and often has the hiccup. The features are pinched and sunken, and there is an air of great suffering. The urine is at first greatly increased in amount, but later in the attack becomes less, even to the degree of suppression. It is acid in reaction when first voided, but on standing, rapidly becomes alkaline and very foul. The perspiration also has a peculiar and distinct odor. If chemic tests are applied to the vomit, the presence of hemin crystals may be demonstrated.

The condition is one of the gravest importance, and cases of complete recovery are the exception instead of the rule. Even when the patient rallies from the immediate attack, pernicious and progressive anemia may result, and, even if there be no discernible ailment, the condition popularly known as "decline" may supervene. Robust health can seldom be obtained after an attack of this malady save in the instances where the patient possesses great vital powers and where the treatment has been inaugurated with great promptitude.

True Malarial Hematuria.

Closely allied to malarial hemoglobinuria, tho far less grave in its prognosis, is the true malarial hematuria, in which free blood is to be found in the urine. A more severe type is the hemorrhagic type of malarial fever, where the blood is not only found in the urine but exudes from the mucous membranes, and, rarely, from the skin, in the form of bloody sweat. Still another form is due to an idiosyncrasy against the use of quinin, and as this drug is the great remedial agent in the treatment of paludal disorders, the existence of such a condition greatly complicates matters, since quinin must be used in cases of this general type with great caution, at least until it is demonstrated that it will not aggravate the trouble, or until it becomes the only alternative.

In the types where a true hematuria is present, the general symptomatology is similar to that of hemoglobinuria, tho the prognosis is far less grave, since the general economy is less completely invaded. Recovery is more frequent and also more complete. Yet the condition is not to be lightly regarded.

Treatment of the General Hemorrhagic Condition in Malaria.

If the physician makes his acquaintance with the case before the gravest of the outlined symptoms have developed, it would be better to direct the attention to the use of other drugs than quinin, reserving that as a last resort, and this for fear of causing immediate collapse by the increase of hemorrhage.

Rest in bed, absolute quiet, the avoidance of irritation, are absolutely necessary as the first measures. The patient should

not be allowed to rise from the recumbent position to even pass the urine or feces. It is an excellent measure to give a dose of morphin to quiet apprehension or exeitement, as the patient's mental condition has an undoubted influence. Ice should be applied over the kidneys and pubes, and warm applications should be made to the feet and limbs.

Medicinal treatment embraces the use of oil of erigeron, in five drop doses every four hours, or eucalyptol in physiologic dosage. Buchu, matico, hamamelis, chimaphila and the tannate of iron have all been used successfully. All articles containing oxalic acid, such as tomatoes, etc., should be carefully excluded from the diet, and tea, coffee and beer should also be interdicted. Ergotin and tannin in small but frequent dosage are much extolled.

Still, in the more severe cases, in spite of such medication, the case may grow progressively worse, and then there is no recourse save the administration of quinin, as the risk of immediate increase of hemorrhage temporarily should not prevent the adoption of the last resort. There is no time for the slow absorption of the drug as when given in enemas or by the mouth. In the state when quinin becomes imperative, cinchonism should be produced as rapidly as possible, and this leaves only hypodermic and intravenous medication possible. The former is preferable, according to the symptoms, altho there are cases in which the latter is the only possible method.

The more soluble salts of quinin should

always be selected for either hypodermic or intravenous injection, the bihydrochlorate being the best. An excellent prescription, in which every minim of the solution represents a grain of the quinin, is as follows:

Quininae hydrochloratis. grs. xx Acidi hydrochlorici . . . m v Aquae dest

m xv

M. Ft. sol. For hypodermic use.

If the hydrochlorate is not obtainable, the ordinary sulfate may be used, rendering it more soluble by the addition of a few drops of sulfuric acid. The irritant action of this drug nearly always results in abscess formation. The hypodermic injection should be made deeply, preferably in the buttock. Should more than one syringeful be necessary, another puncture should be made. So soon as mprovement is noticed, hypodermic administration should be discontinued and thie drug continued by the mouth.

In the most severe types of the disease, particularly where there is hemorrhage

from the mucous membranes and blood extravasations into the subcutaneous cellu

lar tissue, or where there is advanced blood disintegration as shown by hemoglobinuria, death may come so rapidly that even the subcutaneous use of quinin is unavailing, and in such instances intravenous injection must be resorted to. Baccelli has been the chief advocate of this method of administration, according to the following procedure:

B

Bihydrochlorate of quinin. grs. xv
Chlorid of sodium
grs. xj
Distilled water
. drs. ijss

Use this solution lukewarm, and administer with a Pravaz syringe, which holds a dram and fifteen minims. The so ution must be perfectly clear. Make the veins of the forearm turgescent by means of a circular tourniquet, and then introduce the needle of the syringe from below upward into the lumen of a vein, selecting a small one to avoid hemorrhage later, and generrally one on the flexor side of the forea m. After the injection, gently stroke the arm upward to hasten the passage of the fluid,

and close the wound with collodion.

Other means for controlling the hemorrhage may be used in conjunction, such as the tincture of ferric chlorid, and the fluid

extract of ergot in connection with the fresh infusion of digitalis, which acts both as a cardiac stimulant and as a diuretic. Local fomentations of digitalis leaves over the kidneys are of great value. Most excellent results have been reported from the use of nitro-glycerin in doses of r of a grain. Where the cachexia is marked, the use of manganese dioxid is indicated, and great attention must be paid to general hygiene.

How Do You Treat Typhoid Fever?

The consideration of the etiology, diagnosis and prophylaxis of typhoid fever as given beneath will be continued in our next issue by a full presentation of modern methods of treatment. THE WORLD has ever claimed that many of the best methods of therapeusis have been developed rather in general practice than in the routine work of hospitals, and thus invites from its readers for the coming issue any and all notes they may have to send of measures and results. In such comparative gathering of detail lies the best help for the profession, collectively and individually.

The Recognition of Typhoid Fever.

One of the most general and widely distributed of diseases, generally typical in its manifestations, and of recognized etiology, there is yet scarce another disease approached with such diffidence by the average practitioner as is typhoid fever. The importance of immediate diagnosis will not be disputed, nor of the need for the ability to at once differentiate between simulating conditions. There is a vast amount of literature on the subject, and, result of confusion from multiplicity of as a consequence, there follows the usual

detail.

Despite its general prevalence and comparatively high percentage of mortality, typhoid fever must be classed among the preventable diseases. Since the bacillus typhosus of Eberth is generally recognized as the immediate cause and this is a facul

tative saprophyte growing upon dead organic matter, tho possessed of enormous vitality, it can readily be seen that typhoid fever must be classed as a "filth disease," preventable by general hygienic measures.

The Typhoid Bacillus.

The bacilli of Eberth are short rods with curved ends. They seem to have been demonstrated as the causal factor of typhoid by the fact of their presence in every case of the disease and in such distribution as will explain the lesions, and by the isolation of the organism in pure cultures. Unfortunately, in consequence of the insusceptibility of the lower animals to enteric fever, the disease is very difficult to produce in them by inoculation of the isolated organisms, the results obtained being due to the toxic rather than the infective properties of the inoculated bacillus. Still there have been recently recorded a few cases produced in rabbits, dogs and mice thru inoculation with the isolated germ, in which the lesions produced were, both to the naked eye and to histologic examination, identical with those in the small intestine of the human subject. This seems to demonstrate the correctness of the theory of the bacterial origin of the disease.

As with every disease of the germ type there must exist a favoring condition of the person exposed in order to allow the development of the disease, the natural conclusion is reached that such matters as the inhalation of sewer-gas, the living in unhygienic conditions, heat, and general lowness of the water supply, at one time considered as directly causal of typhoid fever, are merely relatively so thru their influence in lowering the vitality of the invaded organism and thus creating a predisposition, or thru forming favoring circumstances for the development of the germ or increasing its virulence. The germ itself must be present or the unhygienic conditions referred to could not produce this particular disease.

Owing to the close resemblance of the bacillus to the bacillus coli communis, there

is some difficulty in the positive demonstration of its presence in the feces of a suspected case. The method advocated by Elsner of growth of the culture upon potassium-iodid-potato-gelatin, by which the two bacilli take differing forms, is the most scientific method of diagnosis yet possible, but implies a greater familiarity with microscopic detail than is possible to anyone except the expert. Where local Boards of Health have a bacteriologic department and where such methods are in use, demonstration of the certainty of typhoid fever may be made in one or two days. In this line also is the famous Widal's test, of which an exposition will be made later.

The Origin of the Typhoidal States.

It has been affirmed by investigators that typhoid fever may arise in consequence of infection by any one or more of a number of closely related micro-organisms. The discovery of specific toxic and immunizing substances produced by the bacillus under discussion is, however, a strong point in favor of the accepted view.

In its most active form this organism has a parasitic existence. It is capable of prolonged existence under favoring circumstances, both in the body of a typhoid patient and in external media. It is not known definitely how long it may exist outside of the human organism, altho in ordinary water the period is measured by weeks. They survive longer in closed cisterns and wells than when exposed to light, and it has been demonstrated that cultures cease to live after a few hours' exposure to direct sunlight. The history of many epidemics demonstrates their viability in running streams, and they have been found capable of culture after repeated freezings and thawings. It is not definitely known whether they multiply in water media, but this is generally believed to be the case.

Milk is one of the most favoring of substances for their development, as in this medium they grow luxuriantly without in any way changing its appearance or taste. But, above all other media, the

because of their cheapness and convenience, have been the sulfates of copper and iron, or blue stone and copperas. Experi

ment seems to show that the direct action of these agents is weak and slow upon the typhoid bacillus, neither acting with the rapidity or thoroness that freshly slaked lime does. Since the lime is equally cheap and convenient, besides being more efficient, preference should in all cases be given to it.

In country places the ultimate disposal of the stool is a matter of moment, and possibly the best means is to mix the dejection, after thoro disinfection, with sawdust and then burn both. Still, the important point is the thoro disinfection, and when this is done, they may be emptied direct into the privy vault or buried in a trench at some distance from the water supply.

General Hygienic Measures in Typhoid.

The mattress used by the patient should be covered with a rubber or oil-cloth cover, and articles soiled should be immediately changed and disinfected, in order to prevent the spreading of the infection. It is well to place all the clothing which has been in contact with the patient directly in a tub with a 5 per cent. solution of carbolic acid, and after they are thoroly moistened, boil them for a time no shorter than a half-hour. Then wash with soft soap and rinse thoroly. They should be exposed to the sun for several hours before they are used again. In case of death it is now generally enjoined that the corpse be wrapped in a sheet wet with a solution of carbolic acid, 1:20. Thoro disinfection of all bedding, furniture, etc., is necessary after either death or recovery.

Since it is generally accepted as a fact that the typhoid germ most generally is taken into the system thru the means of water or milk, all danger from such source should be abrogated by boiling all fluids used for drinking at least thirty minutes, and then cooling them by other means than the direct addition of ice. The use of uncooked vegetables should not be allowed,

since there is little doubt but that the germs often find lodgment upon growing plants. the general health of communities must of Prevention on a large scale as regards course be placed in the hands of Boards of Health, and thus would not come within the scope of an article of this nature. Still it may be said that the extension of the systems of sewers and of filtration of the general water supply, has in every instance led to a diminution of the number of cases and also of the percentage of deaths.

The Typical Case of Typhoid Fever. The most notable symptom in typhoid fever, and the one upon which diagnosis is generally based, is the stadium incrementi, or terrace-like rise of the temperature, rising steadily from morning to night, dropping about one degree from night to morning, each night a trifle higher than the previous night and each morning a trifle higher than the previous morning until about the seventh day when the fastigium or stage of continuous fever is reached. During defervesence, the fever sinks, remitting as it descends, until at last it reaches the normal.

In the typical case of typhoid or enteric fever, the period of incubation varies from one to three weeks, rarely reaching the latter period. The period of prodromes generally lasts about a week, but presents. few symptoms to call attention beyond a feeling of general malaise, evening headaches which are not often severe, and loss of appetite. Slight chilliness is sometimes complained of and "aching in the bones." The patient is disinclined to exertion and says he feels "malarial." There is often irritability and a disposition to worry over trifles. A general outbreak of furunculosis is often observed during the prodromal and incubative stages of typhoid fever, and if advice is asked because of such outbreak connected with a feeling of general malaise, the thought of typhoidal infection would naturally occur. Epistaxis is a common symptom in the opening stages of typhoid fever.

At the end of the week the steady rise in temperature becomes noticeable, and even if the patient has been able to keep