temperature of each ablution is reduced two degrees until 60° are reached. After the patient is dried by patting, not rubbing, with a thin linen towel, a wet compress is placed over the entire abdomen. This compress is prepared by wringing three folds of linen out of water at 60°. This is snugly held by a flannel bandage an inch wider than the compress around the entire body secured by safety pins. If there be a persistent temperature of 103° or over, without local manifestations, the friction bath of 90° for twelve minutes may be administered in the bath room. If the temperature rises to 103° again within four hours, the bath is repeated at 85°, four hours later at 80°, again at 75°, always insisting upon active friction. If one of these baths reduces the rectal temperature more than 2o, the case is pronounced not one of typhoid. Based upon the fact that baths are not an efficient antithermic agent in infectious fevers, this diagnostic bath has been evolved. It is as reliable in the first week of the fever as are the lenticular spots in the second week. The smaller the reduction of rectal temperature from one of these baths the more positive is the diagnosis of typhoid fever, and, pari passu, the larger the reduction, the less positive is it. As soon as a diagnosis of typhoid is made the friction bath is no longer administered in the bath room because the latter is inconvenient and does not permit of nurses standing on both sides of the tub. A tin tub, six feet in length, is placed on the stools alongside the bed. The patient having been inured to cold water by previous ablutions and cold compresses, and the friends having observed their refreshing effect, objection is rarely made to a bath of 75°, which may be reduced one degree at each subsequent four-hourly bath until a temperature of 70° is reached. Chilling must be prevented by continuous friction; the patient should not be removed even if he entreats for escape, unless the teeth chatter and the lips are cyanosed. A thready pulse often frightens the inexperienced into abandoning the friction bath. Careful examination of the pulse will reveal that it is slower and less compressible; smallness being due to contraction of its muscular walls by the cold water. Patients usually dislike the Brand bath and it requires all the persuasive power of the nurse, doctor and friends to retain them, but reliable statistics have demonstrated the value of the Brand bath.

Summing up his observations of the past ten years, however, Dr. Baruch is disposed to modify the strict Brand bath

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in all cases seen after the first week of typhoid, but to approximate it as nearly as the reactive capacity displayed by the patient warrants. In American hospitals cases are rarely seen before the first week expires. He had never seen a case result fatally if the treatment was begun before the seventh day. A good substitute for the Brand bath is the sheet bath, the patient being rubbed vigorously while wrapped in a wet sheet. This repeated every three or four hours when the rectal temperature rises to 102.5°. Reaction must always be insured. else the sustaining value of the bath is lost. In cases of feeble reaction, with compressible pulse and other signs of adynamia, affusion of one or more basins of water at 60 to 50° over the head and shoulders of the patient held in a tub containing six inches water at 95 to 100° is of advantage. These may be applied every two or three hours until reaction is established when resort can again be had to a plunge bath at 70 to 80°, applied either as a dip repeated two or more times successively or as a full bath with friction for five or more minutes. remedial agent is so flexible in dosage as water. Regard must be had to the fact that that brief applications stimulate and are applicable in most desperate conditions as a measure to tide over emergencies, just as alcoholic stimulants are applied. The Brand bath illustrates what the maximum dose is capable of accomplishing in infectious fevers. The treatment is begun with milder procedures, as ablutions, compresses, short tubbings, affusions, towel and sheet baths, the physician always bearing in mind that the longer the bath and colder the water within the limits indicated by the Brand bath, to which the patient has the capacity to respond, the more efficient and enduring will be the effect. It is faulty practice to increase the temperature of a bath or other cold procedure when the patient feels uncomfortable or reaction is imperfect. Instead of increasing the water temperature, the duration of the procedure should be diminished, and more friction applied. Friction during a cold bath prevents the demand for friction, hot water bags and stimulants after the bath.

During the past few years Dr. Baruch has, in advanced cases, adopted a method which has enabled him to apply hydrotherapy in conditions that would otherwise forbid it. To illustrate the method he reported the following case:

Mrs. R., to whom I was called by Dr. Fraenkel, of New York, on the tenth day of a severe case of typhoid, had been

seen on the third day by Dr. Abraham Jacobi, on the sixth day by Dr. Francis Delafield and, her condition growing worse, on the ninth day by Dr. E. G. Janeway. Dr. Fraenkel was anxious to apply cold tubbing and had procured a portable tub. But Dr. Delafield, an earnest teacher and advocate of the Brand, counselled against any cold procedure in this desperate case, because the temperature was only 102°, the heart was feeble, the pulse 160, there was coma vigil and delirium and involuntary movements had existed for several days. I did not favor a cold water procedure until the reactive capacity had been tested without harming the patient. The central nervous system was so overwhelmed that it could not respond to thermic stimuli, as was proved by the absence of the inspiratory gasp when a basin of water at 50° was dashed over her head and shoulders. How was this cerebral obtuseness to be removed? I suggested the addition of a chemical irtitant, harmless and transitory in its effect, for the purpose of arousing the feeble cutaneous arterioles to do their work. By adding the Nauheim salts to a tub bath of 80° and placing the patient into this latter while the carbonic acid gas was bubbling, the cutaneous arterioles were aroused from their lethargy. After five minutes bath the pulse was 150 and five minutes later, friction being constantly applied by three persons, it registered 140 and had become more resilient. The bath was prolonged to fifteen minutes. She was then lifted up and two basins of water at 50° poured over her, despite which she continued her stolid gaze as if nothing had been done. She was wrapped in a previously prepared sheet and blanket, dried and fell asleep, and continued for four hours in a calm slumber. When she awoke the bath was repeated, with the result of again improving the pulse, inducing sleep and diminishing delirium. Not until a fourth bath had been administered did the patient's brain feel the stimulus of an improved blood supply, consciousness return and delirium ceased. A slight intestinal hemorrhage precluded bathing for thirty-six hours. An abdominal compress at 60° was applied every hour to maintain the thermic excitation without disturbing the patient. When washing the rectum brought no traces of blood the bath was resumed with the result of complete recovery.

In conclusion Dr. Baruch said that this interesting case illustrated the flexibility of hydriatic methods and their favorable application in most desperate conditions. He hoped that

as a result of his remarks this remedial agent would be more frequently employed in the daily combat with disease and death.

Case of Chronic Seminal Vesiculitis; Removal of the Vesicles; Recovery.

Presentation of Patient.

BY BRANSFORD LEWIS, M.D.,

ST. LOUIS.

ATIENT, N. H., aged 38 years, was referred to me by

PATI

my friend, Dr. William Winter, November 3, 1902. He was of German extraction; occupation, street car conductor in St. Louis. He had been the subject of one gonorrheal attack, in 1896, lasting about two or three weeks; after which he had felt nothing wrong until the beginning of the present trouble, which began March, 1902. Without any apparent cause, he noted increased frequency of urination, together with some pain in the left groin and testicle; and there was increase in a painful feeling that had been with him occasionally since his gonorrhea of 1896, in the sacral region. This pain had always been increased by cold weather but was better when it was warm, but he had never been really free from it for five years.

Following the onset of the acute attack above mentioned, the patient kept his bed for about five weeks, and was under the care of an able physician of the city. There was subsidence of the acute inflammatory stage and he went to work again; but he was unable to attend to his duties with any degree of satisfaction because of two reasons-the frequent necessity for urinating, and the severe pain in the lower part of his spinal column.

On consulting me he presented a robust appearance, in both weight and complexion. There was no discharge from the urethra, and the urine was perfectly clear in both portions. No stricture was present, though the meatus was smaller than desirable-admitting No. 20 bulb sound. No Read before the Medical Society of City Hospital Alumni,

October 20, 1904.

tangible evidence of urinary trouble was found until rectal palpation was made, when marked inflammation of both vesicles was disclosed by the acute tenderness when they were pressed on, and the fact that several drops of muco-pus were milked from them. This pus did not contain gonococci nor tubercle bacilli, but there were cocci and bacteria in moderate number. After opening the meatus sufficiently, the patient was placed on the methods of treatment usually adopted by us for nontubercular vesiculitis. He was given periodical massages and posturethral irrigations; abdominorectal faradism and, later, galvanism; the regular use at his home of my rectal siphon for hot water, and internal tonics.

While the frequency of urination improved considerably under these measures, the spinal pain did not, and I began to suspect that the patient was somewhat of a neurasthenic; in fact, would have believed him such had it not been for the direct evidence of continued inflammation obtained by the vesical milkings. The pus was persistent.

After ringing in the various changes of treatment usually efficacious, I acknowledged defeat in that respect and suggested extirpation of the vesicles. This was accepted by the patient, who said that anything would be preferable to the continuation of his suffering.

On January 20, 1903, through an inverted L-shaped incision, across the perineum and down to the left of the anus, I removed the greater part of both vesicles, scraping out the residue by means of the blunt curette; sewing up most of the incision afterward with buried catgut sutures and superficial silkworm sutures-with the exception of a small drain space at the lower end, in which I left a small rubber tube.

Union was prompt enough throughout excepting at this point, where there was some delay, but no effort at persistent fistula. The patient was sitting up within two weeks after the operation, and the wound was practically healed in three weeks.

Since the day of the operation the patient has had no return of the pain that had persisted for six years previous to that time. He has again taken up his occupation of streetcar conductor, which necessitates his standing a number of hours at a time, and, under the stress of World's Fair visitors, has been quite arduous. He asserts that he is now as well as he has ever been.