of the character of an eructation, but no gas is brought up with each movement, as it would be in true belching.

A careful examination of the patient fails to reveal any organic disease or any history of indigestion which could account for this symptom. You will notice that her facial expression is somewhat hysterical, and that she appears to be somewhat anemic and suffering from general debility, and inquiry elicits the fact that she is an overworked girl. Now, in these cases, medicines are not particularly valuable, except in so far as they can be used in improving her general condition. Small quantities of iron and arsenic would be useful for her anemia, but far more important in the way of remedial agents will be an abundance of fresh air and exercise, the latter being carried to the point of marked fatigue, and equally important-the employment of hydrotherapeutic measures.

You will remember that I have tried to impress upon you a number of times in my didactic lectures that drugs should never be employed if external therapeutic agents will do the patient as much good, and this is typically a case in which properly applied hydrotherapy can not fail to bring to us the curative effects which we seek. The great difficulty in the application of hydrotherapy is the fact that it can not be readily employed in the patient's home, and that its best results can only be obtained in a hydrotherapeutic institute. If this patient had the means to go to such an institute, that would be the prescription which we would give her, but as she has not this means, we will direct that she shall, as far as possible, carry out a water treatment in her own home. We will instruct her mother to strip the girl, wrap her in a sheet while she stands in the center of a large tub which contains two or three inches of warm water about her feet, and then to dash against her spine and chest several quarts of water at a temperature of about 60°. Immediately after this, the sheet, which is only placed about the patient for modesty's sake, is stripped off her, and she is rubbed down with a rough towel with

sufficient violence to complete the reaction following the cold dash, and to make her entire surface flush with blood. blood. It may be advisable, after she has used these douches for a number of days, to use water at even a lower temperature than I have named. On the other hand, if it is found that these douches chill her because she has not the power of reaction, it may be necessary at first to use warm water, or to use alternate dashes of hot and cold water. This bath, which may be repeated night and morning immediately on rising and just before going to bed, should not last over half a minute to a minute, and it is important that the water should be thrown against her body with so much force as to produce an effect by reason of its impact as well as by its temperature.

Another important point in the case is to impress upon the patient that she has no organic disease, and that this difficulty will speedily pass away, for you will find that in the treatment of these hysterical cases the support of the patient by a stronger will than her own will have much to do toward relieving her condition, and if you can impress upon her the fact that she will wake up on a certain morning entirely free from this complaint, you may be able to produce so powerful a mental effect that on that morning your promise will be carried out. It is necessary,

of course, before you attempt this, that you have the confidence of the patient, so that she will believe implicitly every thing that you tell her.

There are two points in the diagnosis of this case which have not been completed, but which will be valuable as proving that the diagnosis of hysterical eructation is correct. The first of these will be to study the condition of the sensibility of her skin in regard to localized anesthesias; and the second, and more important, would be an examination of her color fields by a competent ophthalmologist, for, as you know, the color fields are often markedly changed in area, and when these changes are present, afford us very important diagnostic data.-H. A. Hare, M. D., in Memphis Lancet.

It is well known that when it is necessary to use a catheter of usual construction-that is, with the ordinary fine perforations as an inlet thereunto-it does not work readily or satisfactorily, or subserve fully the results. expected from it.

Examples of such unsatisfactory operations are seen where there is a good deal of mucus present in the bladder, such mucus being apt to surround or lie upon the end of the catheter, clogging or stopping the apertures thereof and preventing the ingress of fluids to be drawn off; again, when sediment or calcareous matter is present, it clogs, even sometimes filling in part or completely the apertures, with consequent failure of the catheter to fully perform its functions. Such failures are especially apt to happen in nearly, if not quite, all forms of chronic diseases of the bladder, and notably so in cystitis.

My object, therefore, is to present a catheter that is reliable and efficient in operation when the use of a catheter is indicated in all conditions and diseases of the bladder. In this instrument the danger of clogging or failure to perform its functions is obviated, and its interior may be readily made. aseptic, and bits of mucus that usually clog an ordinary catheter may be readily drawn off.

This catheter is of very simple construction, being tubular, with the curve of an ordinary instrument, and opened at the end for an inlet. For the closure of this open end, and for the easy insertion of the catheter, as well as for other purposes, a bulbous or rounded head is used, preferably solid, and attached to one end of a wire, passing through the body or tube and projecting at its rear or outlet end.

This construction forms a very efficient catheter having an area of opening so large as to greatly obviate the danger of clogging, for, if mucus should

tion, or preventing rupture from gases that form in the bladder.

Regarding the treatment of cystitis with the employment of this catheter, presuming that we have a typical case, with ropy, viscid, and tenacious mucus, the membrane thickened and possibly ulcerated, and in deep folds—“ ribbed,' as it were—we begin the treatment as follows:

1. Inject a quarter of a grain of cocaine dissolved in a drachm of water into the membranous portion of the urethra.

2. Anoint the largest hard-rubber catheter that can be well passed into the bladder, and increase the size one number each week until the urethra is normal in size.

3. Begin with dilute hydrogen solutions-preferably hydrozone-one part to twenty of lukewarm water, using this solution freely, especially when employing the large size catheter. If the small size is used at the beginning, I recommend the use of only two or three ounces at a time until removed by the return flow. This can be repeated until the return flow is clear and not "foaming," which indicates that the bladder is aseptic.

4. Partly fill the bladder with the following solution: tincture of iodine compound, two drachms; chlorate of potassium, half a drachm; chloride of sodium, two drachms; warm water, eight ounces. Let it remain a minute

or so and then remove. This treatment should be used once or twice a day. Where I suspect extensive ulceration I recommend once a week the use of from ten to twenty grains of nitrate of silver to the ounce, and neutralize with chloride-of-sodium solutions.

This treatment carried out carefully will be satisfactory, as there is no remedy that will destroy bacteria, fetid mucus, or sacculate calcareous deposits 'ike hydrogen.

Constipation in Infants.

BY WM. M. BEACH.

Recognition of the cause is of first importance in outlining the treatment and giving a prognosis. Each case must be treated upon its individuality. In most cases a permanent cure may be expected; in a few, only temporary relief.

Where constipation depends upon disease of the heart, lungs, liver, or anatomical abnormalities, special measures must be invoked. For atonic and acholic states measures must be used to restore functional activities. Further, a spasmodic condition may exist in the lower half of the large bowel while the upper half is atonic and distended with gases and fecal matter. The distincThe distinc tion between these two is of the highest importance, since active treatment. in the form of electricity, massage, and laxatives, being curative in atonic states, becomes positively harmful in an agitated intestine.

The treatment will resolve itself into measures that are :

2.

Ulcerations of stomach or intes

Acute inflammation of intestines or peritoneum.

The infant's abdomen should be anointed with olive oil prior to the treatment. Use the ball of the thumb, making circular movements beginning at the caput coli and following the colon, also over the liver. This should be done every morning and continued for fifteen minutes at a time. Many cases will readily respond to this procedure alone, but quite a few will require adjuvants by way of dietetics and medicine.

Galvanism and faradism are useful agents, but their inconvenience is an objection to their general use; besides, a formidable instrument is not calculated to enhance the complacency of childhood.

The question of diet and hydrotherapy is receiving a large measure of attention by such men as Rotch, Cotton, Love, Forcheimer, and Tuley.

Laboratories are to be found where the infant's food is furnished by prescription supposed to contain fats and proteids in physiological proportion intended to insure digestion and proper nourishment. The difficulty in infant feeding is to find a suitable ailment for the individual, since the caprices of the latter vary as the trees of the forest. One will require an excess of fats, while in another proteids will be in demand; but I believe that this apparent diversity of conditions arises largely from inactivity of the liver caused by overfeeding and too frequently, and that attention directed to its functions by massage and mild cholagogues will assure ready absorption and perfect metabolism. With these precautions, cow's milk, pure or diluted, will generally suffice. Numerous brands of prepared foods are on the market, and are worthy of trial in many cases; but cow's milk should generally have the preference.

The mother's habit of giving the baby castoria, syrup of figs, etc., is responsible in many cases of constipation to

adult life. Also the habit of giving large enemata should be condemned except by direction of the doctor. The subjective symptom of fullness in the rectum with impossibilities of evacuation, and often a faintness when it has emptied, are well known. The docThe doctor may recommend the enema carelessly and the nurse continue its use indefinitely to the injury of the bowel. In spasmodic conditions of the lower bowel, injections of oil, glycerine, and water are to be commended for the purpose of allaying irritability and relieving the coprostasis. Further, the injection should be given slowly through a long, soft rubber tube, the patient in the right lateral position. The The quantity injected should contain of

The chief object of this injection is to prepare the patient for other and more rational measures.

The medical treatment of infantile constipation should be very simple. The infant should be given plenty of water to take the place of water absorbed. We are signally indebted to my distinguished friend and colleague, Dr. H. S. McConnel, of this society, for the introduction of hydrotherapy in gastro-intestinal diseases of children. His able advocacy in this line has generalized its use in these affections. The systematic use of water will restore the normal secretions. The little subterfuge of adding a colored tablet containing five grains of common salt to a half pint of hot water will convince the mother that her child is receiving proper medical attention. A teaspoonful to a tablespoonful should be administered every hour or two. Cholagogues, according to preceding assertions, will probably be most efficacious, i. e., in alcholic constipation. To this end minute doses of calomel or of magnesia may suffice. A formula that I frequently use for infants is :

Treatment of Constipation.

(1) The salines usually depend for their efficacy upon the sulphate either of magnesium or of sodium. Let us take Carlsbad salts as the type, because its effects upon digestion have been most accurately determined. Jaworski has proven that two results follow the continual dosing of Carlsbad salts: (a) That the production of HCl and of digestive ferments is reduced, often to such an extent that their secretion can not be excited, even by the introduction of food into the stomach. (b) That atony of the muscular wall of the

cosa.

stomach results, provocative of serious symptoms of indigestion and difficult of cure. These results are evident six weeks after the beginning of the dosing. Jaworski's conclusions have been corroborated by those of Boas, Ewald, and others, and may be accepted as facts about which there can be but little dispute. (2) The drastic purgatives, aloes, rhubarb, podophyllin, cascara, and the like act not only in depressing the secretory power of the stomach and in weakening the tone of its muscular wall, as do the salines, but they exert in addition an actual congesting effect upon the gastro-intestinal muFrom the congested blood-vessels serum transudes, peristalsis is increased as in all intestinal inflammations, and a watery stool results. It is the same process as in cold in the head. The nose runs; we blow it. If we have a fresh cold every day it would not be long before a chronic catarrh would be set up. Just as positive as it is that the continual use of vegetable purgatives produces not only secretory and muscular insufficiency of the gastric and intestinal walls, but an actual inflammation, thus perpetuating the condition we are anxious to relieve. Boas, with all his ripe experience, ripe experience, writes: "This is one of the reasons why secretory insufficiency of the stomach is more common in women than in men, although the latter, by reason of the misuse of tobacco and alcohol, are more disposed to gastritis than the women."

actual

I. Diet. The diet suitable for constipation may be divided into three classes (1) Fecal-forming food: Coarse vegetable, coarse bread, cereals. (2) Secretion-excitors: Sugars milk-sugar, honey, fruits, compotes, salts, especially NaCl. (3) Peristalsisexcitors : Cider, buttermilk, fats, organic acids.

Coarse vegetables, such as spinach, Brussels sprouts, turnips, and carrots, should constitute a large proportion of the diet. To avoid irritation of the stomach it is well to have them prepared in pureé form. To this class of foods must be added the coarse cereals. The breads should be of coarse texture, and should be given one day

old.

Porous bread is to be preferred. A very good biscuit is Dohl's dyspepsia cake, somewhat dry, but if moistened with hot water or milk and eaten with a little sugar, really not unpalatable. Care must be taken in all cases to exclude from the diet all constipating food. This is often overlooked. One glass of claret will neutralize, for example, the laxative effect of an entire meal. Tea must be freshly made and never strong.

II. Sugars. It is not definitely proven whether the action of sugars is through the fermentation they undergo, producing butyric, lactic, and acetic acids which increase intestinal peristalsis, or whether they act as do the salines, in producing a transudation of serum through the intestinal wall. Strauss and Boas incline to the latter theory. Certain it is that we have in this class of foodstuffs a very efficient means of combating constipation. tion. Sugars are best given in the form of honey, milk-sugar, and fruit compotes. The simplest and best remedy I know of is a tablespoonful of honey in half a glass of warm milk on rising in the morning. It very seldom disagrees or diminishes appetite for breakfast. Honey, jam, or marmalade. may also be taken with the breakfast roll. Lactose (thirty cents per pound) is to be used instead of ordinary sugar for tea, coffee, and the like. Compotes of stewed fruit may be sweetened by it, and such a compote taken once a day at least. A very good combination is two parts of prunes and one of figs. Raw fruit I do not approve of. Huckleberries and cranberries are to be strenuously avoided. Diluted condensed milk may be used in place of ordinary milk.

Passing to liquids, we have buttermilk, kumyss, and cider. Buttermilk is much lauded by German authorities, and has in my experience proved very reliable. To secure good effects, three glasses should be taken daily. Kumyss has a similar effect, somewhat increased by the stimulating effect of CO2 on gastric and intestinal peristalsis. Kefir is not obtainable in our markets. White wines may be allowed in moderation.-George R. Lockwood, in N. Y. Medical News.