is to keep the temperature reduced, provided this can be done without harm or risk to the patient. The best method of doing this is by the use of hydrotherapy, first insisted on by Brand, but modified to suit individual cases, no strict rule being rigorously applied.

Brand's original method consists in the immersion of the patient in a bath of 60° F. for fifteen minutes, repeated every three hours so long as the temperature is 102.2° F. by the rectum. During the bath cold water is applied to the head and the surface of the body is briskly rubbed. After the bath the patient is dried, wrapped in blankets, and given a hot alcoholic drink if chilliness is apparent. No internal antipyretics are employed.

Under the Brand treatment it is claimed that not only is the temperature reduced, but that there is also a tonic effect produced on the circulatory and nervous centres, the intellect becomes clearer, the stupor less marked, muscular twitchings disappear, and insomnia is lessened, the patient frequently falling into a refreshing sleep. Complications are rendered more infrequent, and, what is most important, the mortality is reduced to a minimum. Brand's latest statistics show but twelve deaths in 1223 cases, a mortality of but I per cent. Not a patient died who came under treatment prior to the fifth day. These statistics, however, are taken from German military hospitals, where the patients are young, robust, and are treated early. Ordinarily, under this treatment the mortality is about 7 per cent. No effect is claimed in reducing the duration of the disease nor in lessening the liabilty to relapses. The contraindications are intestinal hemorrhage, perforation or danger of perforation, and peritonitis. Bronchitis and pneumonia do not prevent the treatment.

While this extreme method may be applicable in military hospitals and in robust, insensitive patients, its rigorous

employment in all cases has decided disadvantages and requires modification. As a general rule, then, the modified bath must be employed, the temperature being 80° to 90° F. at the commencement and being gradually reduced 10° F. by the addition of cold water. This bath should be given whenever the temperature is 102.5° F. or over, provided it be not more frequent than every three hours. Friction of the body and affusion of the head should be employed in all cases.

For nervous, sensitive patients who are in mortal dread of such a modified bath the wet pack may be employed. The bedding being protected by a rubber blanket, the patient is wrapped in wet sheets closely applied by brisk friction. From time to time the patient is sprinkled with cool water.

The most simple method of hydrotherapy is the sponging of the body with water or with water and alcohol. If done for ten or fifteen minutes this will cause a slight reduction in temperature, but the method is too inefficient to be of much benefit in severe cases.

The use of internal antipyretics is attended by many disadvantages, and is less frequently employed now than formerly. While the temperature may be reduced by these drugs, there is also a depression of the nervous and circulatory centres, so that stimulants may be required to overcome the effects of the drugs. The actual mortality seems to be slightly increased by their use. The drugs most frequently employed for this purpose are antipyrine (gr. x), phenacetine (gr. v), and antifebrine (gr. ij). They were formerly given in much larger doses than at present. Quinine is now given, not to reduce temperature, but for its tonic effect. Whatever antipyretic is used should be given in small doses repeated in two hours if necessary, and not too great a fall of temperature should be produced, the re

duction of a degree or a degree and a half being usually sufficient.

The pulse should be watched carefully, with special regard to its weakness rather than its rapidity. Alcohol is the best stimulant, in the form of whiskey or champagne, and when indicated must be given freely until its effect is noticed, even if 8 to 12 ounces of whiskey be given in the twenty-four hours. Strychnine may be combined with the alcohol, and is of service. Digitalis may also be employed. In cases where there is a rapid feeble pulse with marked septic symptoms, large rectal enemata and of intestinal disinfectants often are of benefit.

Vomiting is best treated by regulating the diet. Bismuth and oxalate of cerium are occasionally serviceable. If vomiting seems to be due to the tympanites, the latter condition should be treated. In severe cases rectal feeding may have to be resorted to.

For the diarrhea opium by the mouth or the rectum, with the addition of the ordinary astringent drugs, is to be given. The stools should be examined to see that the diarrhoea is not caused by undigested curds.

Constipation is to be treated in the first week by saline laxatives or by castor oil. Later in the disease enemata are preferable, so that the bowel is emptied every second day.

For the tympanites turpentine stupes or 5-minim doses of turpentine in capsule constitute the best treatment. Intestinal antiseptics, as salol, 3-naphthol, or creosote, may be of service, while the insertion of a soft rectal tube may afford relief.

For hemorrhages the patient should be kept absolutely quiet, opium in full doses being given. The use of internal astringents does not seem to do good. Applications of ice to the abdomen may be employed. The diet should be restricted, although the patient may be given acid drinks

and cracked ice. In case of severe hemorrhage external warmth and stimulants should be used. Subcutaneous in

jections of warm sterilized saline solutions may be given. The treatment of perforation is that, in the first place, of collapse-by warmth to the body and free stimulation, while opium should be given in full doses. Should the perforation occur in a robust person or during convalescence, the question of laparotomy and closure of the perforation should be considered.

Peritonitis is to be treated by the cold abdominal coil and by opium in full doses. In selected cases laparotomy and drainage may be resorted to.

The nervous symptoms are best controlled by the hydropathic treatment, which, acting as a tonic on the nervous centres, reduces the restlessness, allays the delirium, and promotes sleep. Where this treatment can be employed drug sedatives are seldom needed. Where drugs are needed phenacetine (gr. v, q. 3 h.) will relieve the headache and restlessness, sulphonal (gr. x-xx) or chloralamide (gr. x-xv) will promote sleep. In severer cases opium may be neces

sary.

Complications are to be treated on general principles.

Treatment of convalescence is trying to physician and to patient alike. The greatest care should be exercised in the management of the diet, as the patients are ravenously hungry and clamor for food. The patient should be kept in bed for five days after the temperature is normal, and on a fluid diet-not necessarily, however, on milk. No solid food should be given for at least ten days. At the end of this time one solid meal may be given in the middle of the day, of chop or mutton with a baked potato, and afterward a gradual change to three meals a day may be allowed. There are cases where the evening temperature remains irregularly high. These cases are benefited by quinine

and solid food. During convalescence attention should be given to the digestion and the bowels, and tonics should be administered. A change of air is to be recommended, and patients should not be allowed to return too soon to business and daily cares.

The recrudescences are to be treated by a milk diet and rest in bed while the fever remains high. The treatment of a relapse does not differ from that of the original attack.

TYPHUS FEVER.

Definition and Synonyms.-Typhus fever is an acute contagious disease with an acute onset, a characteristic eruption, and a febrile movement of about two weeks' duration. Synonyms: Cerebral typhus; Exanthematic typhus; Spotted, Camp, Jail, or Ship fever.

Etiology.-Typhus fever is endemic in England, Ireland, and Russia, and to a less extent in Poland, Galicia, and certain parts of Southeast Europe. A few cases occur every year in New York and Philadelphia. From time to time the disease occurs in other places in epidemics. These epidemics have usually followed wars or famines, the disease being regularly favored by the overcrowding of people in jails, houses, or camps, by poor hygiene, by starvation, and by filth. It never arises spontaneously, but always from some previous case. It is one of the most highly contagious diseases known, being equally virulent throughout its course. The poison of the disease has not as yet been demonstrated, although it is known to be given off from the bodies of the sick and the dead, to be carried in the air, and to be retained in bedding, clothes, carpets, etc. for a considerable time, so that the poison is conveyed not only from person to person, but also by clothing and bed-rooms. But a very few persons are exempt if they be sufficiently. exposed, and the more prolonged and concentrated the