his abdomen, the incision about six inches in length, extending transversely across the abdomen at a point about two inches below the ensiform cartilage, a large amount of omentum and bowel protruding and bleeding profusely. He was carried to the hospital, where an anesthetic (chloroform) was admin

istered by DR. MORSE. After the hemorrhage from the omentum had been controlled by securing and ligating several blood-vessels, it was found necessary to enlarge the opening for the purpose of making a more thorough examination of the contents of the abdominal cavity. I then made an incision in the median line downwards to, and a little to the left of, the umbilicus, which revealed a condition

often suspected in cases of insanity where visceral illusions are present, but where the opportunity of corroborating one's suspicions is usually wanting, namely, a portion of the omentum firmly adherent to the inner surface of the abdominal walls. While examining the intestines for any perforations, a small quantity of but partially digested meat and potato escaped into the cavity. Upon investigating the source of this I discovered an opening in the walls of the stomach large enough to permit of the passage of two fingers into the cavity, also a laceration about four inches in length, extending diagonally across the anterior surface of the organ, involving both the serous and muscular coats. It was through this opening that the articles of which his breakfast had consisted escaped. The laceration and opening were closed by using a sterilized Chinese silk suture-a modification of the Lembert suture being used. This consisted of taking the stitches in the same manner as a Lembert, but making them continuous, in preference to the interrupted method. By doing this close apposition, with inversion of the edges of the serous surfaces, was secured. A careful inspection of the whole alimentary tract was made, but no other openings were found. The cavity was then irrigated with a hot solution of boracic acid, two per cent., about two gallons being used. The recti muscles, where he had lacerated them with the case-knife, retracted in their sheaths to such an extent, and had been severed so close to the lower border of the ribs, that to have secured and sutured them would have prolonged the operation beyond a point which seemed at the time safe. The wounds were closed by means of deep and superficial sutures, a drainage tube being placed in the transverse incision. Antiseptic dressings were applied, and the patient was placed in bed, being restrained to prevent his moving about should he become restless. Throughout the operation I was assisted by the other members of the asylum medical staff.

The same afternoon his temperature was taken and read as follows: At 3 o'clock in the afternoon, 100° Fahrenheit; 4 o'clock in the afternoon, 101 1-5° Fahrenheit; 5 o'clock in the afternoon, 101° Fahrenheit, with respiration slightly accelerated and pulse rate 120 per minute. The first night he vomited slightly, no blood being present in the ejecta. Nothing of a liquid character was permitted to pass his lips until the afternoon of the 24th-being just one day after the operation; and then water in teaspoonful doses was administered every hour. The drainage tube was removed on the second day following the operation, the wound presenting a perfectly healthy appearance. On the third day it was noted in case book that he had rested well since the operation, had not complained of pain, but requested to be allowed a more liberal supply of water. Nourishment was then ordered, in the form of beef meal, one teaspoonful to a tumblerful of milk, given in tablespoonful doses every half hour, and the quantity of water increased to a tablespoonful every thirty minutes. His bowels not having acted since the operation, an enema was given, with good results. His temperature was then 99° Fahrenheit, and pulse 72. From this time up to August 1-just seven days following the operation - he was comfortable; temperature had not registered above 100° since the first day, and pulse was then 72 per minute and temperature normal. There was a discharge from the wound of a grumous fluid mixed with oil globules and a small amount of necrosed adipose, the subcutaneous fat being over one inch in depth in the neighborhood of the wound. August 5 the sutures were removed, and edges

A

appeared to have united firmly. From this time on he improved rapidly, and was allowed to sit up and go about the hall one month after the operation. body bandage about eight inches wide was worn for several weeks, until the walls seemed firm and strong. After the bandage had been dispensed with the presence of a hernia, at first quite small, beginning at the point where the recti

SIDE VIEW-Showing protrusion of abdomen nineteen months following operation. muscles were severed, was noticed. This hernia has slowly but steadily increased until, as you see him to-night, almost the entire stomach is included in the prolapse. After he has partaken of a meal the organ can be mapped out quite easily. His appetite is excellent and he suffers but little inconvenience from the hernia. At present he wears an abdominal bandage. He goes out of doors

quite regularly and is able to take the usual walk of about one and one-half miles twice a day without being fatigued.

That the act of self-mutilation was not a deliberate attempt at suicide, but the logical outcome of his illusions, which were founded upon the drawing sensations experieneed in his abdomen as a result of the adhesions present, I feel firmly convinced. He had undoubtedly reasoned that if his body were inhabited by another being, that that being should be set free and himself relieved of an uncongenial companion. Cases occasionally occur in asylum practice in which patients who, as a result of adhesions following peritonitis or pleurisy, develop the illusion that some object inhabits their body. Two cases of this nature, for an account of which I am indebted to DR. E. A. CHRISTIAN, will serve to show what such pathological states have to do with the mental condition of patients. The first case was that of a man admitted in August, 1878. At that time he believed that a mouse was located in the right side of his abdomen, and repeatedly struck himself severe blows in the hope that he would get rid of his unwelcome visitor. This illusion lasted until his death, which occurred as a result of tubercular peritonitis, four years following his admission. The post-mortem examination revealed the presence of both acute and long-standing tubercular disease of the peritoneum. The peritoneum was thickened and the bowels matted together, the adhesions being so firm as to prevent separating the coils of intestines without lacerating the walls. Everywhere upon the bowels and peritoneum were small tubercular masses of a grayish white color, varying in size from a head of a pin to twice that size. What had once been the great omentum was then but a fleshy mass of about one and one-half inches in width and onequarter of an inch thick. It was as firm as muscular tissue, and extended diagonally across from the greater curvature of the stomach to a point opposite the anterior superior spine of the ilium, where it was firmly united to the peritoneum lining the abdominal cavity. This condition unquestionably gave rise, from the irritation which it set up, to the illusion regarding a mouse which he had at the time of his admission.

The second case, that of a man who was admitted in September, 1878. At that time he believed that his brother, sister-in-law, and a priest were in his abdomen. This illusion remained until death, which occurred in August, 1885. He experienced a severe chill, accompanied by slight distension of abdomen, dying within forty-eight hours. At the post-mortem held six hours after death, there were found no pathological conditions to account for death. The bloating of the abdomen was due largely to a constriction of the lower part of the descending colon, which would not permit of the passage of the little finger. This condition is believed to have been due to an old colitis. The illusion in reference to his brother, sister-in-law and priest being in his belly can be accounted for by the pain and peculiar sensations which he would experience every time that gas or fecal matter passed through the constricted portion of the colon.

It is reasonable to presume that the patient before you to-night has experienced sensations in his abdomen as the result of adhesions of the omentum, discovered during the operation, which he has attributed to the presence of another being, he having on several occasions stated that he did it to "let the fellow out." At present he excuses his conduct by saying that his brain must have been wrong at the time, or he would not have committed the deed.

THE COOL BATH TREATMENT OF TYPHOID FEVER.*

BY COLLINS H. JOHNSTON, A. M., M. D.,

VISITING PHYSICIAN TO SAINT MARK'S HOSPITAL, GRAND RAPIDS, MICHIGAN.

MANY statistics have been collected showing the mortality of typhoid fever under various methods of treatment. But all writers with whom I am acquainted freely admit that the cool bath treatment introduced to the profession by DR. ERNEST BRANDT, of Stettin, thirty or forty years ago, gives unquestionably the lowest mortality rate. Becoming convinced of the usefulness of this treatment, I began using it in both hospital and private practice two years ago, since which time all of my hospital cases, and almost all of my private cases of typhoid fever, have been subjected to the cool bath treatment. During the past six months it has been the routine treatment for all cases of typhoid fever at Saint Mark's hospital, with but very few exceptions.

For various reasons this method of treating typhoid has not met with much favor in America until recently. One reason for this has been that American textbooks on the "Practice of Medicine" have either entirely condemned it, or damned it with faint praise. Even as recent a writer as OSLER, in his work on "Principles and Practice of Medicine" published last year, after stating that the BRANDT treatment is rigidly carried out in his service in Johns Hopkins hospital, says: "This rigid method is not, however, without serious drawbacks, and personally, I sympathize with those who designate it as entirely barbarous. To transfer a patient from a warm bed to a tub at 70° Fahrenheit, and to keep him there twenty minutes or longer in spite of his piteous entreaties, does seem like harsh treatment; a majority of our patients complain bitterly, and in private practice it is scarcely feasible.”

Recent utterances, however, of some of our leading writers show a gradual change of feeling on the part of American physicians in regard to this most useful treatment. DR. WILLIAM PEPPER, who failed to describe the method and its splendid results in his "System of Medicine," admits 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." ALFRED L. LOOMIS, who was formerly opposed to the BRANDT treatment, taught its value to his students in his last course of lectures, and H. A. HARE, in his recent work on "Therapeutics," says: "The BRANDT treatment should be practiced whenever it is pos sible to do so, as by it is gained a mortality one hundred and fifty per cent. less than by any other known method."

Another reason, I think, why this treatment of typhoid fever has not become more rapidly popular, is, that the descriptions of the method, even when published by its friends, have so often been inaccurate. For instance, HARE, in his "Practical Therapeutics," page 587, says: "The method consists in immersing the patient every three hours in a bath at the temperature of 85° Fahrenheit, or as low as 75° Fahrenheit, if necessary, and allowing him to remain in the water until the temperature fall to 1004°, or 101°, the bath being used with the frequency named as long as the temperature is above 102°." BRANDT, however, immerses his patients in water of 65° Fahrenheit, and allows them to remain, as

* Read by title before the MICHIGAN STATE MEDICAL SOCIETY, May 12, 1893, and published exclusively in The Physician and Surgeon.