most satisfactory one. All the tumefied masses disappeared, although nasal respiration is not yet restored. Interesting features in this case are: its long duration, sixteen years; the complete freedom of the larynx from the disease; the large size of the nose, and the failure of all other forms of treatment to give any relief.

Roentgen Injuries in Medical Radiotherapy. Jour. A. M. A., February 23, 1907.

Engel of Budapest discusses to some extent the by-effects of radiotherapy as reported in literature and observed personally. In cases of mediastinal cancer he calls attention to the fact that suffocation and weakness with nausea was sometimes observed, which he thinks likely of psychic origin. Sometimes he noticed a papulous exanthem, with high and intermittent fever. He thinks this probably of toxic origin, caused by a destruction of tissue preceding exfoliation. The action of toxins liberated by the exposures is probably the cause of the fever in Roentgen treatment of leucemia and pseudo-leucemia. He reports an intense toxemia developed after 350 minutes exposure in the course of eleven days. The patient was a man of 54 with enlarged glands and spleen, 2,223,000 red and 246,000 white corpuscles, the general condition being good. The spleen, the neck and axilla on both sides were exposed to a high vacuum tube for five minutes each daily. The reds dropped to 1,900,000 and the whites to 110,000, but the exposures were continued until the figures were respectively 1,620,000 and 55,000. Then the treatment was suspended. The patient rapidly grew worse and succumbed from weakness of heart and diarrhea. Before treatment the condition had been very chronic and progressed much more rapidly after the treatment, probably explained by the toxemia. Krause has reported a case in which exposures aggregating 3,650 minutes had been given without harm. Schenck has also reported a case of rapid deterioration under Roentgen ray treatment of febrile leucemia. He summarizes the cases of sudden death as occurring after a course of Roentgen ray treatment. Now he thinks that no treatment should last more than two minutes and that the tube should not be nearer than 20 cm., or more than four minutes with the tube 35 cm. He thinks the same surface should not be exposed more than two or three times the same day and the exposed surface should be protected with tin foil and the vicinity with sheets of lead. He thinks the patient's susceptibility should be ascertained by a few brief exposures. After five or six exposures treatment should be suspended for a week, during which time careful pictures should be made of the blood condition, and at the slightest indication of toxemia, the treatment should be suspended indefinitely.

Roentgen Treatment of Exophthalmic Goiter.

Rudinger concludes his study of albumen metabolism under Roentgen exposures in two cases of exophthalmic goiter, with the advice to make a single tentative exposure of the thyroid in every case. The results may justify further treatment in this line, he says; especially if the previously abnormal breaking down of albumen is replaced by retention of the nitrogen after the exposure as in his case.

HYDROTHERAPY.

EDITED BY CURRAN POPE, M. D.

The Routine Treatment and Complication of Typhoid Fever. By Ray L. Wilbur, M. D., Clinical Excerpts, October, 1906. The author calls attention to the variability in manifestation in different epidemics in different individuals at different ages and says that no definite rules for treatment are possible. He outlines somewhat in detail the diet and general measures to be followed and says:

"The most advisable plan for the treatment of a given case is the adoption of proper dietetic, hydrotherapeutic, and symptomatic measures. These, when carefully used, combined with absolute rest, and under the control of a good nurse, who has at her command facilities and orders for all ordinary emergencies, will not only give a low mortality rate, but will shorten the time spent in bed as well as add to the patient's comfort. After the patient has been put in a good bed, in a well-ventilated sunny room, and a competent nurse has been installed, the first duty of the physician is not only to provide careful written directions for all that is to be done, including the method of sterilization of discharges, and the signs and symptoms of the ordinary complications with their first treatment, but also to see that there are at hand the emergency drugs and supplies, including a simple saline infusion outfit, that may be needed. This involves a certain amount of expense, but in the long run will save time and life.

"Hand in hand with the feeding of the patient should go the administration of water, preferably plain, but some simple alkaline water such as Vichy if the urine is irritating. An effort should be made to give the water before the feedings and to keep track of the amount. Some patients will stand very large quantities and show a beneficial effect from its use. Its administration is logical and should be consistent. The addition of grape juice, weak tea or coffee to it will often make it more palatable and beneficial, particularly if the kidneys are inactive.

"Hydrotherapeutic Measures.-The simplest method for the reduction of the temperature is the combination of the abdominal coil and head ice-cap with sponge baths either cool, cold, or ice cold. While it is true that the benefit derived from the use of the coil is probably purely that of reducing the temperature, except perhaps in controlling the circulation of the abdomen, and not at all tonic or stimulating, as are the sponge baths, the combination of the two is most effective. Not only is one able to keep the temperature constantly from three-fourths of a degree to one and a half degrees lower than otherwise, but the sponges come less frequently and do not tax the patient so much. The coil should be kept on constantly, except perhaps for a short time in the morning, whenever the temperature is over 100° F. When the temperature is high it can be re-enforced with a second coil or a superimposed ice-cap. If the temperature rises over 102.5° or 103°, a tepid sponge should be given; if still higher a cold or ice cold sponge bath. If then the temperature is not affected, and the nervous symptoms are great, an ice pack or a sheet wrung out of ice water applied with fairly vigorous rubbing of the trunk and limbs is best used. Occasionally the coil is not well borne, particularly by fat, weak or anemic individuals, and its use should then be only partial or completely discontinued. In some cases even the sponging seems to do harm and to lead to continued cyanosis and chills. Such patients do better without the use of cold at all, and one for comfort need only remember the countless people alive today who have gone through typhoid, not only without water externally, but frequently with almost none at all internally.

The

"While the system of tub baths does admirably for hospital routine, and while its mortality results have been satisfactory,. I do not feel that such baths need be introduced in the care of private patients, particularly where attentive nurses are at hand. Their use in many cases seems to be needlessly severe. amount of shock is out of proportion to the good accomplished, and the amount of movement required is a great objection where there is any liability of hemorrhage and perforation-and such liability is present in most cases of typhoid. There is a wide difference in the susceptibility of individuals to hydrotherapeutic measures, and because such satisfactory results. have been obtained by tub baths this does not mean that each individual must be put through that routine in order to better his chances of coming out alive from the disease. The general point, it seems to me, is the adaptation of hydrotherapeutic procedures as well as the diet to the individual, rather than to try to force our patients through an inflexible treatment in the hope that all but six or seven in a hundred will escape with their lives."

Artificial Nauheim Baths in Heart Disease.

The bath employed by Brown is merely a bicarbonate of soda and acid sodium sulphate bath without the chloride. He says that the cases peculiarly fitted for the Nauheim treatment are those in which the heart muscle acts insufficiently, either from dilatation, poor blood supply or arteriosclerosis with changes in the muscle; poisoning, notably tobacco poisoning, and fatty changes of moderate degree. Brown does not believe that the use of resisted movements with the Nauheim baths is essential. They are often very tiresome to the patient and are dangerous in bad cases, unless given by a person who understands fully the purposes of them and who realizes that every case is a law unto itself. In his experience Brown has found it best to give these exercises an hour or two before the bath, and when this is not possible, a number of hours after the bath. He has found massage in connection with the treatments of advantage, particularly when the temperature of the bath was below 90.

The Hydrotherapeutic Treatment of Membranous Croup.

Sadger says that in 1821 Harder commenced the treatment of membranous croup by means of water and since that time there have been reported by many writers and others remarkable results and cures of the malady.

Based upon the idea of Winternitz that there is a paresis of the posterior crico-arytenoid muscles. This paralysis is to be overcome by powerful mechanical and thermic stimuli which will affect the respiratory centers. The author says that the aim seems to be to introduce a powerful revulsion by a sudden douche of cold water as originated by Winternitz. In the four cases that he reports the treatment was eminently successful and the following technic was employed. The body of the patient was first rubbed with sponges dripping with water at 10° C. (50° F.) for six minutes. (The writer of this editorial would here suggest that instead of sponges a rough crash rag be employed, as it is more cleanly and produces greater friction with a better resulting dilatation of the blood vessels.) During or immediately after this application the head and nape of the neck were repeatedly douched with cold water, falling from a height upon the patient. In the interim, wet packs were employed and the treatment maintained at intervals (say every three or four hours) until the pulse and temperature had returned to or about the normal. In those cases in which the temperature is low the child is placed in a warm bath before giving the douche. As the natural result of the forcible impact of cold water applied under mechanical pressure powerful reflex effects result, stimulating the respiratory center as well as muscles of forced expiration, so that in the cases reported large amounts of false membrane were coughed up and expelled. This treatment will strike American confrères as rather

"heroic" and this must have been the feeling of Sadger, for he says in conclusion that we should bear in mind Priessnitz's saying "that water treatment takes character," which applies to the physician as well as the patient, and further notes that halfhearted water measures do more harm than good.

In the experience of one writer who treated twenty-eight cases in ten years, all of his little patients recovered but he adhered to the strict method. This writer repeated the douche whenever the breathing became difficult and the croupy cough occurred, and where there is much fever he has recourse to cold sponging before the douche is used.

The suddenness of the douche is an essential feature as it causes the child to take a deep inspiration, to struggle, followed by strong coughing and expiration. After five or six douches the child is generally so much improved that it asks for food and generally falls into a refreshing sleep after each application.

It is to be regretted that with these facts before us and the knowledge that the reintroduction of hydrotherapy in the treatment of croup would cure so many cases will not lead the American physician to increase the proportion of his recoveries by early and prompt institution of methods that will do no harm but save many human lives from a tragic end.

THERMOTHERAPY.

EDITED BY DAVID E. HOAG, M. D.

Thermotherapy. By W. Gilman Thompson, M. D. New York Medical Record, April, 1907.

Thompson has brought out in this article what has been so often emphasized in these columns, that we must not have an exaggerated opinion of any certain form of therapy. Medical men are prone to error in this way; in other words, to get a hobby and ride it without producing any scientific data to substantiate the authenticity of their statements. It has long been very well known that heat in various forms is one of the most useful forms of therapy, but it must be borne in mind that it should be an adjunct only to other forms of treatment. Dr. Thompson firmly believes that the topical application of thermotherapy is of little if any value in controlling deepseated visceral hemorrhages, congestions or inflammations. His experiments demonstrate that the ordinary means of applying local heat and cold to the surface completely fail to affect the temperature of structures lying beneath the skin to any practical extent, so long as the peripheral circulation remains active. He believes furthermore, however, that thermotherapy as applied to the peripheral structures of the body is of so much importance that more adequate facilities should be pro