Hypnotic Effect of Warm Bandages.— Warm baths, as is well known, produce a calming effect, and tend to bring on sleep, and Alldorfer has attempted to apply such a method in patients where a sedative effect is desired and yet where a bath is inapplicable. His method consists in wrapping the lumbar region and belly with linen cloths soaked in. warm water, and then covering them with oiled silk or rubber cloth, so as to prevent evaporation, while the whole is kept in place and loss of heat prevented by a flannel cloth. This procedure is of ready performance, and the author says that by this simple means he has obtained the most astonishing results in the treatment of insomnia. By dilating the large vessels of the intestinal tract, by the warmth applied, a condition of anæmia of the brain is produced, favoring sleep. These large intestinal vessels have very properly been termed the waste-gates of the circulatory system.-Jour. de. Med. de. Paris.

Tobacco Smoke.-A large number of investigations have been made by Dr. Tassinari on the influence of tobacco smoke on the germs of cholera, anthrax and pneumonia. His method of research was to line the interior of hollow balls with gelatine containing the germs of the diseases named; tobacco smoke was then passed through these globes for from ten to thirty minutes. The surprising fact was then established that at the expiration of that time the bacilli of true Asiatic cholera and pneumonia were completely destroyed, whatever the kind of tobacco employed for the purpose. The gelatine was absolutely sterilized by the tobacco smoke. The anthrax bacillus was more resistant, however, while the bacillus of typhoid was scarcely acted on at all.Medical Record.

Science and Woman.-Professor William James, of Harvard, announces that woman develops early and then ceases to grow mentally. Professor Crichton Browne finds that women's brains are smaller

very

than men's, and their frontal lobes less richly supplied with blood. Professor Lombroso finds that women are less sensitive than men, and, as regards their receptive and perceptive organs, represent an incompletely developed type. Altogether science is bearing down hard on the ladies. Yet we do not learn that they are becoming any the less popular. The poet has said metrically that without them the extremes of life would be without solace and its middle without joy. The testimony of the poet will probably continue to be received by the mass of humankind, even if the greatest cranial circumference of the gentler sex never rises above fifty centimetres.Medical Record.

A Préscription for Young Physicians. --According to the British Medical Journal, a distinguished Vienna professor gives the following prescription to all young physicians who call to take leave of him before embarking on their professional career; R. Veritatis, humanitatis, fidelitatis, a. a. infinitum. Misce. Ft. elixir vitæ. Signa: To be used constantly throughout life. It is easy, perhaps, for most men to start with a good stock of this spiritual elixir, but the difficulty is to find an apothecary who can dispense the prescription when the supply has run out.-New York Medical Journal.

IN the chapter on "Brain and Nerve Foods," contained in his recent work on "Nerve Waste," Dr. H. C. Sawyer gives the following unsolicited testimony to the value of Walter Baker & Co.'s cocoa : "Baker's breakfast cocoa is a light preparation which. can be heartily recommended; it contains only so much fat as can be digested by almost any one; and is peculiar in not cloying or palling after a time, as so many cocoa preparations do. Such a beverage is far more wholesome and more agreeable, after one becomes used to it, than tea, which is much over used. It is especially useful for children; our little boy has drunk it since he was a year and a half old, has become inordinately fond of it, and has kept as 'fat as a pig,' as we say."

Housework.-To keep the complexion and spirits good, to preserve grace, strength, and agility of motion, there is no gymnasium so valuable, no exercise more beneficent in its result, than sweeping, dusting, making beds, washing dishes, and the polishing of brass and silver. One year of such muscular effort within doors, together with regular exercise in open air, will do more for a woman's complexion than all the lotions and pomades that were ever invented. Perhaps the reason why housework does so much more for women than games, is the fact that exercise which is immediately productive, cheers the spirit. It gives women courage to go on living and makes things seem really worth while.-Medical Record.

The Sultan of Turkey is said to be suffering from pulmonary phthisis. His mother died of the disease, and he developed symptoms of the incipient affection when quite a young man, but was supposed to have been entirely cured.

We offer in this issue of the GAZETTE, page xiv., our first premium list. Physicians will find these instruments the best of their kind that are made.

Contributions and Selections.

A CASE OF GASTRIC HYPERAESTHESIA
AND GASTRALGIA WITH REMARKS
UPON ITS DIETETIC MANAGEMENT.
BY FRANK WOODBURY, A.M., M.D., PROFESSOR OF
CLINICAL MEDICINE IN THE MEDICO-CHIRURGI-
CAL COLLEGE; PHYSICIAN TO THE
MEDICO-
CHIRURGICAL HOSPITAL; FORMERLY PHYSICIAN
TO THE GERMAN HOSPITAL OF PHILADELPHIA,
ETC., ETC.

age,

The following clinical record of a patient in private practice, serves to illustrate some of the difficulties of diagnosis and of treatment that may be encountered in a case, the leading features of which are paroxysmal pain in the stomach, gastrodynia or gastralgia, with vomiting and progressive anemia. Mrs. about thirty-five years of married for ten years, the mother of four children, of whom two were living and healthy; one was still-born and one died with summer diarrhoea at the age of four months. Naturally of strong constitution and good physical development, she usually had perfect health, except on two occasions; one was an attack of typhoid fever when about sixteen years of age, the other was, when on a visit to the South she contracted a severe malarial poisoning. At that time she had congestive chills, and since then had had several returns in the form of irregular intermittent. No other personal or family morbid taint was discovered.

At the time of observation she was entirely unable to partake of food, because as soon as it was swallowed she suffered such paroxysms of pain as frequently to almost produce convulsions. She dreaded the very idea of eating; and preferred starvation to the suffering which always followed an attempt to take any form of food. She begged that she should not be asked to swallow any nourishment. Even the blandest articles of diet would cause such suffering as at times to simulate peritonitis. This condition had

come on gradually within a couple of months, until it was now so severe as to cause the gravest apprehension. The pain would come on almost immediately after eating. After the paroxysm had lasted for ten or twenty minutes, or even longer, vomiting and retching would occur, and the food rejected in an undigested condition; but the pain and soreness would continue for hours, and then subside gradually. At no time was there vomiting of blood. The chief site of pain was over the centre of the large curvature of the stomach, between the umbilicus and the ensiform cartilage; where there was also an area of great tenderness. Even the skin was excessively hyperaesthetic over this spot. No tumor was distinguishable, even upon deep palpation. Uterine functions were normally performed, and there was no local lesion or malposition. There was well-marked anemia, and loss of adipose; the bodily weight had suffered a steady decline, and she appeared to be wasting away, having lost over forty pounds within less than six months. There was no alteration in temperature or pulse, except that the latter was small, deficient in force, and became rapid under excitement.

In spite of the loss of flesh and evidence of denutrition, there was no marked appearance of neurasthenia or hysteria. Other than paleness there was no change in the color of the skin; there was no jaundice, and no discoloration such as accompanies internal cancer. She had sleepless nights, but during the day was not confined to bed, but was able to go about, although her strength had failed to a considerable degree. She was seen by several physicians who, after examining the case, and taking its salient points into consideration, adopted different views of its nature. Among the diagnoses suggested were gastric ulcer, painful cieatrix from previous and latent ulceration, simple gastralgia of functional type; gastralgia, due to malarial poisoning; duodenal ulcer, gall-stones, cancer of the pancreas, or of the stomach (non-ulcerative), dyspepsia, hysteria, etc.

The subsequent course of the case excluded all

forms of malignant disease. It is true that no tumor could be detected; but it is a clinical fact that in carcinoma of the stomach this physical sign is often wanting, especially in the early stage. Vomiting of blood was also not present; but neither is this always encountered in malignant disease, and many cases of gastric ulcer run their course from beginning to end without evident hemorrhage; or the hemorrhage may be of late symptom. On the other hand, haematemesis may occur in hysteria due to capillary oozing, without more serious lesion. Dyspepsia is at the present day only a symptomatic diagnosis, and, by itself, is unsatisfactory. Moreover, there had been no digestive disorder previously; her digestion had always been good and has been equally good since her recovery. Hysteria is a convenient diagnosis. In fact, the only question when a woman is sick is, "How large is the hysterical element in the case?" and not "Is it a case of hysteria, or not?" What is usually meant by hysteria is a purely psychological affection. But as Weir Mitchell has observed, the nutrition of hysterical patients is usually kept up and does not fail.

The present case was ema iating rapidly, and had lost some forty pounds. At the same time the possibility of the hysterical element will not be denied, but as it is a constant factor in the problem it may be disregarded. With regard to gall-stone, the case did not present the clinical picture of biliary colic; there was no tumor, no jaundice, no deficiency of bile in the stools, no sudden relief from pain. With regard to the rest, the diagnosis is divided between a pure neurosis and an ulcer, either actual, or healed leaving a cicatrix which in contracting had involved some nerve filaments, and this had caused hyperæsthsesia.

The fact that the patient was not a neurotic subject, and had never been subject to nervous attacks or neuralgia, and has not had any since, is decidedly against the theory of a functional, visceral neurosis. The tendency of the attacks to occur at about the same hour each night, even when no food had been taken, was, at least, suggestive of the continued activity of the malarial poison. The possibility of a malarial element, therefore, cannot be disputed; like the hysteria, however, it had to remain sub judice, and is stil unsettled. With regard to ulcer either in the stomach, or duodenum, it can only be said that the classical symptoms were not present. It is true that there was sensitiveness of the skin and great tenderness manifested upon deep pressure, but the pain did not increase with the pressure, which fact was more in favor of hysteria than of gastric ulcer. The suffering was also more acute than it ordinarily is in ulcer, and it occurred not only after taking food, but when the stomach was empty. The suggestion that a tender cicatrix from previous latent ulceration existed, was an highly ingenious hypothesis which could neither

be disproved nor confirmed. The safe diagnosis, therefore, and the only one possible under the circumstances, was that of hyperesthesia of the stomach with gastralgia, and emaciation from deficiency of nourishment, or inanition.

The therapeutic problem was twofold. First, to relieve pain; and, secondly, to improve nutrition.

In order to overcome pain, recourse was at first had to opiates, which afforded no apparent relief, and only threw the patient into a stupor. The bromides were likewise of no avail. Valerianates produced no effect. Ice gave temporary relief after swallowing small pieces. After trying pepsin, bismuth, hydrocyanic acid and other usual agents, the idea came to me that carbon dioxide might afford the desired relief. Effervescing waters were found to be grateful. Champagne was given, and a quart was consumed the first night with decided temporary relief. It was not vomited, and the pain was found to be not so severe. It was subsequently discovered that a light lager beer had even better effect; as it was retained the pain ceased and a good sleep followed. Having found out how to control the pain, she was directed to drink three or four bottles of beer daily, not only for its anodyne effects, but because of the value as a tonic and nutritive.

The problem of improving nutrition was a complete failure until the beer was given. Nutritive enemata had been practiced for a time, every four hours, but were abandoned after commencing the beer. After trying to add various articles to this, it was found that she could not take anything in the way of food until bovinine was given, which caused no disturbance. For a period of five or six weeks she subsisted entirely upon a teaspoonful of bovinine every four hours, and about four bottles of beer daily. At the end of this time she began to eat ice cream and a litthe sponge cake or fresh water crackers, light broths, and ultimately completely regained her ability to digest food, and has since been in good health, and is now as robust as ever. Less than two years after her attack of gastralgia she was confined, and her last child is stronger and more active than the others. She attributes her recovery to bovinine, but the beer certainly deserves part of the credit.

In conclusion, I may state that I commonly order bovinine to be given with malt liquor as a vehicle, either in the form of beer, or the now fashionable diastatic extract of malt.

218 So. 16th St., Phila.

Dr. W. Thornton Parker has accepted the invitation of the Faculty of the College of Physicians and Surgeons, Chicago, to deliver the course of lectures on Medical Jurisprudence, during the approaching session of 1892-3.

TREATMENT OF TYPHOID FEVER.

THE LESSONS OF A NOTABLE DISCUSSION. The first earnest appeal in behalf of the systematic Brand treatment of typhoid fever was made in this country before the New York State Medical Society in February, 1889. The echoes of this appeal are now resounding through the land, and the first fruits are coming in from the harvest of good work. Our heart is made glad by the tidings from an association which numbers among its members the elite of the physicians of internal diseases in this country.

Dr. Wilkins, of Montreal, presented a paper before the American Association of Physicians on the "Treatment of Typhoid Fever by Cold Baths," which demonstrated that even in that cold climate they are no longer afraid of cold water. Thirty-nine cases are reported, with a mortality of two. Despite the fact that "during the first six months he adopted the method of Liebermeister" (whose object, as is well known to those familiar with the history of bathing in typhoid, is the reduction of temperature, and which has now been abandoned by this able clinician in favor of the strict Brand bath), and that only lately has he " adhered to Brand's method, with slight mod ifications," Dr. Wilkins' results are far better than those obtained by the fatal expectant method or by the objectionable medicinal antipyretic treatment, whose chief advantage seems to be that the patient is able to die with an almost normal temperature.

The ideal results of the Brand method were not attained, however, in Montreal, simply because the method was "slightly modified." And it is upon And it is upon this point that we may draw a valuable lesson-viz., that, while an approach to the Brand method may furnish an approach to its good results, an exact adherence to it must furnish the same favorable clinical results here as it has done abroad. As Dr. Kinnicutt wisely insisted in a discussion before the Practitioners' Society of New York, statistics of the exact Brand method have, except in a few isolated cases, not been attempted in the United States, and, therefore, we cannot form a correct estimate of its results.

Dr. Wilkins' effort is valuable, as it only testifies to the unwillingness of the profession to follow Brand's method with precision. "I seldom keep the patient in the bath longer than ten or twelve minutes," says Dr. Wilkins. Brand seldom keeps the patient in the bath a shorter time than fifteen minutes. A difference in the result must ensue from one-half or onefifth shortening of the duration of a bath which has been ascertained to approach as nearly as possible perfection in detail and technique, judging from its clinical results. In another detail, such as the temperature of the bath, Dr. Wilkins deviated from Brand's express rule, which is, for an average of cases, 65°. "In thirty-one cases the temperature of the bath

was 68° to 70°; in the remaining cases, 80°, reduced to 68°. Dr. Wilkins has "not yet adopted the routine of treating every case of typhoid by cold baths"; he "treats mild cases on the expectant plan." This is again in opposition to Brand, who justly claims that all cases should receive the bath treatment when the temperature reaches 102°, etc., because no one can foretell how soon "a mild case " may become complicated. While we grant that it is not rational practice to adhere to a hard-and-fast rule in the treatment of any disease, we must urge, with all the force in our power, that it is unjust to claim that Brand's treatment is adhered to when a few conditions only are really fulfilled. As Brand has again and again insisted, a large number of cases, twelve hundred, in his own practice and that of Juergensen and Vogl, have demonstrated that, whenever the ideal treatment, baths at 65° when the temperature registers 102°, begun before the fifth day, is strictly pursued, there is absolutely no mortality. Startling as this proposition may seem, we have the clinical proof from these trustworthy sources, coming from private and hospital practice. We realize the difficulty of conforming to all these conditions, the chief and most difficult of which is the early beginning of the treatment. But it is the ideal towards which all our efforts must be bent. If, instead, we deviate from it, we must not be surprised if our results deviate equally from those attained by the clinicians quoted. We say this in all kindness, and not for the purpose of captious criticism, but in the interest of suffering humanity, to alleviate which the paper of Dr. Wilkins is a

valuable contribution.

Dr. Osler's experience offers a good lesson also. "From the opening of the Johns Hopkins Hospital, 1889, till July 1st, 1890, thirty-two cases were treated symptomatically, with seven deaths. From July

1st, 1890, til February 1st, 1892, there were one hundred and seven cases treated 'rigidly' (?) by the Brand method. The temperature of the bath was 70°; the patients were bathed every three hours when the temperature rose above 102.5°. There were only eight deaths. The death rate is practically that which has been obtained by the Brand method in all the general hospitals in which it has been employed-about seven per cent." When so learned and conscientious a man as Dr. Osler tells an audience of intelligent physicians, without contradiction, that he rigidly followed Brand's treatment by using baths of 70°, we deem it our duty to call attention to the error. Brand distinctly says that "the temperature of his baths varies with a number of circumstances, amongst which the most important is the intensity of the fever and the resistance it offers to the cooling process. There are, however, limits which should not be transgressed, 15°-20° (59°-68° F.)."

Dr. Pepper's contribution to the discussion pays a just tribute to our venerable and honored contributor, "Dr. Hiram Corson, of Pennsylvania, who has advocated and practised cold water treatment of the infectious diseases for the past sixty years in opposition to all kinds of criticism." This is a deserved tribute to a man who was the pioneer of hydrotherapy in America, and to whose practical writings on the subject we personally are indebted for conversion to the hydriatic treatment of acute diseases. Dr. Pepper testifies to his "own progressive conversion to belief in the treatment and the desirability of its use in the vast majority of cases of typhoid as a routine treatment." He justly emphasizes the importance of friction during the bath, upon which we have so often laid stress in discussions.

Dr. W. G. Thompson expresses just surprise that the author of the paper did not dwell with more emphasis on friction. We have seen a strict (?) follower of Brand bathe a typhoid patient without friction, and express his surprise when, in answer to his inquiry if the bath had not been à la Brand, he was informed that the most important element, friction, had been omitted. We will be pardoned for quoting fully from Dr. Thompson's remarks a point which we often endeavored to emphasize years ago. "It does not seem to me," says Dr. Thompson, "that the reduction of the temperature is the principal good obtained." Whenever the profession will realize that the "principal good" of the bath is in the endowment of the system with power to resist the inroads of the disease by the refreshment of the central nervous system resulting from it, we will hear less of the fallacious antithermic conception of the bath.

Dr. Tyson relates a case, admitted on the tenth day of the disease, which died of peritonitis due to perforation, and argues from this one case that "the cold bath treatment evidently does not prevent perforation." We have ample statistical evidence on this point. Murchison's statistics of 1,271 cases give 196 cases of perforation (11.38 per cent.), while Brand's 4,884 cases furnish only 12 perforations (0.24) per cent.). Brand never claimed that ulcerations and consequent perforations can be prevented, unless the method is rigidly adhered to; one prime condition is the early treatment of the case (before the fifth day). He claims that the latter confines the pathological changes to the stage of infilteration, and he furnishes one autopsy in proof of this fact. But the most conclusive evidence of the correctness of his view may be obtained from the influence of the bath treatment upon the intestinal condition, as manifested by the symptoms. There are fewer cases of diarrhoeas and less meteorism, as shown by Vogl's statistics. In the second division of the Munich Garrison Hospital, in which a "combined treatment, consisting only in part

of baths, was used, the average number of diarrhoeas per person per day was 1.9, while in the first division, in which the rigid Brand method was pursued, the number was 0.7 per person per day." Vogl explains this remarkable result by insisting that the cool baths have not an antipyretic effect only, but that by their influence on the circulation they furnish the necessary conditions for the afflicted organs-such as the glandular structure of the bowels-to protect themselves, so that the pathological process will stay within certain changeless limits; the bathing process makes out of a severe case a mild one. "Just as in other organs and tissues," says Vogl, "an improvement in the blood current-i.e., its equalization-is brought about by the tonic action of the cold bath, so it happens in the mucous membrane of the intestines. A shortening of the course of the disease through the annihilation of pathogenic organisms by some thermic effect of specific abortive action cannot be ascribed to the cold bath treatment; this method only keeps up the vital processes in the diseased and endangered tissues, which is, of course, the more readily possible the less the physiological conditions in the diseased parts are disturbed." It were well if these golden words were deeply engraved upon the memory of every man who treats a case of typhoid. The mortality, in private practice especially, would be enormously diminished. It is so constantly urged that as it is impossible to diagnose typhoid fever positively before the sixth day, Brand's rule to treat the case before the fifth day is impossible of fulfilment. By adopting the rule to bathe all cases of fever whose type is not clear, from the beginning, no harm can be done, and, in the event of typhoid developing, we have clutched the enemy at the throat, as it were, and are able to throttle him by slow and steady tightening of our grasp until he yields to our power. This is no idle theory, for it has been demonstrated by the writer in practice. In the hospital it is usually impossible to begin treatment before the fifth day, but even here the rule we adopt in the Manhattan Hospital-that the house physician subject every suspicious case with a temperature of 103° or over at once to the graduated bath-has been of value, as evidenced by the case of pneumonia reported in Medical Record, page 321, March 22d, 1891.

That this can be readily done in private practice is evidenced by the case of Mr. W―, which the writer was called to see with Dr. E. Hochheimer last fall. With the acuteness of an experienced observer, Dr. H. diagnosed probable typhoid fever on the second day of the illness, and insisted upon the bath treatment. The writer confirmed this view of the case, which was further confirmed two days later by Dr. A. Jacobi. Thus a most intense case, with morning