without the aid of volitional exertion or the aid of nervous centers, a healthful excitation of the vessels and increased flow of blood to the tissues which they feed. . . The visible results as regards the surface circulation are sufficiently obvious, and most remarkably so in persons who, besides being anemic and thin, have been long unused to exercise. In my own hospital, where about two hundred and fifty cases have been under treatment, I have seen adolescent girls anemic, depressed, hysterical and even insane, react under massage, rest and isolation to a degree that is really remarkable. The whole tint of the body changes, a warm healthy glow, full vessels, pink nails, pink cheeks and a wholsome comfort and physical gain results. Bodily weight increases and a new lease on life certainly is the result. The circulation of the blood is improved both superficial and deep, anemic conditions disappear and the wholesome benefits which results are lasting. Massage genuinely given by genu-. ine manipulators who know their business, from principles and practice, is one of the most valuable adjuvants of treatment of nervous diseases of malnutrition. Its value is not appreciated, and every physician should have at his command this valued service. Mitchell says that bad massage even is better than none in these cases in which it is needed.

Electricity. Faradism applied to the masses of muscles is another adjuvant used to exercise muscles in a passive way. It is not used as often as it should be and when given should be under the direction of one properly trained to administer it. Electricity, unfortunately, in the layman's view, is a mysterious agent, capable of curing most anything of obscure origin, especially along the lines of nervous disorders. It requires a clever operator, trained in the work, to give electricity properly and to know when it is indicated. Its object is to stimulate the activity and nutrition of the muscles and joints, improve general nutrition, stimulate the lym. phatic system, digestive organs and improve circulation. In the proper blending of these necessary and important adjuvants of treatment by rest methods, experience will lead to skill in determination of the degree and direction of the treatments, of the character and form of rest and the adjustment of environment to meet the indications during convalescence. This experience can not be detailed on paper very well; and yet it is just here where abuses occur and results are not attained, all of which leads to a condemnation of the rest treatment. Every now and then some one feels he is called upon to cry

in the wilderness telling of his discovery of means and methods which are to supersede the Mitchell rest treatment-by occupation, by education, by exercises, by baths, etc., etc., but like all fads they have a mushroom existence which soon tells the tale, while the time-tried methods of Mitchell, like Tennyson's brook, go on, and, we trust, forever.

Diotherapy.-I have not mentioned another and exceedingly important part of treatment, which, as regards the building up of bodily weight and founding permanent capital in fat and blood, is always an important consideration-I refer to diet. Diotherapy is one of the factors in the treatment of nervous and mental diseases little appreciated in practice outside of special practice. Experience and prudence, tact and judgment are required to successfully carry out the indications for diotherapy. It is important first to ascertain the needs of the patient, especially where gastro-intestinal neuroses are features of the disease. To differentiate by careful clinical methods the nature of the neurosis and to plan treatment accordingly. Not infrequently it becomes necessary to make a prolonged examination in order to differentiate between organic and functional disease. Here is where prudence is necessary and experience important for other therapeutic indications that diet must be considered. I think that we should take plenty of time in working out these problems of gastro-intestinal neuroses.

Now, as regards diet, I follow Mitchell's precepts wherever they are indicated. Milk diet is the sheet anchor in almost every case, and rare indeed is the case where milk can not be used, if the patient is approached with tact and consideration. Where milk is the exclusive diet, four to five pints & day are used and given from four to six or eight ounces at a time-the schedule for giving to be determined in each case. Milk is progressively increased and other foods added, egg-nog, toast, bread and butter, etc., gradually adding until a full tray as well as the milk constitutes the daily diet. To assist in digestion, assimilation, etc., it is necessary that the seoretions be in good form, and sometimes aids are necessary. Malt extract is given alone, and when constipation is a factor, with cascara, with the object of aiding digestion and impairing the bowel condition. It is to be

noted that with the aid of massage that assimilation is improved and cases accept and tolerate food in greater quantities than without this valued aid. Bodily weight is increased, new form is given to the anemic, emaciated, wasted patient, and life becomes worth while to these afflicted ones. Patience,

preseverance and judgment, under wholesome environment, are required to carry to successful issue this treatment by rest methods. The abuse comes in not appreciating the value of each factor; in leaving out one or the other; in lax methods of isolation; in absence of tact in securing the confidence of the patient; in the failure to appreciate the time required to accomplish results; in the absence of the proper environment and of the real and essential factor; an educated, tactful, resourceful, wholesome, genuine good nurse. Then, too, last but not least, the hopefulness which the physician can inspire; the patience he can cultivate and the tranquility he can inculcate are all useful factors in treatment.

Now as to the uses of rest treatment, the selection of cases and carrying out of details. First, and abcve all, it is to be remembered that if success is to follow that there are several things to be impressed upon the patient and her friends-of these, consent to absolute control of the patient during continuance of the treatment, and that she is to be removed from home, away from the environment, too frequently vicious, and that isolation to the point of seclusion is to be followed without à quibble from the parents or friends of the patient. I have learned this lesson by bitter experience, and it is the failure of this one important factor that all other adjuvants failed, partially or wholly. In young girls, neurotic, hysterical, with or without imagined pelvio, digestive, heart or other disorders, it is absolutely necessary that isolation be enforced.

What is worth doing is worth doing well, and along this line let me quote yɔu Clifford Allbutt. He says: "The three legs of the tripod are isolation, full feeding and massage, without all three legs the tripod can not stand." Yet, one patient is submitted to massage without isolation; or, to another massage is applied without rest, which is a condition of its use, for even a healthy person would find it hard to undergo daily massage and concurrently therewith to go about his ordinary work. Again, the feeding has to be calculated on a special scale, having regard, of course, to each case; this calculation calls for skill on the part of nurse and physician. No case of any severity can be cared for in the midst of the fuss and fidgets of the home."

My own experience is that in young women with indulgent parents, one or both of whom are neurotic themselves, overly anxious, overly indulgent and overly critical of physician and nurse, supply an atmosphere in which a most beautiful and chronic case of hysteria can flourish and a continuous neurasthenia, with its perennial story, go on

to the limit.

I know, and in this statement

I am sustained by Mitchell, Playfair, Allbutt and other authorities, that in properly se. lected cases, a cure may be expected, especially in women, a cure that will remain a cure as long as proper mental and nervous hygiene is maintained. Allbutt especially dwells upon its efficacy in cerebro-spinal, cardiac and gastric forms in ill-nourished subjects and with comparative certainty and permanency of its results.

Again, another class which I believe is a growing class with the advance of abdominal surgery, and that is the post-operative neurasthenic class. It has fallen to my lot to see within the past few months six cases, all of whom have had abdominal section for one reason or another, and all of whom have developed neurasthenia or more pronounced mental disease. Surgeons should study the needs of their patients from this standpoint and enforce rest treatment to its fullest in the cases wherein neurasthenic symptoms are pronounced. I really believe that rest in such cases has as much to do with the bril liancy of recoveries in some cases as the operative interference.

The time spent in bed under appropriate environment and regulated hygiene has been a very potent influence in many cases of the surgical diseases of women. As my own experience accumulates, and I have treated over four hundred cases by rest treatment, I am more and more convinced of its value. To insure success, however, we must organize for it and be just as careful in our technique as is the surgeon in his modern organization and technique in his work, Each factor is to be considered and none left out, for it is the treatment as a whole which accomplishes results. The factors, then, are isolation, rest, massage, electricity, diet, an educated, tactful nurse, a hopeful, helpful, optimistic physician and a suitable, wholesome, restful environment.

VACCINATION FOR FILIPINOS. $100,000 has been appropriated by the Philippine Commission for conducting vaccination throughout the islands.

NEW MEDICAL COLLEGE.-Pekin, China, has recently had formally opened the Union Medical College. The Protestant missions are responsible for its establishment.

MORE LEGISLATION.-A bill has been introduced in the New York legislature fobidding the marriage of insane, epileptic, imbecile or feeble-minded persons. It also makes it a felony for a healthy person to intermarry or live with such an individual.

ACUTE CATARRHAL DYSENTERY WITH A REPORT OF FORTY-SIX CASES TREATED DURING SUMMER OF 1905.

R. B. CHAMLEE, M. D.

N. BIRMINGHAM, ALA.

IN discussing the subject of dysentery I will speak mainly of the acute catarrhal type, or in other words the disease the ordinary practitioner sees most often in temperate climates.

Dysentery affects most often the large bowels, usually the solitary nodules and generenteric mucous membranes, although the small intestine may be involved, and under the same heading different kinds of intestinal flux are described. The disease usually occurs sporadically or epidemically, and the exact cause is not yet clearly understood, it has occurred under conditions that favor the development of malarial fever, that is to say, hot summers with sudden changes in the temperature, accompanied by a great deal of rain fall; low marshy and poorly drained sections of country predispose to epidemics, although there is not a more widely distributed disease than dysentery. To quote Ayres: "Of dysentery it may be said that where man is found there will some of its forms appear."

Osler describes it as one of the four great epidemics of the world and in the tropics it kills more people than cholera, and has been more fatal, to armies, than powder and shot.

Etiology.-Bacteria play an important role in the causation of this disease. Booker's Study of the Summer Diarrheas of Children, is most convincing on this subject. No single varieties of micro-organism is found to be a specific exciter of the summer diarrheas, but the affection is generally considered to be the results of a number of bacteria, some of which belong to well known species and are of the ordinary varieties, and of wider distribution, the most important being the streptococcus and proctus vulgaris.

Symptoms.-Dysentery is usually ushered in without prodromal symptoms, however there may be slight colicky pains with some dyspepsia, free loose movements of the bowels of a diarrhea character, which diminish in amount and increase in frequency. There is usually no rise in temperature, the pulse may be slightly accelerated; the stools soon become very viscoid contain blood and mucus, and later pure blood accompanied by tenesmus.

The number of stools vary in frequency in

*Read before the Tri-State Medical Society, Chattanooga, Tenn., September 26, 1905.

the twenty-four hours. Except in very mild cases the patient suffers a great deal of pain, and the temperature may vary from 103 deg. to 105 deg. F. In severe cases the patient has loss of appetite, nausea and a coated tongue, whitish or gray in appearance, which later may become very red and glazed, especially if the case be a very severe one.

Headache, though not the rule, may be present. The patient complains of weakness, and in a great many cases complain only of the weakness and the frequent stools containing blood.

The abdomen is usually flat and hard and tenderness along the course of the colon, especially the ascending and transverse portion may be mapped out in some cases.

At times the patient will be bathed in a profuse perspiration, especially during defecation. Thirst is a feature in severe cases.

Prognosis.-The disease according to Flint, runs its course in about eight days, although in severe cases, may last from two to four weeks. It is hard to estimate the exact mortality, it ranges in different epidemics from 1 to 25 per cent. In armies, among soldiers, it has proven very fatal, also in the tropics it is very severe, but herein the temperate climate the mortality is very slight. In over sixty cases treated by me, in the summer of 1905, there was not a sin. gle fatal case.

I wish to mention briefly a few cases of the acute catarrhal type of dysentery which I have treated in Birmingham this year.

During the months of May and June I tabulated 46 cases of the above type, ranging from the mere presence of the mucoid and bloody stools with tenesmus, to the more severe cases, accompanied by high fever, frequent and bloody stools with great prostration, while in a few cases coma and mental disturbance occurred.

The following symptoms were present in most of my cases, viz., in the majority there was no chill, there was absence of fever, and a slightly accelerated pulse; a furred, moist tongue, sometimes red and glazed; then loss of appetite, slight nausea and frequent diarrhea stools. In about thirty-six hours the stools would contain blood and mucus in abundance; about the third day, pure blood and great tenesmus with severe colicky pain. The abdomen would be flat and hard, with

some tenderness over the area of the colon. The average time of confinement in bed for each patient was nine days, although in several the stools were loose, occasionally contained blood for several weeks later.

The majority of the cases were abrupt in origin without any prodromal symptoms.

Treatment.-Flint has shown that sporadic dysentery in its mildest forms is a self-limited disease and runs its course uninfluenced in any great degree by drugs. This is owing to the great amount of surface involved by the disease, and the fact that necrosis and the ulceration following, are hard to control.

If a patient is seen only with loose bowels. then the indications are that the bowels are not thoroughly clean; then we give a mild saline, or a dose of castor oil to empty the bowel. Of the internal medicines, ipecac justly holds the first place, especially in the tropics. It is best to give a hypodermic in jection of morphine or tr. opium (by the mouth) about half an hour before giving the ipecac, which should be fully twenty grains or more; if this is rejected, repeat in a few hours.

Osler does not give satisfactory reports of Bismuth in one-half the ipecac treatment. drachm to a drachm doses, every two to four hours is beneficial. It must be noted that bismuth must be given in large doses and often repeated. It acts better in chronic rather than in acute cases. Morphine is the best agent for the relief of pain.

Opium suppositories are indicated in extreme irritability of the rectum, and to facilitate the use of an enema or high rectal injection. In order to give a rectal injection the patient is to be placed in dorsal position supported by pillow, and a long rectal tube inserted, then from one to four parts of water at temperature of 100 deg. is to be used, in which from 20 to 30 grains of nitrate of silver has been dissolved. A small per cent of the silver solution does but very little good. Alum, sulphate of zino, acetate of lead, and salts of copper are also recommended by the authorities. Osler has found injection of quinine to be of great service in the amebic type.

Local applications to the abdomen of light poultices and turpentine stoops are of value in some cases.

The injection in the milder cases of laudanum one-half drachm to a pint of common starch water is found to act nicely.

The course of the disease is improved both in acute and chronic cases by careful regulation of the diet, which should be restricted to milk, whey and broths, and the stools should be watched for curds, and if any ap

So I have no apology for choosing such a subject. It is our duty as physicians to keep persistently warning the public against In recent years the danger of this trouble.

the public, thanks to many open meetings to which the laity are invited, are becoming educated along this line, and it is rare indeed to find among intelligent people, those whom are not aware of its dangers and of the importance of an early diangosis. I mean a diagnosis made before the bacilli are found in the sputum. One who delays the diagnosis until the bacilli are found, are in my opinion guilty of gross carelessness and subject to censure by the patient.

Tuberculosis can be diagnosed before the microscope if of any value.

I do not wish to be understood as not an advocate and an unbeliever in the use of the microscope, but the point I wish to emphasize is, that tuberculosis can and should be made before the microscope is of value.

Speaking from a personal standpoint, if I suspected I was afflicted with the disease and my physician should delay his diagnosis until he was able to make it by the microscope alone, I should consider him incompetent and seek advice elsewhere.

It is well known that tuberculosis discovered early ere it has made very great progress, is a curable disease. The time is past when we inform our patient as soon as a diagnosis is made, that they are suffering from an incurable disease.

Some have claimed that 85% of all post

*Read before the First District Medical Society of Iowa at Fairfield, January 26, 1906.

mortems made, show some tuberculosis being present at some time in the individual's lifetime. Twenty-five or more percentage of cases found early are curable, hence it is our duty to diagnosis our cases early.

There is one thing 1 have found in my short experience and that is, it is difficult indeed, at times, to make the patient or friends believe they have the disease, and many times after informing them of the fact, they seek advice elsewhere.

But I believe they should be told the truth and so be enable to place themselves in the best possible condition to overcome the trouble.

How often patients will come, to us with a tubercular cough and inform us some phy. sician has told them is a "bronchial trouble." A physician who would so inform his patient, knowing they had tuberculosis, is as much guilty of gross carelessness as one who fails to report a case of contagious disease.

1. Among the first symptoms which manifest themselves is loss of weight and impaired nutrition. A patient will complain of becoming wearied upon the least exertion and has a pronounced lessening of the power of endurance. This, many times, is what drives the patient to the physician for a "tonic" saying, "they are run down in health and tired all the time."

2. Cough. It will be learned upon close questioning that there is a slight cough, so slight as to escape notice only upon the closest attention. This cough is a slight hacking and consists usually of a single effort. It may be elicited upon change of position and deep breathing. Many times a patient will deny having a cough, but even while making such denial will cough, not realizing they have done so. As the disease progresses the paroxysms become more and more frequent, and if hoarseness is present, there is little doubt of its being tubercular.

3. Gastric disturbances are of frequent occurrence. The appetite is slightly impaired and erratic. During febrile reaction, it fails, the tongue becomes coated, bowels constipated, there may be nausea and vomiting and these are sometimes called "bilious attacks." 4. Thoracic Tenderness.-Soreness pain are rarely absent in early stages. The favorite location is in the upper part of the chest, though may be in any part of the chest, which of itself is suggestive.

and

5. Hemoptysis occurs in a moderate proportion of cases, but is very significant when present, and is of prime importance. This may be the first symptom which causes the patient to seek medical attention.

-

6. Pulse. A quickened pulse is often present at the onset preceding the sputum

test many weeks, or even months, and is suggestive, though less so than the evening temperature. Anders says, "A rapid, feeble pulse is one of the most unvarying features of early phthisis in the very young. The arterial tension is early and notably reduced. Frequent daily countings should be taken. The pulse of early phthisis will vary from 90 to 110, but it may be less or more. It is usually a high speed pulse, and should have considerable weight in the summing up of diagnostic points. The frequency, is but little changed by position.

7. Temperature.-Frequent and methodical observations are necessary to learn anything by the temperature. It should be recorded every two hours. A rise late in the afternoon rather than late in the evening is very suspicious. If the mean of the morning and evening temperature taken for twelve consecutive days exceed 99.5, the patient is either tubercular or strongly disposed to the disease. The rectal temperature is the more reliable. Tradeau says, "When there is any disturbance of general health, not accounted for otherwise, where the temperature rises above 99.5 in the afternoon, it almost always tubercular." Another says, "Fever starts one-third of the cases with the first local symptom." It may be present a long time before the sputum test gives positive results. On the other hand, MacKenzie claims, in cases where fair number of bacilli are present, the temperature for several weeks may be perfectly normal. An intermittent fever, resembling malaria sometimes, is present in early stages. An elevation due to other causes as anemia suppurative processes and the like may be eliminated by the blood examination. In tuberculosis in early stages there is a lessened number of the red blood corpuscles.

8. Physical signs variable in character are quite frequently met with and may precede the sputum test many weeks, or even months. They are found in the subapical space and usually posteriorly.

The percussion sound may be deadened. This test is unreliable.

Palpation.-Tactile fremitus may be increased but may be absent on account of a pleurisy. Defective expansion at or a little below the apex is profoundly significant, particularly in the infraclavicular space. This lagging is best appreciated by palpation. Auscultation.-Among the earliest

and

most significant sign, is the diminution and almost total loss of the vesicular murmur, also prolongation and sharpening of the expiratory murmur is heard. At times an extremely delicate catarrh may be detected by the slight sense of moisture or stickiness, and