AND PECULIAR SOME INTERESTING AT CASES POONAMALEE, MADRAS, FROM 1883?1885. Br Sukgeon JOHN D. T. REOKETT,
(Concluded from page
m.
s.
.)
Case VII.? Dysentery?Peritonitis?Recovery. February 10th, 1884.?Private Chas. P.?,at.
admitted on February 3rd for a relapse attended with most acute pain of abdomen and much tympanites, caused probably by eatinrr course oatmeal porridge very soon after bein? from discharged from hospital convalescent " was good for sentery. and which lie thought the bowels." Anxious and partially
23,
dy?
collapsed
countenance.
Treatment.?Perfect rest in bed. Hot fomentations to abdomen continually with turpentine sprinkled on the flannels. Liq. morphiaj m. 20 to relieve pain. Beeftea with a pint of chicken broth.
February 14th, 1884.?Abdomen much less tympanitic. He passed a large clot of blood last night, and since then the tympauites has much diminished.
February 17th,
and
much
more
1884.?Very
comfortable.
little dysentery He is takin?-
Ipecac, bismuth, and morphia pills. Abdomen a little February 21 st, 1884. tympanitic. To have poppy fomentations, Liq. ?
morphias mur. m. 20 at bed-time?also sin euema Milk diet with of 1? pint of warm water. chicken broth. Dysentery quite well. March 9 th, 1884.?Scarcely auy pain ; but the abdomen is still
a
little swollen.
19th, 1884.?Discharged to proceed to England, he had been the subject of frequent March
as
Abdomen enlarged and attacks of dysentery. the dull, enlargement being probably due to swollen mesenteric glands and serum. Remarks.?I considered this was a case of perforation of the wall of gut. He had been under treatment for a considerable time, and after leaving hospital, he ate horribly of course Scotch oatmeal, and it is very probable a halfliealed dysenteric ulcer was perforated by a grain of the meal, or that some of this food became impacted in one of those ulcers causing acute
peritonitis.
Perfect rest, sedatives, soothing applications with a mild uustimulating diet were attended
by
recovery.
Case VIII.? Chronic voluminous injections
Dysentery of
Nitrate
treated by Silver?
oj
Recovery.
February 10th, 1885.?Private J. J.?, cct. 27,
admitted
January 17th suffering from a relapse, having been under treatment a few on
weeks ago for a very severe attack of acute dysentery which was most obstinate in yielding to
[Jan.,
THE INDIAN MEDICAL GAZETTE.
12
treatment.
This
nating
instance of the disease origiPoonamallee. Since admission has
was a rare
at
suffered severely from tenesmus, and calls to stool have been very frequent, often between 20 aud 30 times a day. Has passed much blood. A peculiarity about the case is the very dirty condition of his tongue, which is covered every morning with a thick, creamy, yellowish white fur. Much pain in abdomen which has been relieved by sedative euemata and hot poppy fomentations. Has become much reduced. Treatment:?Euemata of Ipecac 1 dr., Liq. opii sed. m. 40 and solution of starch 2 oz. Bedside warm baths. Pulv ipecac ^ dr. at night, occasionally by the mouth and turpentine fomentations. Liver was found enlarged in a downward direction with much pain on palpation, and he was put on the Ammon. chloride treatment, which however increased the dysenteric diarrhoea and had to be abandoned in a few days. To have milk diet. February 25th, 1885.?Liver still found enlarged, but as regards the dysentery, it has been much better since last entry. There has been more or less diarrhoea every day, but stools have beeu free from blood. To have the region of liver rubbed night and morning with turpentine and to resume Ammon. chloride gr. 20, ter Beeftea with milk and chicken broth. die. Much better. No February 26th, 1885. ?.
1888.
but stools sire not yet formed. To continue Ainmon. chloride. March 3rd, 1885.?Return of dysentery last night. Ordered warm bath aud Ipecac i dr. at bed time. March 7th, 1885.?Has been much worse, and is much pulled down with pain and frequent calls to stool. Surgeon-Major Davey saw him, and ordered Liq. ferri pernit. m. 12, Aq. 1 oz. To discontinue Ainmon. chloride. t. d. s. March 10 th, 1885. Dysentery continues with much blood in stools and nothing seems to relieve the straining and pain. Is getting worse and causing anxiety. To continue Ferri pernit. and to have ipecac, bismuth and morphia; pills, ter die. Diet: tea, milk 2 pts., sago jelly 2 pts. March 19th, 1885.?-Much worse and looking dangerously ill. Calls to stool number about 2Q daily. Passes little else but blood and shreds of membrane with undigested food. To have an injection of warm water 2 pints with Acid tannic gr. 3 ad 1 oz. March 20th, 1885.?I examined anus and rectum. Sphincter so much relaxed that I could see the condition of the mucous membrane for nearly two inches, and this was quite ulcerated, uo doubt an index of the condition of mucous membrane for a large tract of the bowel,us judged at this by the severe abdominal pain. The man " time expressed himself as " nearly done; and indeed the disease did not seem to yield in the least to our treatment, but rather to become worse daily. Accordingly, with the carelessness of lost hope on the part of the patient and with the sanction of Surgeon-Major Davey, the senior medical officer, I gave him by means of a long india-rubber tube attached to the tube of the stomach pump and with a funnel connected to the distal extremity ail injection of 3 pints of warm distilled water containing in solution 60 grains of nitrate of silver, poured into the funnel held about two yards higher level than the patient. Retained about five minutes : six hours after he was much easier and quite free from pain. Calls to stool five times throughout the day with passage of large quantities of slime and membrane. March 21 st, 1885.?Calls to stool four times in night. Very little pain and expresses himself much better. To have in addition to diet 3 oz. portwine and 1 pint mutton tea. February 22nd.?Had 11 motions yesterday. No blood. Light colour, and contained much undigested food. No abdominal pain, and he To have a mixture says he feels much better. of bismuth, mix vomica, and liq. morphia mur. 23rd.?Had 8 motions yesterday. No blood. No pain, and very little straining. Says he feels quite easy. Anxious and painful expression of countenance has disappeared, though he is extremely emaciated. He said to me this
dysentery,
?
morning.
" What you did for me the other day, that these injections saved my life, Sir." No doubt
lie is
wonderfully improved. No
24th.?Good night. pain. Up 3 times Motions of a light colour and semi-solid. 25th.?Had 7 motions yesterday. No blood. No pain except in left chest, just below nipple, to
Btool.
the cause of which I canuot make out, unless it is from dyspepsia. 26th.?Had 6 motions; but, I noticed a little blood in the semi-solid stools. Repeated injection of nitrate of silver, which was retained five minutes, and which brought away a little fosculent matter mixed with coagulated mucus aud slime. 27th.?To stool 5 times yesterday. No blood and no pain. 29th.?Up only once last night and 4 times altogether yesterday. No pain or blood. Ordered a little astringent mixture (Creta gr. 8, Conf. aromat. gr. 5, Tinct. catechu m. 20, Aq. cinnam., ad 1 oz. t. d. s.) 30th.?Continues to improve and motions semi-solid. No blood at tiiis juncture. I left the station for England, and was pleased to hear a few weeks after from Surgeon-Major Davey that our patient recovered, and was duly discharged from hospital. Remarks.?This was the only case of chronic dysentery at Poonamallee, which resisted all ordinary treatment. Ipecac, by the mouth, rectum, and numerous astringents had little or no effect. He became emaciated to an extreme, and the relaxed and powerless sphincter allowed the contents of the bowel (mucus, slime, blood and undigested food) to pass away unconsciously, and no doubt there was extensive ulceration of a The patient had very large tract of the gut. literally given himself up. It was at this time I had been reading in the Lancet of the treatment of chronic dysentery by voluminous injections of nitrate of silver, carried out m England by a physician, whose name I cannot recall at this moment, and the very favourable result of his treatment by this method seemed to offer a shady chance, and I cannot but believe was the means of saving this man?at least he
thought,
so
himself.
Conclusion.?In
my
previous
reference to
dysentery, I alluded to the fact that for the year ending December 31st, 1884, we admitted 53
cases, all of which recovered more
pletely.
or
less
com-
The character of dysentery with which we to deal was sub-acute or chronic. Many cases were complicated with hepatitis and with hepatic abscess, and in two instances with violent peritonitis, caused in the one case as suspected by perforation of a dysenteric ulcer with a grain of coarse oatmeal, and which recovered, .siml in the other by the rupture of a liver ubscess and discharge of its contents into the
-had
13
Dr. RECKETT'S CASES.
Jan., 1888.]
peritoneal cavity, and which, after a lingering illness and extension of inflammatory mischief
right lung, died. Many cases of the chronic
to the
form of dysentery attended with great anaemia and debility, requiring the soldiers to be invalided Home, and which, whilst under treatment at Poonamallee for these results of the great albuminous waste they had undergone, seemed to obtain little or no benefit from medicines directed to these conditions. My impression was that such cases would rather have been further benefited by residence in a more bracing climate, after recovering from dysentery, because it is apparent that the constant effect of a high and relaxing temperature on the system, does tend to cause it when once proanajmia or to aggravate CD were
duced. In
much abdominal pain was comand the character an aching or sore one, sometimes spasmodic and straining. Sleepless and restless nights were the consequence requiring opium in some form. The greatest and longest relief seemed to be from enemata of some cases
plained of,
Liq. Opii. Sedat. Sol. Atnyli. ad
injected syringe.
...
...
...
into the rectum with
an
m
xl.
ij ordinary pewter ...
3
Where great debility and anaemia were present, I observed that the digestion of even the very light food ordered was very imperfectly performed, and often passed with very slight alteration. Pepsine in 20 gr. doses combined with acid acted favourably in such cases, and I believe this remedy justifies a more extended use where the digestive tract is so out of gear as it is in chronic forms of dysentery. The temperature I observed to be little affected; sometimes a degree higher than normal at uight, but more often a degree lower. The condition of the tongue was certainly a good guide in some part of the treatment, and until it became cleau or at any rate free from red sides and tip, it was unsafe to change the diet substantially or to discharge the patient from hospital, although dysenteric stools might for some days. I often have disappeared noticed that where this slightly irritable looking tongue attended the case and patients were discharged, a relapse quickly occurred and which generally required a much longer stay in hospital than the original attack. So convinced was I of the importance of noting the exact condition of the tongue and this particular guide that I made it a stringent rule never to discharge a dysentery patient who had it, although dysentery and diarrhoea might have before. They always returned gone many days if so discharged., and it was easy to see that when the tongue as an indicator was discarded or iudifferently noted .mischief resulted,?of
14
THE INDIAN MEDICAL GAZETTE. sucli a tongue only pointed to ulceration catarrh of intestinal mucous membrane or
course or
glands.
Tlie liver was affected in many cases, and I certainly concluded that during the course of an attack of chronic dysentery, hepatitis Supervened far more frequently than the existence of this disease was observed previous to dysentery making its appearance. When I speak of hepatitis, perhaps I am using the term not quite correctly, but at any rate in accordance with the nomenclature of diseases in Indian hospitals. Hepatitis was the name we
assigned
to a
condition involving
some
enlarge-
either upwards or downwards, pain 011 palpation, and slight increase of temperature? for aught we a subacute form, with probably In these know a point or two of suppuration. cases of hepatitis, however, abscess which was unmistakeable, only twice occurred. To both I have alluded. Tympanites was a common accompaniment of chronic dysentery, and in most cases caused considerable distress or discomfort. I always readily relieved it by an enema of Sp. terebinth, Tinct, assafoetid, and soap and water, combined with perfect rest in bed. Abdominal pain was best relieved by sedative enemata of Liq. opii sed. and solution of starch ment
to 2 ounces.
of treatment I adopted in when first sent into the ward give by the rectum the following simple at bedtime : The
every
plan
case
R
Pnlv. Ipecac. Liq. Opii Sed.
...
...
3i
...
...
m.
Rice starch solution ad
...
nearly
was to
enema
xl.
5ji.
There was never any difficulty in retaining this small quantity, which caused only a little nausea, and no vomiting or discomfort. This enema was repeated every other evening with pulv. ipecac., gr. 20, by the mouth on the intervening night until the motions were reduced to three free from slime and or four in 24 hours, and blood. Afterwards the looseness was generally cured by a dose of mist, cretie co., night and morning. I only had one case which resisted all ordinary treatment, and this I have referred .
length. Many cases of a mild form were readily cured by taking care the patient stuck to milk-diet only, with rest in recumbeut position. No medito at
cine was needed. The line of treatment I carried out was to give, by enema, large doses of ipecac, combined with opium, and there is 110 doubt the good j-esults were very materially aided by most careful dietetic measures?milk and things made of inilk:?until all symptoms of the disease had dis-
appeared, and, subsequen tly, very gradual change
to more
Substantial food, such aarchickeu
pliicken,jfishj and meat,
i
?
(Concluded from page
m.
s.
.)
Case VII.? Dysentery?Peritonitis?Recovery. February 10th, 1884.?Private Chas. P.?,at.
admitted on February 3rd for a relapse attended with most acute pain of abdomen and much tympanites, caused probably by eatinrr course oatmeal porridge very soon after bein? from discharged from hospital convalescent " was good for sentery. and which lie thought the bowels." Anxious and partially
23,
dy?
collapsed
countenance.
Treatment.?Perfect rest in bed. Hot fomentations to abdomen continually with turpentine sprinkled on the flannels. Liq. morphiaj m. 20 to relieve pain. Beeftea with a pint of chicken broth.
February 14th, 1884.?Abdomen much less tympanitic. He passed a large clot of blood last night, and since then the tympauites has much diminished.
February 17th,
and
much
more
1884.?Very
comfortable.
little dysentery He is takin?-
Ipecac, bismuth, and morphia pills. Abdomen a little February 21 st, 1884. tympanitic. To have poppy fomentations, Liq. ?
morphias mur. m. 20 at bed-time?also sin euema Milk diet with of 1? pint of warm water. chicken broth. Dysentery quite well. March 9 th, 1884.?Scarcely auy pain ; but the abdomen is still
a
little swollen.
19th, 1884.?Discharged to proceed to England, he had been the subject of frequent March
as
Abdomen enlarged and attacks of dysentery. the dull, enlargement being probably due to swollen mesenteric glands and serum. Remarks.?I considered this was a case of perforation of the wall of gut. He had been under treatment for a considerable time, and after leaving hospital, he ate horribly of course Scotch oatmeal, and it is very probable a halfliealed dysenteric ulcer was perforated by a grain of the meal, or that some of this food became impacted in one of those ulcers causing acute
peritonitis.
Perfect rest, sedatives, soothing applications with a mild uustimulating diet were attended
by
recovery.
Case VIII.? Chronic voluminous injections
Dysentery of
Nitrate
treated by Silver?
oj
Recovery.
February 10th, 1885.?Private J. J.?, cct. 27,
admitted
January 17th suffering from a relapse, having been under treatment a few on
weeks ago for a very severe attack of acute dysentery which was most obstinate in yielding to
[Jan.,
THE INDIAN MEDICAL GAZETTE.
12
treatment.
This
nating
instance of the disease origiPoonamallee. Since admission has
was a rare
at
suffered severely from tenesmus, and calls to stool have been very frequent, often between 20 aud 30 times a day. Has passed much blood. A peculiarity about the case is the very dirty condition of his tongue, which is covered every morning with a thick, creamy, yellowish white fur. Much pain in abdomen which has been relieved by sedative euemata and hot poppy fomentations. Has become much reduced. Treatment:?Euemata of Ipecac 1 dr., Liq. opii sed. m. 40 and solution of starch 2 oz. Bedside warm baths. Pulv ipecac ^ dr. at night, occasionally by the mouth and turpentine fomentations. Liver was found enlarged in a downward direction with much pain on palpation, and he was put on the Ammon. chloride treatment, which however increased the dysenteric diarrhoea and had to be abandoned in a few days. To have milk diet. February 25th, 1885.?Liver still found enlarged, but as regards the dysentery, it has been much better since last entry. There has been more or less diarrhoea every day, but stools have beeu free from blood. To have the region of liver rubbed night and morning with turpentine and to resume Ammon. chloride gr. 20, ter Beeftea with milk and chicken broth. die. Much better. No February 26th, 1885. ?.
1888.
but stools sire not yet formed. To continue Ainmon. chloride. March 3rd, 1885.?Return of dysentery last night. Ordered warm bath aud Ipecac i dr. at bed time. March 7th, 1885.?Has been much worse, and is much pulled down with pain and frequent calls to stool. Surgeon-Major Davey saw him, and ordered Liq. ferri pernit. m. 12, Aq. 1 oz. To discontinue Ainmon. chloride. t. d. s. March 10 th, 1885. Dysentery continues with much blood in stools and nothing seems to relieve the straining and pain. Is getting worse and causing anxiety. To continue Ferri pernit. and to have ipecac, bismuth and morphia; pills, ter die. Diet: tea, milk 2 pts., sago jelly 2 pts. March 19th, 1885.?-Much worse and looking dangerously ill. Calls to stool number about 2Q daily. Passes little else but blood and shreds of membrane with undigested food. To have an injection of warm water 2 pints with Acid tannic gr. 3 ad 1 oz. March 20th, 1885.?I examined anus and rectum. Sphincter so much relaxed that I could see the condition of the mucous membrane for nearly two inches, and this was quite ulcerated, uo doubt an index of the condition of mucous membrane for a large tract of the bowel,us judged at this by the severe abdominal pain. The man " time expressed himself as " nearly done; and indeed the disease did not seem to yield in the least to our treatment, but rather to become worse daily. Accordingly, with the carelessness of lost hope on the part of the patient and with the sanction of Surgeon-Major Davey, the senior medical officer, I gave him by means of a long india-rubber tube attached to the tube of the stomach pump and with a funnel connected to the distal extremity ail injection of 3 pints of warm distilled water containing in solution 60 grains of nitrate of silver, poured into the funnel held about two yards higher level than the patient. Retained about five minutes : six hours after he was much easier and quite free from pain. Calls to stool five times throughout the day with passage of large quantities of slime and membrane. March 21 st, 1885.?Calls to stool four times in night. Very little pain and expresses himself much better. To have in addition to diet 3 oz. portwine and 1 pint mutton tea. February 22nd.?Had 11 motions yesterday. No blood. Light colour, and contained much undigested food. No abdominal pain, and he To have a mixture says he feels much better. of bismuth, mix vomica, and liq. morphia mur. 23rd.?Had 8 motions yesterday. No blood. No pain, and very little straining. Says he feels quite easy. Anxious and painful expression of countenance has disappeared, though he is extremely emaciated. He said to me this
dysentery,
?
morning.
" What you did for me the other day, that these injections saved my life, Sir." No doubt
lie is
wonderfully improved. No
24th.?Good night. pain. Up 3 times Motions of a light colour and semi-solid. 25th.?Had 7 motions yesterday. No blood. No pain except in left chest, just below nipple, to
Btool.
the cause of which I canuot make out, unless it is from dyspepsia. 26th.?Had 6 motions; but, I noticed a little blood in the semi-solid stools. Repeated injection of nitrate of silver, which was retained five minutes, and which brought away a little fosculent matter mixed with coagulated mucus aud slime. 27th.?To stool 5 times yesterday. No blood and no pain. 29th.?Up only once last night and 4 times altogether yesterday. No pain or blood. Ordered a little astringent mixture (Creta gr. 8, Conf. aromat. gr. 5, Tinct. catechu m. 20, Aq. cinnam., ad 1 oz. t. d. s.) 30th.?Continues to improve and motions semi-solid. No blood at tiiis juncture. I left the station for England, and was pleased to hear a few weeks after from Surgeon-Major Davey that our patient recovered, and was duly discharged from hospital. Remarks.?This was the only case of chronic dysentery at Poonamallee, which resisted all ordinary treatment. Ipecac, by the mouth, rectum, and numerous astringents had little or no effect. He became emaciated to an extreme, and the relaxed and powerless sphincter allowed the contents of the bowel (mucus, slime, blood and undigested food) to pass away unconsciously, and no doubt there was extensive ulceration of a The patient had very large tract of the gut. literally given himself up. It was at this time I had been reading in the Lancet of the treatment of chronic dysentery by voluminous injections of nitrate of silver, carried out m England by a physician, whose name I cannot recall at this moment, and the very favourable result of his treatment by this method seemed to offer a shady chance, and I cannot but believe was the means of saving this man?at least he
thought,
so
himself.
Conclusion.?In
my
previous
reference to
dysentery, I alluded to the fact that for the year ending December 31st, 1884, we admitted 53
cases, all of which recovered more
pletely.
or
less
com-
The character of dysentery with which we to deal was sub-acute or chronic. Many cases were complicated with hepatitis and with hepatic abscess, and in two instances with violent peritonitis, caused in the one case as suspected by perforation of a dysenteric ulcer with a grain of coarse oatmeal, and which recovered, .siml in the other by the rupture of a liver ubscess and discharge of its contents into the
-had
13
Dr. RECKETT'S CASES.
Jan., 1888.]
peritoneal cavity, and which, after a lingering illness and extension of inflammatory mischief
right lung, died. Many cases of the chronic
to the
form of dysentery attended with great anaemia and debility, requiring the soldiers to be invalided Home, and which, whilst under treatment at Poonamallee for these results of the great albuminous waste they had undergone, seemed to obtain little or no benefit from medicines directed to these conditions. My impression was that such cases would rather have been further benefited by residence in a more bracing climate, after recovering from dysentery, because it is apparent that the constant effect of a high and relaxing temperature on the system, does tend to cause it when once proanajmia or to aggravate CD were
duced. In
much abdominal pain was comand the character an aching or sore one, sometimes spasmodic and straining. Sleepless and restless nights were the consequence requiring opium in some form. The greatest and longest relief seemed to be from enemata of some cases
plained of,
Liq. Opii. Sedat. Sol. Atnyli. ad
injected syringe.
...
...
...
into the rectum with
an
m
xl.
ij ordinary pewter ...
3
Where great debility and anaemia were present, I observed that the digestion of even the very light food ordered was very imperfectly performed, and often passed with very slight alteration. Pepsine in 20 gr. doses combined with acid acted favourably in such cases, and I believe this remedy justifies a more extended use where the digestive tract is so out of gear as it is in chronic forms of dysentery. The temperature I observed to be little affected; sometimes a degree higher than normal at uight, but more often a degree lower. The condition of the tongue was certainly a good guide in some part of the treatment, and until it became cleau or at any rate free from red sides and tip, it was unsafe to change the diet substantially or to discharge the patient from hospital, although dysenteric stools might for some days. I often have disappeared noticed that where this slightly irritable looking tongue attended the case and patients were discharged, a relapse quickly occurred and which generally required a much longer stay in hospital than the original attack. So convinced was I of the importance of noting the exact condition of the tongue and this particular guide that I made it a stringent rule never to discharge a dysentery patient who had it, although dysentery and diarrhoea might have before. They always returned gone many days if so discharged., and it was easy to see that when the tongue as an indicator was discarded or iudifferently noted .mischief resulted,?of
14
THE INDIAN MEDICAL GAZETTE. sucli a tongue only pointed to ulceration catarrh of intestinal mucous membrane or
course or
glands.
Tlie liver was affected in many cases, and I certainly concluded that during the course of an attack of chronic dysentery, hepatitis Supervened far more frequently than the existence of this disease was observed previous to dysentery making its appearance. When I speak of hepatitis, perhaps I am using the term not quite correctly, but at any rate in accordance with the nomenclature of diseases in Indian hospitals. Hepatitis was the name we
assigned
to a
condition involving
some
enlarge-
either upwards or downwards, pain 011 palpation, and slight increase of temperature? for aught we a subacute form, with probably In these know a point or two of suppuration. cases of hepatitis, however, abscess which was unmistakeable, only twice occurred. To both I have alluded. Tympanites was a common accompaniment of chronic dysentery, and in most cases caused considerable distress or discomfort. I always readily relieved it by an enema of Sp. terebinth, Tinct, assafoetid, and soap and water, combined with perfect rest in bed. Abdominal pain was best relieved by sedative enemata of Liq. opii sed. and solution of starch ment
to 2 ounces.
of treatment I adopted in when first sent into the ward give by the rectum the following simple at bedtime : The
every
plan
case
R
Pnlv. Ipecac. Liq. Opii Sed.
...
...
3i
...
...
m.
Rice starch solution ad
...
nearly
was to
enema
xl.
5ji.
There was never any difficulty in retaining this small quantity, which caused only a little nausea, and no vomiting or discomfort. This enema was repeated every other evening with pulv. ipecac., gr. 20, by the mouth on the intervening night until the motions were reduced to three free from slime and or four in 24 hours, and blood. Afterwards the looseness was generally cured by a dose of mist, cretie co., night and morning. I only had one case which resisted all ordinary treatment, and this I have referred .
length. Many cases of a mild form were readily cured by taking care the patient stuck to milk-diet only, with rest in recumbeut position. No medito at
cine was needed. The line of treatment I carried out was to give, by enema, large doses of ipecac, combined with opium, and there is 110 doubt the good j-esults were very materially aided by most careful dietetic measures?milk and things made of inilk:?until all symptoms of the disease had dis-
appeared, and, subsequen tly, very gradual change
to more
Substantial food, such aarchickeu
pliicken,jfishj and meat,
i
?
