authorities in medicine, that it was impossible for these two micro-organisms to exist simultaneously as factors in the disease, since they were antagonistic.

Dr. Cohen has seen no evidence that it is possible to "abort" typhoid fever. Many cases naturally run a short courseabout fourteen to nineteen days-without any treatment, and it is possible that some of the claims for shortening the course of the fever are based upon cases of this type.

The Polyclinic Hospital.

The Brand treatment is favored at the Polyclinic Hospital, where the same general lines are followed as at the Jefferson. There is a general favoring of intestinal antisepsis, this being obtained early in the disease by enteroclysis, and occasionally by the use of antiseptic doses of calomel.

Hemorrhage is treated by absolute rest, the withholding of food, local application of ice, and opium in the form best borne by the patient.

Guaiacol has been used to lower the temperature, and occasionally good results have been obtained, altho sometimes it has been found too depressing. Hydrotherapy is the main reliance when delirium appears, altho the usually indicated remedies have also been used.

In the usual treatment of the uncomplicated cases five drops of hydrochloric acid are given four times daily, some form of alcohol is used both as a food and as a stimulant, and strychnia is given in tonic doses.

There have been a number of quite severe cases at this hospital, but gratifying results have been obtained. The cases have not presented the coryza and other grip symptoms noticed elsewhere.

Peculiar Points in Diagnosing Typhoid in Children.

In children, who cannot relate the symptoms with which they are disturbed, there is sometimes some difficulty in diagnosing typhoid fever. Outside of the Widal test, which, being considered a test of immunity, is of more value in confirming than in originating a diagnosis, reliance must be

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placed upon physical signs which necessarily vary somewhat from the characteristics of the disease in an adult.

In children the period of incubation naturally depends upon the resisting power of the child at the time of receiving the infection, but varies from two days to three weeks. The curve of temperature follows the same scheme as in the adult, but in the child the febrile condition usually ends in about fourteen days, the length of the period depending upon the age of the child attackt, the time named being for children from three to five years old. Children from seven to ten years are apt to have a febrile period of about seventeen days. During convalesence in children subnormal temperatures are usually found in the morning.

Epistaxis is common in children, and the emaciation is markt and progressive. Constipation may occur, but is rare, the stools being generally frothy, watery, very foul smelling, and of a greenish hue.

The rose spots generally make their appearance from the sixth to the ninth day, and are far more characteristic than in the adult, and more unvaryingly present, possibly because the skin of the child is thinner.

The following may be given as a characteristic picture of the disease in a child. The patient is drowsy in the beginning, and very irritable, especially on being disturbed. The eyes will appear injected, and there will be disinclination to face the light. The child prefers to lie on its back, and if placed in another position, will work itself around on the back so long as its There will strength is equal to the effort. be all the appearances of severe frontal headache.

If cool water is proffered, the child will drink eagerly, and the lips will have a parched, dry look. The tongue is coated with a grayish, sometimes brownish fur, the tip and outside edges being usually a bright red. There is a total lack of appetite, the child usually refusing food in a very peevish manner.

The pulse beats vary with the temperature, running from 100 to 120 or even 140 per minute, the pulse being dicrotic as in the adult. There are less pulse beats in the morning than in the evening. An intermitting or irregular pulse must be carefully watched, as it is often a sign of possible cardiac paralysis.

The abdomen is soft, and the child shrinks if pressure is made in the right iliac region. The spleen may easily be recognized by percussion, but not easily by palpation.

A good prognosis can generally be made in infantile typhoid since the condition is seldom so serious as in adults, while the child is usually tenderly cared for. There is also apt to be closer restriction to the liquid diet, and less giving way to the whims of the patient. In addition the recuperative powers of the average child are usually enormous.

Since the establishment of the fact that the cause of typhoid fever is a bacillus, it will readily be seen that its presence in other parts of the body than the intestines may produce lesions complicating the fever itself or appearing as sequelae. It is a strange fact in medical literature that but little attention has been paid to these complications by writers, and that hence there is but little book lore upon them. This is especially true of such lesions as demand surgical interference, the literature upon these being very scant and scattered.

Among the lesions that may be traced directly to the presence of the bacillus of Eberth and which require surgical interference, may be mentioned not only the obvious one of perforation of the bowel, but abscesses of the abdomen, the brain, the ovary, the kidney, etc., appendicitis, necrosis of the bones and of the cartilages of the larynx, venous thrombosis, epididymitis, stricture of the esophagus, fistulæ, gangrene, glossitis, synovitis, malignant edema, meningitis, orchitis, parotitis, pericarditis, peritonitis, phlebitis, and many others. It has been well said that typhoid fever may be regarded as the typical disease, since to treat it successfully requires a knowledge of all branches of modern medicine and surgery.

Treatment of Hemorrhage in Typhoid.

Possibly first of the complications in point of importance and frequency is hemorrhage from the bowels. The obvious first point in the treatment of this condition is rest, so nearly absolute as possible. Food of all kinds should be withdrawn for a time, this to lessen peristalsis, or if the patient requires some food, so small quantities as possible should be given. It would be better to even lessen the amount of water ingested, giving this in the form of ice to be melted in the mouth whenever possible.

Elevate the foot of the bed, place an icebag or a bladder filled with broken iee over the abdomen in the region of the right iliac fossa, and if the hemorrhage is severe give enemas of ice water, about four ounces

at a time.

Medicinal treatment should comprise the employment of opium both by mouth and in suppositories, if necessary, giving until the pupils show contraction and great drowsiness is produced. If such degree of administration is considered necessary, the patient must be closely watched in order to prevent too profound narcosis. The inhibiting effect upon the bowels can also be assisted by the use of liberal doses of bismuth.

Occasionally the loss of blood is in so great quantities as to cause a practical exsanguination, and in such case recourse must be had to hypodermoclysis as the best means of supporting the failing circulatory system. The sterilized normal salt solution, .2 per cent. of salt to recentlyboiled water, must be used, and this is best administered by a Pravaz syringe with a hypodermic needle. Select for the place of the injection the loose skin on the thighs, the abdomen or the buttocks and have the solution so near blood-heat as possible. So much as a half-pint should be injected at a time, the operation being repeated so frequently as indicated by the condition of the patient. Transfusion of blood has been advocated, but this is attended with serious risks, as also is the intravenous injection of the saline solution, and therefore these should scarcely be considered.

There seems to be a widely-growing belief that the occurrence of hemorrhagic cases has largely increased with the grow ing popularity of the cold-water treatment, and also that the rate of fatalities in such cases is greater. Since the tendency to sluffing of the typhoidal ulcer is greatest in the third week of the disease, it would seem that at this period great care should be taken in the use of cold applications to the skin.

As to prognosis in cases of typhoidal hemorrhage, a fatal result may be anticipated when there is a tympanitic condition of the abdomen with a continual discharge of black clotted blood. Sometimes the blood-vessels are kept patulous by the bowels being distended with gas, and this would cause a continuance of the hemorrhage. If there is associated renal trouble the prognosis is grave, since this often alters the blood in some way, making it less coagulable. If there is marked organic heart disease the blood, being impoverisht and lessened in quantity is propelled slowly and the tissues are consequently imperfectly supplied with blood. In such event the hemorrhage is the last factor in

the exhaustion which immediately causes death. If the patient is a hemophiliac or bleeder it is practically impossible to save him, as the blood is so altered that there is little likelihood of its ever being staunched.

Intestinal Perforation in Typhoid Fever.

This is a most grave complication, the percentage of death running so high as eighty-three. It is supposed to be due in a large proportion of the cases on record to too energetic purgation, especially in the earlier stages of the disease. The perforation occurs in the last two feet of the ileum in over four-fifths of the cases. There is no traceable relation between perforation and the severity of an attack, since it takes place in the mild as well as in the severe cases. The symptoms foreshadowing an attack may be sudden and severe or may be either very mild or even entirely wanting.

One of the most dependable symptoms of perforation is the occurrence of a sudden acute pain in the abdomen, with symptoms of collapse, accompanied with an abrupt fall in the temperature. Occasionally vomiting is also present, tho this is a somewhat unusual symptom. When present, the obliteration of liver dulness, a gurgling sound on respiration, and hiccup, are useful signs, but as yet there has been noted nothing that might be termed a pathognomonic symptom.

Perhaps the nearest to a positive diagnosis can be obtained thru examination of the blood. During the course of typhoid fever the number of white corpuscles gradually sinks, reaching its lowest point about the end of the febrile period. With the development of an inflammatory complication there is a marked increase in the number of leucocytes, such as takes place under no other known conditions.

The general results of surgical interference are far more encouraging than those of expectation, and hence this would seem the advisable method of treatment. The prospects are more favorable when the per

foration has occurred at a late stage of the fever, and particularly during convalescence or during a relapse. Still, under all circumstances, unless operation is absolutely contraindicated by the condition of the patient, the surgeon should proceed with the least possible delay, a condition of success of the procedure of interference, since it is so seldom that an immediate diagnosis of the condition is possible. So soon as the condition is suspected, delay is fatal; since septic peritonitis, with an abdomen full of pus, is almost certain to follow and end in death. There is no other treatment to directly meet the condition than that of operation.

There seems an impression that the condition of hemorrhage is invariably associated with perforation, but this is far from the rule, the percentage of cases in which the hemorrhage appears being so low as only 12 per cent. of the total of perforative cases. Nor, on the other hand, is perforation sure to be present in the hemorrhagic

cases.

The treatment may thus be summarized: Do not operate while a condition of shock exists, but so soon as possible after the appearance of beginning reaction. Give first a hypodermic of morphin, since this lessens pain and arrests peristalsis, thus limiting extension of the septic fecal matter. After closure of the perforation with a double row of Lembert's sutures, thoroly cleanse the abdominal cavity with sterilized normal salt solution, by means of a soft rubber tube which will give a return. Provide free drainage by strips of iodoform gauze introduced in all directions between the coils of the intestines, and by a large glass open-ended drainage tube passed down to the end of the pelvis. Dressings should be frequently changed during the first two days, a good surgical nurse thus being an essential.

It may be emphasized as a truth that it is far more dangerous to allow perforation from a typhoid ulcer to go without operation than for the operation to be made by the most inexperienced physician.

The Occurrence of Jaundice in Typhoid Fever.

The somewhat rare cases in which a jaundice appears in the progress of typhoid are apt to be confused with malaria, and hence have often not been carefully studied. According to Da Costa, jaundice in typhoid is not always associated with the same lesion, and is no more to be regarded as significant of any one hepatic disorder than when it occurs independently of the fever. It generally, however, occurs from blood infection, and without organic lesion, and is a very grave symptom.

Jaundice does not usually set in until the middle or latter part of the fever, tho it may occur earlier. When this complication is present there is often delirium, and the temperature is commonly very high. Chills are rather common, as is also pulmonary congestion, and vomiting is frequent, also epistaxis, the latter being distinctly related to the intensity of the jaundice. The urine shows traces of bile, and usually albumin and casts. It is very rarely that the stools are clay colored, the usual dark color of typhoid prevailing.

The most important diagnostic points of this complication are prolonged and repeated chills, great variations in temperature, profuse sweating, and pain in the region of the liver. A sense of fluctuation is a valuable diagnostic point when present. The condition is most liable to be con

founded with appendicitis, the pain being, however, commonly higher, tho its position is variable.

The treatment is somewhat uncertain. altho favorable results have been obtained from the use of mineral acids. Large doses of quinin may be employed, and leeches have been applied over the liver with benefit. If the discharges are dark. calomel should be used. If there is suppuration, supportive treatment is indicated. and surgical interference seems the best form of treatment to effect a cure.

The Nervous System in Typhoid. The nervous system is liable also to many derangements, sometimes these being