All

borne by the patient. With sufficiently large and well-protected electrodes I find that the average bearable strength is 30 ma. sudden variations in the strength, especially interruptions and reversals, are to be avoided. The current should be gradually increased from a feeble one till the required strength is reached, and as gradually reduced. Of course the skin should be thoroughly moist.

In closing I would summarize the conclusions arrived at in this paper as follows:

Modern pathology, by revealing the pathogenesy and morbid anatomy of tabes, affords a scientific basis for its electro-therapy, concerning which subject the greatest confusion has prevailed.

In the grave type of tabes the morbid process is in the cord itself and is uninfluenced by electricity because of its inaccessibility.

The observations of reliable investigators make it legitimate to recognize a form of tabes in which the lesions are largely confined to the peripheral sensory neurons, and therefore accessible to the galvanic current.

These cases may be differentiated from those of central origin by the predominance of pain and their early appearance after primary syphilitic lesion.

They may be differentiated from multiple neuritis by the absence of electrical changes, motor palsies, and local tenderness, and by the presence only of those symptoms which can be referred to sensory neuron disturbance.

Their lesions are primarily due to vascular changes which may be arrested and greatly modified by galvanism through vaso-motor stimulation and catalysis.

To obtain the best results strong cathodal currents should be applied through a specially constructed electrode.

Finally I would suggest that for the term peripheral or benign tabes, usually applied to the condition herein described, there be substituted the name "Pseudo-tabes."

THE ADVANTAGES OF GIVING PATIENTS WRITTEN HYGIENIC INSTRUCTIONS CONCERNING THEIR DAILY MODE OF LIFE.*

THE

BY CHARLES MCDOWELL, M.D.

New York City.

HERE are certain diseases and pathological conditions which are readily controlled by medicines; there are others which are influenced but slightly and uncertainly by them, and there are a few over which drugs exert no restraining power. On the other hand, in every form of disease hygienic measures may with certainty assist the bodily powers in their struggle against adverse conditions, even though at times the battle may end in defeat, for the reason that in every case of disease there are operating a number of causes to keep up the morbid condition and to depress the powers of the patient; and some or all of those causes are removable causes. In each case some rule or rules of health are broken-occasionally it is true to a very slight degree. Therefore, besides our investigation into the abnormal condition of the organs, we should no less diligently and as a matter of routine, search out the causes which have led to the diseased state, and also the influences which are maintaining it. We should make a diagnosis of the causes as well as of the pathological condition. And it follows, also as a matter of routine, that we should not only prescribe a medicine but proceed to remove all the causes which are removable. But this can be done only with the co-operation of our patient. In fact, the first thing to impress upon him is that he must work out a large part of the cure himself, that he is a partner with the doctor in this campaign for making him well. So we proceed to give him instructions concerning his environments and habits, not only those habits relating to the organ especially diseased but any or all of his habits. For every organ is

helped or hindered in carrying on its work by every other organ. Although with increasing intelligence people desire more and more hygienic advice and instruction, and although many patients ask for such help, there are still some who wish to be cured without any effort on their own part and without any attempt to overcome the causes of their ailments. Such persons need to be impressed with the importance of this part of the treatment. On the other hand, most people will listen to our advice with interest and respect, and then promptly forget a goodly part of it; for our instructions

* Read before the American Institute of Homeopathy.

will embrace a number of different topics, and they will enter the ears of one poor in health, whose memory is below par and whose will-power is inefficient. Therefore, to magnify the importance of what we have said, to assist the memory of the patient and to support his oft-yielding resolution by a reminder, we give him a written. memorandum of instructions. This we hand him as we would a prescription for a medicine, telling him to observe its provisions as carefully as though it were the directions for taking a drug, and that this prescription of conduct is generally quite as important as, and is sometimes more important than, the medicine which he is to take. Nor does the advantage from this procedure lie all on the side of the recipient. Applicable here is the oft-quoted saying of Lord Bacon: "Reading maketh a full man, conference a ready man, and writing an exact man." The mere act of writing these things helps to clarify our minds, helps us to decide more clearly, more precisely, what this patient should do; teaches us to avoid vague words and generalities, and to give specific understandable directions. Just as the writing of telegrams tends to compactness of style, so writing varied instructions on a single slip of paper calls for a welcome brevity and condensation. A few suggestive words only are needed, such as may be jotted down while conversing with the patient. To make clear my meaning I will suppose a few cases

as types:

First, we are consulted by a young man threatened with pulmonary consumption, fever and tubercle bacilli being thus far absent. This patient receives a memorandum worded somewhat as follows:

Live in open air; ventilate rooms day and night; windows open top and bottom; avoid direct draught; avoid dust; avoid fatigue; breathe deeply; dress warmly; retire early; generous diet, especially meat, eggs, milk; eat slowly.

We explain to the patient that these instructions are tentative, that some of them may need modification and that additions as well as changes in 1 is rules must be made from time to time.

The first card of instruction for our next patient, a high liver of a gouty or rheumatic tendency may read something like this:

Diet sparing, vegetables, fruit, milk, etc.; very little meat, eggs, etc.; drink wat freely; no stimulants; exercise regularly, vigorously; exercise all muscles; exercise out doors; dress warmly; keep dry; warm baths with friction.

The third supposed case will be a dyspeptic. Some cases of dyspepsia may be relieved by attention to diet alone. The study of food for the various kinds of dyspeptics is a complicated one,

and in practice the prescribing of diets is more or less experimental, often involving a number of changes before the successful course is found. But diet is not the only thing, and in a given case after noting the food, or foods, to be tried first, we might write these further suggestions:

Eat slowly; meals regular hours; rest after meals; brush teeth with up and down motion; alkaline dentifrice; fresh air; exercise all muscles; exercise muscles waist and back; massage abdomen; regular time, evacuations.

Very different instructions may be given to other dyspeptics, and later on very different instructions will be needed by this patient.

Lastly let us suppose that a so-called "nervous" man consults us, one suffering some of the protean symptoms resulting from overwork or ill-balanced work of the nervous system. To some patients of this class, complete rest from all forms of effort may be an absolute necessity, whether they can afford it or not, while others less severely overworked may recuperate if they resolutely cut down their amount of work and nerve strain. This patient, we will assume, has suffered only a partial break-down, and although a long vacation would be the ideal solution of his trouble, the restricted means of the patient require that we attempt to secure for him sufficient rest while he continues to support his family. So we start him off with this little list of suggestions:

Cut down work; do one thing at a time; make memoranda, instead of remembering; walk part way to business; breathe deeply; avoid alcohol, coffee, tea, spices, pickles, pastry; forget business in evening; retire early; warm bath first; ventilate bedroom.

In each of the above cases the written instructions were very brief, fragmentary and incomplete. In actual practice they may be still shorter and less complete, it being sufficient to write merely catch words to remind the patient of what has already been explained to him at greater length.

Since the advent of the trained nurse we have appreciated the help which comes from accurately written reports of patient's condition from hour to hour; and even though such notes may contain unnecessary and tedious details, we would never on that account think of dispensing with their important information. On the printed blanks used by the nurses are places also for the doctor's instructions. But when the trained nurse is absent, in cases of acute or chronic illness confining the patient to room or bed, in which the care of the sufferer falls upon an untrained helper or upon a member of his own family, it is all the more important

that the medical man's orders be not misunderstood or forgotten. Therefore he should plainly write his directions in regard to diet, bathing, ventilation, heating, visitors, conversation, etc. This paper should be kept on the table with the medicines and supplies, and should be looked over by the physician when he comes again. In a like manner when the doctor gives his written slip to an office patient, the patient should be directed to post it in a convenient place in his bedroom, or, better, to carry it in his pocket-in either event to read it over once a day to see whether he is carrying out its provisions, and, above all, when he consults the doctor again to bring the slip with him for corrections and additions. My experience has been that the patient often neglects to do this-sometimes mislays the paper, and not rarely fails to carry out the instructions; but that need not embarrass the physician, since the responsibility for such neglect lies with the patient. We shall make a big mistake if we expect our directions to be carried out invariably. We must remember that we are not infallible, and that, if we were, our patients are not patterns of perfection. We must use tact, must be ready to change our orders when they have been experimental and seem to have been ill-advised; but when sure we are right, we must be firm and insist with cheerful good nature on the continued efforts of the patient to do as we bid him. But with our firmness we must combine sympathy and patience, remembering that the sick man is only human, and that he has less of courage and resolution than the well man.

Our written directions, then, must be modified from time to time in the light of experience and of the changes in the patient's condition. They should constitute a sort of educational course for him with progressive lessons, during which he may learn to look upon his doctor as a "guide, philosopher and friend.” If the physician can establish this relationship with the patient, if he can teach him to form and fix habits conducive to health, he will not only be a force for good during that patient's life, but he will forge a bond between the patient and himself of the strongest and most enduring kind.

As I said before, patients will sometimes fail to bring back the written slip; and while we may expect it of them, we should not depend on them but keep our own records. This can be done with almost no labor, and I believe with an actual saving of time, of work, and of tax on the memory, surely with a gain in exactness and precision. More easy of reference and more elastic than a book of record is a modification of the card index system. Instead of the rather expensive sheets of card board sold by the manufacturers,