ache, bone-ache and restlessness and nocturnal delirium, the regaining of a healthy tone to the stomach, and general amelioration of all symptoms. This leads to the conclusion that the symptoms enumerated were not due to the fever proper, but to auto-toxemia from absorption of toxic mat ter from the alimentary canal.

Dr. Waugh claims for his methods these results: The whole course of the attack is ameliorated and shortened, and the proportion of abortive cases is increased, this in direct relation to the earliness with which efficient antisepsis has been secured. The convalescence is short, the debility and emaciation inconsiderable, and the occurrence of suppurative and other complications and sequelæ is prevented. crown all, the mortality is reduced to nothing, as Dr. Waugh has had no death from typhoid fever for many years.

Το

For the second indication, to reinforce the leucocytes, Dr. Waugh considers nucleinic acid the best agent, since by its administration the number of white cells can be doubled in a short time.

the advocates of the principle involved in the Brand treatment are increasing in number. There is no doubt but that excellent results follow the judicious use of cold water, and the nearer the treatme follows the exact laws of Brand, the bet the results obtained, if reliance may be had on statistics presented. The system, considered as a routine treatment, has the advantage of avoiding useless medication, which entails upon an impoverished sufferer the influence of unnecessary drugs and the necessity of absorbing and elimi nating them. The treatment is not always available to country practitioners, who lack the facilities and mechanical appliances common in hospital practice. Then, too, the method is one that would not readily commend itself to the laity, unless producing results brilliant with success. Failure would be likely to not only arouse widespread criticism, but would probably

Temperature.

The distinctive feature of the Brand treatment is based upon the assumption that the point of danger lies chiefly in high temperature. This is open to cavil on the ground that many cases prove fatal without reaching any notable pyrexia, altho perhaps the majority of the serious cases do present that phenomenon. Naturally the quickest and most generally available method of lowering temperature is by the cold bath or cold pack, and this is the means adopted, the patient being immersed in a cold bath whenever indicated by rise of temperature to 102.2°, taken in the rectum. The originator of the treatment advises the use of the bath at about 65°, and enjoins the pouring of water at a still lower temperature upon the head and shoulders of the patient. This should be continued for at least fifteen minutes, and during this time the patient should be rubbed somewhat vigorously, assisting in the rubbing himself unless too prostrated.

There exists a diversity of opinion as to the best method of using the bath, altho

If the case is seen

If the Brand system be adopted, water should be used freely, both externally and internally, since there is but little use in half-way measures. before the tenth day, it would be well for those favoring this method to adopt systematic plunging in cold water, and to

follow all the directions of Brand. Beis, however, somewhat doubtful whether tween the tenth and the twelfth days it plunging should be begun. After the twelfth day, plunging begun earlier should be continued or discontinued according to the condition of the patient. In a few cases the plunging is not well borne by the patient, and in these frequent cold sponging should be done, partly to reduce the temperature, but also to promote the general metabolism of the body, to stimulate excretion, and to keep up the tone of the peripheral vessels, so aptly called the "skin-heart."

In regard to the frequency of the treatment, when the temperature in the mouth does not exceed 103° the patient may be sponged or bathed every second or third hour with water at a temperature of 70°, which may, if necessary, be reduced to 50° in the course of ten or twenty minutes.

Should the temperature rise above 103° sponging or bathing must be resorted to

at least every second hour, and the temperature of the water should be correspondingly lowered; 60° or even 50° to begin with, and rapid reduction to even 32° being useful at times.

Care should be exercised in the adminstration of the baths to watch the effects In temperature, pulse, respiration, excretion, sleep, and general well-being, and these must determine the time, the temperature, and the other details of the treatment. Sleep should not be interfered with for a period of at least four hours if natural, even when applications are being made so frequently as every second hour during wakefulness.

The Lately-Introduced Methods of Cold Air and Local Applications of Cold in Treating Typhoid Fever.

In the same line with the Brand treatment is the general one of the local application of cold. This has lately been much extolled, the method most advocated being the applying of ice-bags over the ileum and the beginning of the colon, the object being to maintain as low and constant a temperature as possible near the lesions. hysiologically, this is in accordance with the proof offered by Prudden that intermittent thawing and freezing or chilling and warming, five times or more, completely destroys the bacilli. Thus, local applications lowering the temperature of the bowel below 60° are thought to materially retard the culture process in the bowel. The close contact of cold to the coils of the intestine cools the vessels of the portal circuit, sending thru the liver cool blood, which emerges still cool from the hepatic vein. This is a natural antipyretic influence which it seems should be more commended than drug medication.

As the continuous use of an ice-bag would cause congestion and even occasionally, in the case of a very sensitive skin, sluffing, it would seem necessary that the applications of cold in this manner should be intermittent. Applications of an hour and a-half to two hours with an intermission of a half-hour seems to give the best result. These periods may be varied according to the hight of the temperature, and when it is very high, sponging with

ice-water and alcohol in the intermission may be tried.

one.

Some interest has been aroused thru recent enthusiastic recommendations of treatment by cold air. This is made by means of a tube mattress upon which the patient lies, and is covered by a second When the temperature is to be lowered a cooling mixture is allowed to flow thru the tubes, bringing down the temperature of the surrounding air in the same way as is that of storage houses. In this manner no handling of the patient is necessary, and the shock attending the treatment by cold baths would be avoided.

The Olive Oil Treatment for Irritative
Indications.

Excellent results are reported from a treatment based chiefly upon the use of olive oil. This has proven particularly efficacious in districts where it is difficult to obtain fresh milk. The greatest amount of literature upon the subject is by Owen F. Paget in a recent issue of the London Lancet. In the cases he reports, nearly all the patients suffered from constipation or diarrhea when they first came under his observation. He states the problem presented as follows: During constipation the typhoid bacillus develops its infectious powers. This is followed by diarrhea and solution of fecal accumulations. Being intensely irritating, the infectious fluids aggravate the condition of Peyer's patches, give rise to violent peristalsis, and prevent rest of the inflamed tissues. A part of the fluid poured out being reabsorbed and saturated with ptomains, induces constitutional disturbances, high temperatures, tympanites, exhaustion, delirium, occasionally abscesses, and sometimes death. Hence the thing necessary is to find the best means of treating the inflamed and possibly irritated surface of the bowel by rest and protection from irritating substances and collection of discharges. For this he considers olive oil the best agent.

He begins treatment by injecting high into the bowel a quarter of a pint to a half

a pint of oil at intervals of from twelve to twenty-four hours during the first four or five days. After the injection the temperature generally falls at least a degree and the patient becomes quiet. After the fifth day the oil may be given every other day or left off entirely if the patient is having natural movements at least once in twenty-four hours and if the temperature is steadily falling.

If the patient does not respond readily to injections, the bowel being apparently empty, accumulation is to be suspected, the temperature is apt to rise and the case assumes a serious look. In such case Dr. Paget gives olive oil by the mouth, in doses of a large cupful. The bowels almost certainly respond to this and then the injections may be continued. If the first dose fails of effect, another may be given after twelve hours.

The Antitoxic Remedy for Enteric Fever. Since the establishing of the toxicity of the disease, the serum treatment would seem the ideal method, yet it has hitherto met with but slight success, altho some successful trials of anti-typhoid serum have been reported from England. There does not seem to have been much experimentation in this country.

The Cardinal Points in Treating Typhoid Fever.

To sum up the consensus of modern opinion upon this disease, it may be said

that the cardinal points in treatment are: To control undue pyrexia; to keep the emunctories active so as to expedite the elimination of toxins from the system and limit their absorption, promoting intestinal antisepsis; to support the

circulation.

in order to prevent local engorgements and congestion; to heal the lesions in the intestinal glands; to tranquillize the nervous system and maintain its tone so far as possible; and to nourish and sustain the patient. These conditions may be met by application of cold; by calomel in divided doses, and the sulfocarbolates; by friction and light massage; the use of a bland agent, such as olive oil; plenty of nourishment and stimulants in carefully graduated doses whenever indicated.

Additional points of more than ordinary importance are the enforcement of rest so nearly absolute as possible; the use of the bed pan, etc.; the adoption of a liquid diet, preferably milk; free use of cool water or ice; the meeting of complications by special treatment as indications appear. Should there be indications that a too exclusive milk diet is causing injury, such as a sudden rise of temperature not to be otherwise accounted for, eructations and flatulence, or the discharge of the undigested curd, the milk must be mixed with limewater or be predigested or a temporary change made to broths, soups, gruels, eggs, koumyss, etc. In connection with eggs, koumyss, etc. the matter of diet, the fact must not be overlooked that bouillion or gelatinous materials form the best breeding ground for bacteria and that hence, so far as possible, their use should be interdicted.

It is important to see that the patient is not exposed to continued infection, and hence a close watch should be kept upon the water supply and the milk used. It may even be necessary to remove the patient to more hygienic surroundings. There should be free ventilation, and the use of antiseptics in the sick room, such as chlorin, generated by pouring muriatic acid upon powdered potassium chlorate, the use of the chlorids, and where possible of formalin, generated by the burning of should be removed from the room. It methyl-alcohol. All unnecessary hangings would be well to place the patient upon a single bed on account of ease of access and of handling. Disturbing influences of all kinds are to be avoided, such as street noises, conversations, etc. If the patient at any time has shown the slightest symptom of delirium he must on no account be left alone, as a suicidal tendency so frequently accompanies the disease, why, there has never been assigned any reason. The fact remains that suicide is not rare, many patients having destroyed themselves during the brief absences of their attendants.

In conclusion, good nursing is of the utmost importance, and perhaps in no other disease is this so true. Careful reports must be made to the physician at each visit, the patient must be carefully but unobtrusively watched, and the best use must be made of the remedies at hand. In all

these points dependence must be placed upon the nurse, and thus to a large extent responsibility for recovery must rest upon her.

What Has Failure in Treatment Taught You?

This concludes the resumé of late literature upon the general management of the usual case of typhoid fever. Fuller consideration will be given in the future to the matter of complications and to symptomatic treatment, to the consideration of diet, and to the variations in treatment advocated by various general practitioners. The statement has been made that anyone can treat a case of pure, uncomplicated typhoid who can control the desire to treat too much, but that the cases out of the usual line require something out of the routine, often to the adoption of measures so unusual as to receive merely the briefest mention in lectures and text-books. Disease is no Procrustean bed to which the patient and the remedy must be adjusted by means forcible or otherwise. It is an equation compound of the lesion and the individual, in which the treatment is the unknown quantity to be demonstrated.

To solve such problems the judicial mind, absolutely without prejudice, is necessary. The investigator must bring to the case no preconceived idea that his pet theory is the only possible solution of the problem, no desire to bend results to the glorification of any particular line of treatment, no prejudice against any possible measure for good simply because at the first blush it does not recommend itself to his under

standing of the conditions. The wise man, the philosopher, has no objection to acknowledging a mistake. He considers this is merely an indication of progress, a proof that he is wiser to-day than yesterday. He is a fool who claims to be always right, instinctively correct in all conclusions and measures.

Not only in medicine but in all walks of life, humanity profits more in accumulated knowledge by its errors than by its success es, and perhaps in consideration of any one or all of the special lines of treatment here

mentioned more might be learned by a close study of the percentage of failures, which must indubitably indicate the weakest point of the so-called specific, than by consideration of a long list of recoveries which after all might have recovered under other treatment. Post hoc ergo propter hoc is not sound reasoning, tho it may be plausible. Therefore, let us have your mistakes, the cases that gnawed your hearts with a sense of failure, that lowered your pride and made you feel the powerlessness

of the individual in conflict with little understood but immutable laws of being.

Soldier Typhoid Cases Among The Philadelphia Hospitals.

Seldom is there afforded such an opportunity for the investigation of typhoid fever and allied diseases as in the recent outbreaks in the different camps of our soldiers, and much will doubtless be gained to the cause of science thru careful study of causation and methods of cure.

The high mortality of the army, from typhoid fever particularly, in these camps, has been the cause of much adverse comment upon the management, especially when this rate is compared to that of the Civil War, when equally large numbers of men were gathered together, and knowledge of hygiene was far less advanced than at the present day. The statement has gone on record in army reports that deaths from enteric fever during the Rebellion averaged 3.28 per thousand per annum. It is claimed, with apparent truth, that in the present war this rate has been exceeded per week, or in other words if continued to the expiration of the same period, one year, the result would be the death of at least 170.56 men from this cause in the present war per annum to 3.28 in the Civil War; and this proportion has been exceeded.

There is no doubt but that "some one has blundered," and the only question remaining is the placing of the responsibility. This can be done only by a careful investigation of the causes leading to the outbreak of the disease and its continuance, and of the reasons for the enfeebled resist

From these

trouble in

ing powers of the victims. facts there will be little determining just who should be held to account for the frightful mortality reported.

There is a general agreement in the statement that the camps were badly planned in regard to hygiene, the latrines being frequently placed above the wells from which the water supply was obtained. Another point of no little interest is that these latrines were open to the light and were infested by swarms of flies, which were also exceptionally numerous around the kitchens and the mess-tables, conveying the germs of infection as directly from source to victim as any water-supply could. Of course the effect of light in destroying the typhoid bacillus is recognized, but light is not of efficacy applied in such manner without due protection. Flies will not so readily seek dark places, and hence their agency in conveying infection from excrementitious matter exposed to light is made more obvious. This may seem a little matter to mention, but often the solution of a problem of great moment depends upon some such apparently insignificant point. Also, in the investigation of the causation of disease, no point is really unimportant.

The number of soldiers who were killed

in battle and who died from the effect of wounds is only about one-fourth of those who died from disease as shown from records, and this not taking into account the many whose death has occurred in such way that no official notice was taken. An article recently compiled for the Chicago Tribune told of 1284 men whose names are recorded as having died from disease in camp, on transports or at home, after having contracted typhoid fever or malaria at some one of the different camps. The statement is made that there are hundreds of others dead whose names could not be secured on account of lack of records and because of the inability or unwillingness of army officers to furnish lists of the dead. The article gives the

statistics of dead in each camp, giving in every instance a full list of names and the nature of the fatal disease. The list by camps is as follows, this, however, being carried out only to September 1. By the time this issue of THE WORLD reaches our readers several hundred more will doubtless have joined "the vast majority": Camp Thomas Santiago San Francisco Camp Alger Camp Wikoff Jacksonville Tampa Miami

Fernandina, Lakeland, Camp Meade, other camps, in private hospitals, at home, etc.

State camps

Transports and hospital ships

352

341

78

65

63

50

58

76

115

36

90

. 106

Reported simply as "fever"
Miscellaneous and cause not reported. 327

The regular army heads the list with 290 dead, and among the volunteers the highest number of deaths was distributed by States as follows: Massachusetts, 130; Illinois, 100; Michigan, 91; New York, 85; Wisconsin, 46; Pennsylvania, 45; Ohio, 43; Iowa, 31.

Following upon the general indignation caused by the revelation of the state of affairs at the pest-ridden camps, effort was made to remove the sick to more salubrious surroundings, and hospital trains were sent from various points North to bring the sick to cities where special attention could be given to their cases. A number of hospital trainloads have been brought to this city, embracing over 1100 soldiers.