These, so far as can be ascertained, have been distributed as follows:

University, 191; Medico-Chi, 315; Pennsylvania, 133; St. Agnes, 109; St. Mary's, 38; Hahnemann, 29; Orthopedic, 14; Episcopal, 41; Presbyterian, 87; Jefferson, 54; German, 63; St. Joseph's, 89; Polyclinic, 31; Samaritan, 14. These have been variously from Chickamauga, Camp Alger, Fernandina, Camp Meade, and the ship Relief (Ponce). The greater number of cases were from Camp Meade, Chickamauga and Ponce.

Recognizing the point that much of interest to science must be developed thru the massing together of so many cases of disease, THE MEDICAL WORLD has made a special effort to investigate peculiar conditions of the cases brought to Philadelphia and also to collect and compare the different methods of treatment. This has been done both by personal interview and by correspondence with those in charge of the hospitals, and tho some difficulties have been met and the work necessarily at this stage is a little incomplete, still a beginning has been made, and much of interest learned for study and inference. In some cases those who had the work in charge were contemplating the writing of elaborate articles indicating treatment and results, and in such cases data given was rather meager. Occasionally the attitude of refusing to be "investigated" was adopted and here still less was gained. In no case is it possible to arrive at statistical results as yet, but still the reader will be able readily to see the trend of treatment.

Taking into account the prostrating effects of a journey in any case of disease and the advanced state of the case in so many instances of those brought to this city, the fatalities have been surprisingly few. This may possibly be due to the fact that the soldiers enlisted were carefully chosen because of their excellent physical attributes, representing the flower of American young manhood, and thus had unusual resisting powers, but is no doubt also due

to scientific measures taken to overcome disease.

The Medico-Chirurgical Hospital.

At the Medico-Chirurgical Hospital a most important point is considered the reduction of temperature by application of water, altho there is no adherence to the Brand treatment. If the patient presents a temperature of 102° or over, he is gently sponged with water at a temperature of about 65° until a reduction to less than

100° is obtained. If there is not a ready response to the sponge bath, or when the temperature has risen above 104° the ice pack is used. These cases are exceptional, however. The plunge into cold water is objected to on the ground that it tends to increase internal congestion and thus may predispose to hemorrhage.

Absolute rest is enjoined and liquid diet given. Milk, with small quantities of varied by broths, clam bouillion, etc., stimulant, is the general diet, but this is avoiding gelatinous foods. Effort is made to keep the bowels moderately open, both constipation and diarrhea being treated as unfavorable conditions.

The medical treatment is, for the average case, embraced in the administration of two-grain doses of quinin, particularly in the mornings, and two and one-half grain doses of salol. Both are regarded as antiseptic and antipyretic.

Special cases are treated according to indications. If there is hemorrhage, turpentine is given, also lead acetate and extract of opium. In a few very severe cases recourse has been had to hypodermics of ergotole.

Guaiacol does not seem to be in favor, either for antiseptic or antipyretic purposes, and there does not seem to be any consideration of methods discussed for "aborting" the disease. Nor has there lately been much trial of intestinal antisepsis. On the whole the treatment here may be characterized as conservative. Excellent results are claimed, but naturally there is not yet opportunity for the tabulation of the cases.

The Hospital of the University of
Pennsylvania.

The University Hospital has adopted what might be called a modified Brand treatment, not believing in hypermedica

tion. A temperature of 102.2° is considered an indication for the bath, and the plunge is generally the form taken, altho there are contraindications, such as the shock not being well borne, extreme weakness of the patient, or hemorrhage.

Medicinal treatment mostly consists in the use of salol, this both for antipyretic and antiseptic effect. It is given usually in doses of five grains every three hours, tho this is varied according to the case. Hemorrhage is treated by the use of silver nitrate and extract of opium.

The diet may be characterized as an exclusively milk, other liquids being substituted only when there is a personal idiosyncrasy against the use of milk. The chief stimulant used is whisky, tho this is not given in all cases. A dose is generally given before a bath, however, to enable the patient to withstand any possible shock.

It is not thought possible to abort typhoid fever, and no use is made of the Woodbridge system. Objection is made. to the purgation which forms a part of this method, on the ground that it increases weakness and tendency to hemorrhage to a far greater degree than even movement on the part of the patient could do.

Use has been made of guaiacol as an antipyretic, but without creating a sentiment in its favor. "Its effects are transient, and whenever tried it has been at the expense of the patient." Good results. are claimed for the course of treatment pursued.

Treatment at the German Hospital. The German Hospital is declared as uncompromisingly in favor of the Brand treatment, tho modifications are made to meet the indications in individual cases. Still, the cold plunge is adhered to as the chief form of treatment, and the claim is made that, altho a large number of cases of typhoid fever are annually treated there, the mortality for this disease is a little below seven per cent.

No use is made of the Woodbridge treatment, as it is not thought possible, in the present state of knowledge upon the mat

ter, to shorten the course of typhoid by the use of any method. "We obtain such excellent results that there does not seem any necessity for a change of method until it is proven that better may be obtained by other means."

Drug medication seems to be here considered of less importance, altho salol is used to some extent. Special indications, such as delirium and hemorrhage, receive the usual treatment" for these symptoms irrespective of the disease.

The usual diet is milk, with small quantities of alcoholic stimulant unless where this is not well borne.

St. Joseph's Hospital.

At St. Joseph's Hospital what might be characterized as a conservative selective treatment, individualized to the case, is the prevailing system. Particular attention is paid to keeping the bowels soluble, altho too free movement is not considered desirable, and any tendency to diarrhea is promptly checked. Each case is especially watched, and each indication is met as it appears. The desire is to particularize each case, not to glorify any system, nor to work for a fine showing in statistics alone. Care means more than mere enthusiasm in cases of the typhoidal type.

If there does not exist a tendency to diarrhea, the patient is put upon calomel in doses of grain every hour. If the bowels cannot be kept soluble in this way, small doses of epsom salts or of the solution of magnesia citrate are given until the desired effect is produced. These are chosen because they have so little tendency to produce griping. The calomel is given as much for its antiseptic effect as it is to keep the bowels open. "The antisepsis is produced both thru its exciting the flow of bile, the natural antiseptic, and thru its direct effect by its change to the bichlorid."

There is some prejudice against the Brand treatment on the ground that it is too severe, since the temperature can be brought down and kept down by the milder measure of sponging. It is thought here that the Brand treatment increases the tendency to hemorrhage thru the disturbance of the circulation, consequent upon

the sudden contraction of the external blood-vessels. This must necessarily cause congestion of the internal organs.

A temperature of 100 or over is an indication for the sponging, but instead of using cold water better results are claimed to be obtained from tepid water, or at the temperature of about 85°. This avoids all possibility of shock, lowers the temperature more gradually, and has a more permanent result, the resulting low temperature often continuing so long as ten or twelve hours when established, without any appreciable rise. There is not the slightest tendency toward the weakening of the patient in this way, but the effect seems to be a gentle stimulation of anabolic

processes.

In addition to the bathing, elevation of temperature is met by giving aconite in small doses. Delirium is calmed by the use of bromids, and acetanilid is occasion

ally given when the headache is especially severe. Ice is also applied to the head.

Rest is enjoined and a liquid diet, preferably milk, is given. Stimulants are given as indicated, and every effort is made to conserve the patient's strength. Too much stress cannot be laid upon the admirable manner in which each case is specialized at this hospital. No doubt much of the success reported may be due to this, but if the chief object is the saving of life, such measures are to be advocated.

Following are two prescriptions used at this hospital to meet the indication of fever:

In conjunction with the bathing, salol and guaiacol are given as intestinal antiseptics where such medication is indicated Guaiacol has not by tympanites, etc. been used as an antipyretic, dependence being placed on bathing.

If there is hemorrhage of the bowel, ergot, ice and opium are given, and delir

ium is treated in accordance with the casual indications.

The Woodbridge treatment has not been used here, not because of any particular objection, but because those in charge are well enough satisfied with the treatment outlined. Doubt is expressed as to the possibility of aborting typhoid fever.

St. Agnes' has a very low death rate, altho the medical director attributes this in some degree to the specialized education of the nursing Sisters in the bath treatment. There have been a number of very severe cases but the mortality will probably not exceed three per cent. This group of cases will be reported separately from the usual typhoid cases received from the city, and thus some idea may be had as to the peculiar comparative effect of camp life upon the patient.

The Presbyterian Hospital.

gtt. xxiv drs. vj oz. j Aquæ ozs. iij M. et. sig.-Teaspoonful every two hours.

q. s.

St. Agnes' Hospital.

At St. Agnes' hospital the Brand method is held in high favor, and is practically the adopted treatment, being used except where especially contraindicated. The mild cases are, however, treated by sponging instead of the plunge.

Calomel is given in one-sixth grain doses every two hours, both to keep the bowels soluble and for its antiseptic action. Salol and quinin are also given in the usual dosage. No use has been made of guaiacol, nor have the sulfocarbolates been tried. If the bowels do not respond to the calomel, enemas are given, especially if there is tympanites. Occasional use is made of the salines.

Turpentine is a favorite therapeutic remedy when there is tympanites or where

hemorrhage from the bowel has occurred. This is applied by stupes, by enema and in small doses by the mouth.

Particular attention is paid to the diet with reference to each patient, and altho a strictly liquid diet is enjoined, this is not necessarily milk, broths, gruels, fruit juices, etc., having their place in the menu unless contraindicated by the symptoms of the case. There is objection to too free purgation, altho it is deemed necessary to have at least one movement daily, to prevent the accumulation of fecal matter in the bowels. The keynote of the treatment here is conservation of strength, care in attendance, subduing of temperature.

The Pennsylvania Hospital.

The Pennsylvania Hospital generally favors the Brand treatment, altho this may be varied according to the prejudices of the medical officer, certain of the staff having a strong bias in its favor, while others prefer a more conservative line of treatment. In no case, however, is there disregard of special indications. Plunge baths are not invariable, the milder cases being sponged or packed for the lowering of temperature.

No use has been made, here, of the Woodbridge treatment, and it is not thought possible, in the present state of medical knowledge, to abort typhoid fever, tho a method should eventually be dis

covered. The antitoxic method would seem the ideal one, but this has not been proven and has its objections.

Distention of the abdomen is regarded generally as an indication for the use of some intestinal antiseptic, and for this some of the staff use salol in five grain doses every three hours, and others beta naphthol. No use has been made of the sulfocarbolates, but it is thought that copper arsenite with nucleinic acid affords possibilities as a treatment that should be investigated, if possible.

Guaiacol has occasionally been used to lower the temperature, and with excellent results. It is applied in the usual manner and its effects are generally very quickly obtained.

Should there be hemorrhage from the bowel, cold is applied locally, the foot of the bed is elevated, and astringents are given. Delirium is treated in the usual way with opiates.

Altho there have been some very severe cases here, presenting hemorrhage and hyperpyrexia, there have been no unusual complications, and the death rate is very low.

Homeopathic Treatment.

At the Hahnemann Hospital treatment varies in some degree according to the medical director in charge, but the treatment thruout must be characterized as conservative.

The Brand treatment is not in use here.

and has been characterized as cruelly severe. Moderate sponging is used in the

more severe cases as it would be used in any hyperpyrexia.

The medical treatment is the administration of bryonia and rhus tox with the "usual form of treatment" for special indications such as delirium, constipation,

diarrhea, etc.

The treatment of hemorrhage also varies according to the physician in charge and the case, tho the general principles of local application of cold, elevation of the foot of the bed, the use of astringents, etc., are followed. A number of such cases have been treated surgically with very flattering results.

The diet is strictly liquid with a strong leaning toward the use of milk, altho other fluids are used as possible. In such matters there is no hard and fast rule, and an earnest endeavor is made to discover what is best for the good of the patient, and when any such principle is found it is applied without reference to any individual prejudice. Much stress is laid upon careful watching and attendance.

At the Samaritan Hospital.

At the Samaritan Hospital the Brand treatment is favored, but the visiting physician states that in his opinion the great majority do equally well without it or with modifications. At this hospital sponging with ice water has almost entirely super

seded the pure Brand treatment. When it is employed a temperature of 103° is the indication for the plunge. Its greatest value is in the cases presenting very high temperature with profound nervous symptoms.

The Woodbridge treatment has been tried here, but was soon abandoned in favor of other well tried methods. It is quite possible that good doses of quinin will sometimes abort true typhoid, but this is an open question.

In regard to intestinal antisepsis the attitude is non-committal. The belief is expressed that the occurrence of meteorism, delirium or other grave nervous symptoms is due to septic intestinal processes, and that their absence must be because of some modification of these, preventing autotoxis. Just how this intestinal antisepsis occurs, whether indirectly by modified secretions or directly, cannot be positively stated.

There has been a very limited experience with guaiacol, and this with results not sufficiently favorable to warrant discarding the adopted treatment in its favor.

The formulæ used for the usual case of typhoid are the following:

or hyoscyamus are given. Sometimes hyoscin hydrochlorate has been given hypodermically.

In several cases delirium has been coincident with the stoppage of the alvine discharges, and has been modified or controlled by the use of saline cathartics.

At this hospital a number of very severe cases have been treated, but none particularly bad from the soldiers. Among the complications noticed may be mentioned one case presenting an eruption of large blebs over the entire body. Another presented very extreme jactitation and muttering delirium, etc. There have been a number of instances of hemorrhage, but there has in all cases been recovery. Altho there have been a large number of typhoid fever cases treated at this hospital, there has not been a death here for many years, a most desirable and enviable showing.

The Widal Test.

The general interest concerning the Widal reaction led to a special inquiry into its value, with the usual result of the finding of different camps. Still those enthusiastic in its commendation as a diagnostic measure are far in the minority, and the general conclusion is that it is to be regarded as chiefly accessory to other diagnostic features, and not in any sense. absolute.

Negative results have been reported in a number of cases where the typhoid picture was marked, the eruption well defined, the tongue characteristic, and other symptoms as the peculiar fetid breath, right iliac gurgling, etc., present. On the contrary, the reaction has been positive where the most marked symptoms were a general malaise, coryza, aching of the bones, and headache, cases more resembling grip than typhoid fever.

This leads to the conclusion that there is an element of, to say the least, uneertainty in this form of diagnosis. The general statement has been made that if the test confirms the diagnosis made in the usual way, well and good; but if it runs counter to the diagnosis of fever already made, it is ignored and the treatment for typhoid fever continued.