mostly ignorant and careless so-called cleaning necessarily entail; if in sleeping-cars and hotel bedrooms the well are to follow consumptives in their occupancy without warning, or even the poor show of official disinfection; if in ill-ventilated and ill-cared for dwellings the well must breathe again and again the dust-borne seeds of tuberculosis; if no persistent warning is to be given to the ignorant of the dangers which lurk in uncleanliness-then our task will be most complex as well as difficult in limiting the contagiousness of tuberculosis."

Of course cleanliness and plenty of water are necessary; but, after all, it is the expectoration which carries the germ and promotes the spread of disease. Spitting, it seems, is not only a vile, but an increasing, habit. This is an unfortunate social fact which reformers do not seem to have grasped, despite its noxiousness. Shall we not have to have a Society for the Prevention of Expectoration - except into sanitary spit-cups? If one could stop the spitting habit, prevent the spread of consumption, and finally stamp it out, he would be greater than a tariff reformer.— Record, May 7, '92.

Tea-Tippling.-In an editorial on tea-tippling the Lancet says: We desire to assist in impressing upon women especially the fact that the immoderate use of their favorite beverage is fraught with considerable danger to health, and that this is especially true of those who lead for the most part an in-door life. Too often, unfortunately, conviction that the habit is injurious comes only after the breakdown, and the harm which has been done takes a good deal of undoing. It is idle to argue that Australian shepherds or half-savage Tartars drink tea in immoderate quantities, and are none the worse for it. Their mode of life enables them to do many things-we shall not say, with impunity-which town dwellers cannot do, and we are convinced that no one living for the most part an in-door city life can continue to indulge freely in tea five or six times a day without suffering for it in the end. Whether or not " envy, malice and all uncharitableness" are, as some assert, productive of indigestion, there is no doubt that excessive teadrinking is; and for our own part we are inclined to think that indigestion is at least as often the parent as it is the child of the vices which have been mentioned. Med. Record.

BELLEVUE HOSPITAL MEDICAL COLLEGE,

New York. DEAR SIRS: I have tested Cottolene in my chemical laboratory and have tested articles cooked in it on my table.

The accompanying analytical report, as well as repeated kitchen experiments, show it to be superior to lard.

I find that it is composed of materials which are now recognized the world over as wholesome articles of diet.

Edibles that are cooked in Cottolene are as acceptable to the palate as those prepared in lard.

As a substitute for lard, which is its purpose, Cottolene possesses all the desirable qualities of lard, without having the objectionable features inherent in all products obtained from swine.

Yours respectfully,

R. OGDEN DOREMUS, M.D., LL.D., Professor Chemistry, Toxicology and Medical Jurisprudence, Bellevue Hospital Medical College.

(Seal.)

BELLEVUE HOSPITAL MEDICAL COLLEGE,

New York.

DEAR SIRS: The sample of Cottolene brought me for examination possesses the following characteristics :

Color, light yellow-natural and not due to addition of coloring substances.

Consistency-that of lard.

Boiling point-that of lard, 570° F. Specific gravity at 120° F., 0.9042. Microscopic appearance-masses of semi-crystalline fat, mixed with distinct crystals of stearine.

When subjected to chemical tests it showed absence of water, absence of rancid fat, absence of ash, therefore absence of salt or similiar mineral substances used for preserving fats.

The of cotton seed oil was proven by seppresence aration of said oil by pressure; by tests applied to said separated oil; by the action of Iodine solution on Cottolene.

These tests were confirmed by the tests, color and odor of the separated oils.

The presence of suet was made evident by several of the foregoing tests, and was corroborated by further chemical reactions.

Cottolene is therefore a mixture of cottonseed oil and suet. Yours respectfully,

R. OGDEN DOREMUS, M.D., LL.D., Professor Chemistry, Toxicology and Medical Jurisprudence, Bellevue Hospital Medical College.

(Seal.)

Dietetic

Contributions and Selections.

THE TREATMENT OF EPILEPSY.

BY FREDERICK PETERSON, M. D., ATTENDING PHYSICIAN NEW YORK HOSPITAL FOR NERVOUS AND EPILEPTIC; CHIEF OF CLINIC, NERVOUS DEPARTMENT, VANDERBILT CLINIC COLLEGE OF PHYSICIANS AND SURGEONS.

There has been great advance of late years in the treatment of the epileptic, and I am not aware that there has anywhere appeared a condensed practical account of the methods in vogue at the present time. Somehow or other, the epileptic and his needs as an individual have been forgotten, although empirical attempts enough to cure his obstinate malady have been made for many centuries.

In the first place, we have come latterly to look upon epilepsy not as a disease sui generis, but as a symptom of a number of pathological conditions, some in the central nervous system, some in the blood, and some of a reflex nature. At any rate, each and every case must be studied upon its own merits and in the light of modern discoveries in the nervous system. It is only thus that we can learn which cases are particularly well fitted for dietetic and medicinal treatment, and which require the intervention of the surgeon. It is not the province of this article to point out the methods of diagnosis. With due care and continuous observation the physician will differentiate the features of attacks, whether petit or grand mal, nocturnal or diurnal, or a larval form. He will look for gastro-intestinal irritation and ocular disorders, he will examine the genital organs, he will exclude hysteria, he will make a chemical study of the urine for the light it may throw upon nutritional disturbances. Then the character of the seizure, its mode of origin, whether preceded by sensory hallucinations (aure) and its limitation to certain groups of muscles, or its general nature must be

studied. After such careful investigation a line of treatment may be marked out.

Surgical Treatment.-A limited number of epileptics may be treated surgically with benefit in the vast majority of cases and with good hope of cure in a select few. The cases eligible for trephination are those that give good evidence of a cortical lesion, such as a palpable depression in the skull with a history of an injury, or where the epilepsy is distinctly Jacksonian in character, thus indicating a certain point of cortical irritation where the epileptic explosion begins. Trephining, when done by a skilful surgeon and under strictest antiseptic precautions, may be looked upon as a comparatively safe operation. It should be resorted to more often than it is as a preventive measure. I refer to cases of head injury which seem on first examination to be trivial, but which in the course of time develop epilepsy. A case in point presented himself at the Vanderbilt Clinic a few days ago. A boy of twenty was struck on the head by a bottle falling from a third story window. There was no loss of consciousness and apparently no injury to the skull. At any rate the scalp wound, which was severe, was sewed up and healed readily. This was three years ago. During the first year after the accident he had one epileptic fit; during the second year, two or three; now he has them two or three times weekly. There is a large scar and an apparent depression over the right frontoparietal region, very near the median line. I consider this case a proper one for trephination, although there are no focal symptoms of the epilepsy. At this point will be found either a depressed spicula of bone, a meningeal thickening, or a cortical sclerosis, requir ing removal.

Dietetic Rules.-Eating and drinking should be always moderate. Alcohol, coffee and tea should be eschewed, and smoking also, in most cases forbidden. Undoubtedly the best food for the epileptic is a vegetable and milk diet, but meat should not be altogether

140

excluded. A vegetable diet does no harm to an adult, but should be combined with fats in the shape of oils, butter or fat meat. We know very well that whole nations live almost exclusively upon such a diet, as I have myself observed among the hard working muscular Egyptian fellaheen. But growing children require proportionately more food than adults. They have not only the daily waste to supply, but a growing organism to build up and to form a large amount of proteid (Bunge); and a mixed though light and easily digested diet should be ordered. The dinner should be in the middle of the day; the evening meal should be light. There is as yet no explanation of the nature of the epileptic explosion in the convulsive centres. Theoretically, they are looked upon as nutritional disturbances in nitrogenous compounds in nerve cells. That we have to deal with profound chemical changes in the central nervous system in most of these cases there is no doubt. Recent studies in the urine of epileptics have demonstrated the truth of this, and after a time we shall by more careful study be able to modify by diet alone the frequency of seizures in many cases.

Employment. It is too frequently the fact that the unfortunate epileptic is given a prescription, a few words upon diet, and then allowed to take his own course. But the employment of mind and body is of vital importance in most of these cases. An out-of-door life in the country is that best adapted for them. If the patients are so badly off that they cannot fulfil their usual social obligations, get an education in the schools, or carry on their trades or professions among their fellows, they must be sent to an institution for epileptics where provision is made for all such needs. The best institution in the world of this kind is that at Bielefeld, Germany, which I have fully described on many occasions,* and whither I have had the pleasure of sending several patients from various States in this country, to the great happiness of themselves and the relief of their families. I am glad to say that similar institutions are now being organized in this country. There is one already in embryo at Santa Clara, California; one nearly completed at Gallipolis, Ohio, and New York will have located a site and secured plans for buildings on the colony system before the end of this year.

Hydrotherapy.-Cold shower-baths and cold sponge-baths daily are beneficial. The shower baths should be rain like in character, that is, not too forcible.

In many cases a morning and evening bath, (the "half bath,") proves very serviceable. The "half bath" is taken in a bath tub only half filled with

*N. Y. Medical Record. April 23, 1887; Journ. of Nerv. and Ment Dis.. Dec. 1889; State Charities Record, N. Y., June, 1890; Journ. Nerv. and Ment. Dis., Aug., 1892.

water and when taken should be accompanied by energetic rubbing of the patient by an attendant. This bath lasts five minutes, and the temperature should be not under fifty and not over seventy degrees Fahrenheit.

Where there is evidence of hyperaemia and increased blood pressure in the head, the cold cap is useful.

While these are the general indications for hydrotherapy, certain measures are often of use at the time of seizures. During a fit or during a status epilepticus it will be observed that there is one of two vascular conditions present; either the face is pale and there are signs of brain anaemia, and in this case warm wet compresses should be applied to the head and genitals, accompanied by friction of the trunk upward, the body being placed with head low and arms uplifted; or there is turgescence of vessels in the head, the face is red, the carotids beat strongly, and under such conditions a contrary procedure is indicated-cold compresses to the head, neck and genitals, strong wet beating of the feet, with a high position of the head.

Treatment with Drugs.-For the great majority of cases of grand mal and petit mal a bromide will be found by far the most useful drug. Only one bromide should be used, and the experience of some of the best practitioners (like Gowers) and of one of the greatest epileptic colonies for twenty five years (Bielefield) is that the bromide of potassium is the best salt having the least irritating effect upon the gastric mucosa. It is a pity that it cannot always be obtained in pure form, for as ordinarily sold it has impurities, like chlorate of potash, to the extent of six per cent. I hope some chemist will undertake a careful comparative analysis of the various bromides in our market, as it is very important that a pure drug be employed.* The bromide of potash may be prescribed in powders of ten to fifteen grains each, to be taken with plenty of water after meals, or may be given in a solution in water simply as follows:

as a rule better in the nocturnal form to prescribe either an extra dose at night or the whole amount of forty to sixty grains in one dose at bedtime in a full glass of water.

While children will bear large doses of bromide fairly well, it is better in those from ten to sixteen years of age to begin with ten grains three times daily and under ten years still less.

Each week an additional dose should be added for three or four weeks, the object being to push the drug to the limit of physiological tolerance-very nearly to the state known as bromism. But extreme discretion must be used in the early part of the treatment to discover the patient's susceptibility to the remedy, and to guard against its harmful effects.

Chloral may often be advantageously combined with the bromide (Seguin), particularly in cases with a tendency to severe cutaneous eruptions, and when thus administered the bromide itself should be proportionately reduced.

Where indicated, other agents may be employed for concomitant conditions-iron for anaema, arsenic for the acne, and saline waters and salts for constipation.

To sum up in a brief sentence the treatment for epilepsy in general of all forms must consist of careful regulation of the diet, hydro-therapeutic measures, out-of-door employment and the bromide of potash.

Occasionally there are cases that do not do well on a bromide. To these may be given borax in fifteen to twenty grain doses three times daily after eating, or lactate of zinc seven to twelve grains at a dose. 'Tincture of simulo will at times be found useful in one to two drachm doses (Starr).

In petit mal I have seen excellent results from the use of nitro-glycerin in doses of 1-100 of a grain three times daily.

In the nocturnal form tincture of belladonna five to ten minims, or atropine 1-130 grain alone is at times. strikingly effective.

For patients who feel their attacks coming on, we are in the habit at the Vanderbilt Clinic of providing a wide mouthed glass-stoppered bottle containing nitrate of amyl in a plug of cotton. When an attack is impending the patient smells of the vapor and often in this way wards off a seizure or diminishes its severity.

Whenever a case is taken in charge, he should be provided with a blank form, upon which not only should the patient register his attacks as they occur, but the physician should write his regulations for baths and diet, and put down in cipher for his own use his treatment; the blank to be returned to the doctor in charge at the end of a year. I have had made for my own use a special form of blank by G. P. Put

nam's Sons, of New York, which is exceedingly serviceable. It is printed on a heavy paper so that it will not wear out when carried in the pocket for a year, has spaces for monthly notes of treatment, for a daily record of attacks, for a monthly, half-yearly and annual statement of the number of seizures, for the orders as to baths, and, furthermore, the proper regulations as to diet and kinds of food are printed upon the back of the register. I should be happy to send a sample of this epileptic record to any one who desires it, or application may be made to the publishers.

201 West 54th Street, NEW YORK.

THE HYGIENE OF THE MILK QUESTION. BY W. THORNTON PARKER, M. D., M. M. S. S. MEMber of the ACADEMY OF HYGIENE, FRANCE. The erection of a superb institution, devoted to the science of hygiene, which has lately been dedicated in Philadelphia, marks an era in our National development well worthy of serious attention. It has long been a popular belief that the American greed for the accumulation of money was so universally predominant that any serious move in the interest of preventive medicine, popularly known as hygiene, would be forced to wait patiently for some opportune time for action. We have seen the light of the dawn of this great movement gradually appearing, but it is yet early in the day, and much must be accomplished before the bright sunshine of hygienic knowledge shall have made itself generally discernible. Through the labors of many faithful sanitarians, ably seconded by the general medical profession, a tremendous amount of good has been accomplished; so much, in fact, that we can only realize the benefits by looking back at sanitary science as we understood it 25 years ago. In this manner we discover how much has been won in the battle against uncleanliness and disease. The war has begun, but the obstacles to be overcome seem well-nigh insurmountable; it is a long way before we can hope to obtain victory.

For his welfare man needs pure fresh air, pure water, wholesome food, suitable clothing, healthful occupation, pleasant surroundings, security against injustice and wrong. Of all these subjects, which are so interesting to the hygienist and sanitarian, the question of food is not the least important. The fourth annual report of the State Board of Health of New York, published at Albany in 1884, is a valuable document, and among the many chapters on sanitary matters is one relating to "Milk and Its Adulterations," by Edward W. Martin, which deserves wide circulation. When we consider to what a large extent milk is used as food, and from how

many sources the supply is derived, it would seem to be high time that some means were adopted to protect the community from dishonest and careless venders of this most important nutriment. The penalties attached to the sale of adulterated groceries and of meat are being more carefully attended to each year, but milk, whose proper care requires the greatest faithfulness, honesty and intelligence, seems to have been wellnigh overlooked. The adult can more easily detect and repulse unwholesome groceries and meat, but the tender infant, helpless to express its dislike, and totally unconscious of danger, swallows the liquid which is capable of destroying its life. Few seem to realize the serious dangers existing in our common milk supply, or appreciate how carefully the precious food should be handled.

After making nutrition a most careful study for years, we return to milk as the most perfect and convenient food possible, either in health or in disease. It is well-known that a very great proportion of milk. offered for sale is adulterated, and the means used to accomplish this end baffle the most careful analysts. Pure water is by no means the most frequent adulteration used, and when water is employed to increase the amount for sale, it is apt to be taken from unhealthy country wells, or even from shallow convenient streams containing death-dealing products.

Many families, ordered to the country for the sake of some unhealthy child, and where milk had been ordered as the principal prescription next to fresh air and exercise, would shudder to discover where the milk, they willingly pay a large price for, spent the night.

Often it has happened to me in visiting the homes of country patients, who sold milk in the neighboring villages, to be startled by the discovery that the place used for storing the milk in pans was close to the privy, where the poisonous atmosphere could find ready access to the room containing the milk. I have also noticed that the windows of the milk room would be quite near a manure heap or surface drain. In houses where I have been called to treat diphtheria, scarlet fever, typhoid fever, and other diseases, I found the milk closet close to rooms containing the sink, and the poisonous smells having free access to the fluid which would be offered for sale in countless houses hours later on. The water used for cleaning pans is often very dirty and poisonous, but the great danger is from the ready absorption of poisons conveyed by means of the atmosphere; and milk, the most precious of foods, seems to possess a dreadful readiness to absorb every poison which can be so conveyed. The substances used in adulterations are often very unhealthful, and the water supply of those living in the country is notoriously bad. In the Sanitarian for February, 1884, is an article copied from

the Practitioner, concerning milk as a vehicle for infection. The following table may illustrate the remarks which I have just made concerning this dan

ger:

Coal gas..
Paraffine oil....
Turpentine.
Onions..

Tobacco smoke.
Ammonia..
Muck....
Assafoetida.
Stale urine.
Creosote.
Cheese, stale.
Chloroform..
Putrid fish.
Camphor....

Decayed cabbage....

Smell in Milk. . Distinct. .Strong.

Very strong.

Very strong.

Very strong. Moderate.

Faint.

Distinct.

.Faint.

.Strong.

Distinct.

Moderate.

Very bad. Moderate. .Distinct.

In several other instances the sense of smell was not alone relied on. Sulphuretted hydrogen, in addition to giving rise to a strong smell, indicated its presence by means of a black precipitate with sulphate of iron and ammonia.

"Human fecal matter gave a strong scent to the milk, and a black precipitate, indicating the presence of sulphuretted hydrogen, was produced on addition. of ammonia and sulphate of iron.

"It thus became obvious that the milk had absorbed the emanations of all the substances to which it had been exposed, and it further transpired that all the specimens examined retained their distinct odors for as long as fourteen hours after their removal from the glass jar in which they had been exposed."

It has been repeatedly proved that milk is not only capable of absorbing these poisons, but various diseases have been communicated in this manner, such as small-pox, diphtheria, scarlet fever, etc. Not long ago, several cases of typhoid fever occurred on a very healthy street, and it seemed quite impossible to detect the cause, until it was discovered that the cows, from which the milk had been taken, drank of a stream contaminated by fecal matter. Country people do not feed their cows properly in many cases, and I know of several well educated people who supplied swill, and in summer months, too, to their cows. little child, under my care, was fast losing strength by reason of intestinal disturbances, until I ordered the milk supply changed, having discovered that the cow from which the milk had been received was fed on swill. Any water is considered, by many, good enough for cows, for will it not all be filtered before it becomes milk? In the typhoid cases, already mentioned, this even is demonstrated.

A

Milk is kept too long in the house after milking,