minutes, see only one ball where he had seen two. The reason for this was that the vibratory action of the current had conveyed the proper vibrations to the injured nerve in the muscle and for the time being, at least, that nerve was functionating properly and his vision was normal. As soon as the machine was stopped he again saw two balls.

Another illustration is seen in the case of persons who have had their eyes atropined so that they could not read even the large headlines of a newspaper. Start the static machine and after a very few minutes they are able to read the very finest print. When you examine the eye you can see that the pupil, which was widely dilated, is now contracted to its normal size. This is the result of the restoration of function in the paralyzed muscles of accommodation.

Static electricity is an equalizer of the nervous force. It will temporarily reduce a high temperature, or it will elevate a low or subnormal temperature. It will reduce a high pulse or raise a low pulse. You can also see the good effects of static electricity in the increased elimination of the waste products, such as urea, CO2, sweat, etc. What seemes to be the most pleasant of all forms of electrical treatments is the most far reaching in its effects.

We are now, after these preliminary remarks, ready to come back to the subject of our work