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cilli may be found in a single c.c. of was more than double that occurring urine of a typhoid patient. Richard- among those inoculated, which is very son of Boston, Blumer of Baltimore encouraging at least, and we may and Horton Smith of London have also hope that the day is not far distant emphasized this fact.

when something in this line may be It has been found on investigation produced that will rank with antitoxin by carefully separating the discharges, in the prophylaxis, and treatment of that in the earlier stages of the disease diphtheria. the stools contain great numbers of As to the treatment of typhoid, if we bacilli, which decrease as the disease but for a moment stop to consider the progresses, while the reverse condition great difference in degree of severity maintains with regard to the urine. and extent of infection and general

When we consider the intestinal manifestation of the disease, we will canal as the culture tube where the ba- readily see how absurd it would be to cilli are grown, to be later taken up attempt to lay down any hard and fast and emptied into the circulation to be rules to be followed or be governed by. still later excreted by the kidneys as I know of no disease that requires a one of the principal avenues of elim- greater amount of tact and skill and I ination, the above statement would might add, good common sense, than seem to be substantiated. But in this the management of typhoid. There connection it would be well to state are cases, though rare, with no fever in view of what may be said later on and even a subnormal tempture that in regard to treatment that the intes- show a profound toxemia, manifested tinal tract is not always the battle by a weakened heart action, great exfield of the bacillus, but the meninges haustion and mental disturbance. of the brain the lungs, kidneys, etc., How foolish to use the cold bath are sometimes the favored point of the which has proven itself so valuable in attack, and cases where typhoid has well-selected cases, in a case like this, caused death and the autopsy has then again take the other extreme in shown no intestinal ulceration, have temperature with a weak and rapid frequently been recorded.

heart, patient tympantic and with disProphylaxis by anti-typhoid inocula- tressed breathing, too weak to move tion has been given a great deal of or help himself, and plunge him into study by bacteriologists in the past a cold bath, I feel as Osler says, “When few years and Wright of England has

I see

poor fellow (who has been been using an injection of a four

dumped like Falstaff, hissing hot into a weeks' old culture of virulent typhoid cold tub) chattering maledictions upon bacilli in one per cent. lysol solution nurses and doctors, I am inclined to and his reports in the Lancet of Jan- resent it, and to pray for a method uary 30, 1900 and February 9, 1901, of which may be, while equally lifeexperiments by the medical officers of

saving, to put it mildly, less disathe British army, both in India, and greeable.” But are such measures unwith soldiers inoculated before leav. der such circumsances life saving? I ing England for South Africa to take question it very much indeed. part in the English-Boer War, go to To submit such a patient to such a show that the mortality was greatly treatment, not only tends to produce lowered in case of those inoculated, shock and heart failure, but congestion as compared with those not so treated. of the abdominal viscera and subseWhile the percentage of cases of ty. quent hemorrhage. Then again do we phoid occurring in the uninoculated, accomplish any real benefit by tempor

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or

arily reducing the surface temperature and attendant exertion and handling of the body? As it is a fact that the , of the patient increases the tendency temperature of the rectum shows very to hemorrhage and also perforation of little decrease, unless the bath be the bowel is proven by the records of greatly prolonged, when the thermome- the best authorities in both Europe and ter under the tongue indicates America. marked depression. As the principal Personally it is my judgment that benefit gained from the use of the bath the proper course is a happy medium, is derived from the rubbing and mas- or combined antiseptic, bath (or probsage, and consequent improvement in ably sponging with liberal rubbing,) the circulation of the skin, improving and supportive treatment. Though It the tone of the blood vessels them- is admitted that it is impossible to selves and stimulating the emunctories render the intestinal canal aseptic, yet in ridding the system of toxins.

I use

calomel to keep the bowels. Why may we not accomplish the free from retained and putrifying desired end a great deal easier and feces, assisted by such remedies as with more comfort and less danger to salol, thymil, guicol carbonate, the patient, by cold sponging and in guiaquin (a combination of guiacol and extreme high temperature, ice ap

quinine bisulphate,) oil of turpentine plied to the spine, which not only or eucalyptus, thymol, and menthol. We cools and relieves the tired and aching can in a great measure inhibit the formuscles, and deeper tissues of the mation of toxins and gases which by posterior portion of the body which distention of the gut causes tympannaturally suffer from stasis, owing to ites, which not only increases the liaposition, but by cooling the spinal bility of perforation, but distresses the fluid, have a beneficial effect on the patient and interferes with the action brain as well? Statistics are often mis- of the lungs, heart and general circulaleading, while the conceded mortality tion. At the same time you lessen the is about 12 per cent. under all forms necessity for 'baths, antipyretic of treatment.

drugs, (which by the way are as a Brand has collected 19,017 cases rule bad) by cutting off the supply or treated by cold baths showing a mor- fuel, and by these measures lessen the tality of 7.8 per cent. Leibermiester danger of hemorrhage by encouraging records the treatment of 150 cases, 50 the healing of the ulcerated bowel, and by iodine; 50 by calomel; and 50 by also shorten the duration of the disgeneral and indefinite treatment,

And again by keeping the bowels lecting cases admitted to the hospital clear of offending material, there is a about the same time, and all of whom better condition of the whole digestive were looked upon as grave cases in tract, which will enable our patient to their early history, all calomel cases take and assimilate more nourishment, recovered, and yet he rejected all cases which is one of the chief factors to be which did not reach an axillary tem- considered. perature of 104, or over.

Give the patient liberal quantities of Mason of Boston records five differ- boiled or distilled water not only beent series

cases, aggregat- cause it is refreshing and grateful to ing 242 with a mortality of only the patient, but it assists in rendering two per cent. The treatment soluble the poisons to be eliminated, consisted of cold sponging, affusions, and flushes the sewer, so to speak. As the use of antipyretic drugs, antisep- to diet let it be of easily-digested tics and tonics. That the cold bath liquid food, and that which is digested

or

se

ease.

of

use

in the stomach as nearly as possible of the case in its earlier stages. When so as not to tax the already weakened hemorrhage occurs, use measures acintestinal digestion, and leave matter cording to the severity of the case, to decompose and act as an irritant. sometimes the administration of opium

I believe it is a mistake to feed our in some form to quiet peristalsis, is all typhoid patients beef extract and ani- that is required; then again when hemmal broths as we formally did for the orrhage is severe it is necessary to rereasons above stated. Milk is the ideal tain the blood in the extremities as food as it contains all the elements much as possible, by of elastic necessary to nourish the patient and bandages to the arms and legs close has the advantage of being always to the trunk, external application of ice available, readily sterilized, can be and internal uses of some astringent combined with farinaceous foods, eggs, such as per sulphate iron. aerated waters, or stimulants when When perforation takes place, there required; and this leads me to speak is only one thing to do that offers any of alcohol which may be given in vari- hope of relief and that is abdominal ous forms with advantage in properly- section, and suturing the gut, and that selected cases, the same as you might must be done promptly. give strychnia or digitalis, but not as Bronchitis and pneumonia will rarea routine treatment.

ly occur where the patient is properly One point we must not overlook is watched, the position frequently the cleansing of the patient's mouth, changed, draughts of air avoided, and which is as essential to his comfort the patient properly rubbed, and the and well being as baths and clean linen chest protected after baths. some mild antiseptic wash such as lis- When these complications ensue, terine, or 5 per cent. solution of H.20.2 they should be met with such measure with a little glycerine added, does very as would ordinarily be called for, and well.

especially, carb. ammonia, infusion Should the bowels be constipated, digitalis and whisky, with codeine or and moderate doses of calomel fail to heroin to control the distressing give the desired results, magnesia sul- cough. phate may be given, or enemeta of nor- In conclusion I might say treat each mal salt solution, carefully given individual patient according to the exthrough a colon tube.

igencies of the case, using such measAs to the complications of typhoid ures as have been outlined, or others fever, it is impossible to take up and that will accomplish the same ends, as discuss them in a paper of this nature, in your judgment may give your pafor I have already taken up too much tient the most comfort during an entime; suffice it to say of the most im- forced illness. Help him to withstand portant hemorrhage, perforation, bron- the necessary depression that he must chitis and hypostatic pneumonia, pre- undergo, and give him the best chance vent, if possible by proper management for ultimate recovery.

SELECTED.

DEPARTMENT OF TUBERCULOSIS.

*

CLIMATIC TREATMENT OF PULMONARY TUBERCULOSIS.—The author said the objects of treatment by climate in cases of pulmonary tuberculosis seemed to be the following: 1. 10 arrest catarrhal conditions of the air passages. 2. To improve nervous and circulatory tone. 3. To increase the activity of the digestive functions, and thus stimulate nutrition by promoting the desire and increasing the power to take exercise. 4. To raise the normal tone-by no means an unimportant matter-by affording a clear, bright, and cheerful environment. 5. To diminish by its asepticity bacterial activity. It is a question for consideration whether socalled "open-air" treatment, without regard to suitable climatic conditions, will do all this. It should be our object when practicable to place the consumptive patient under conditions and in circumstances where, without risk or injury, he may obtain the most complete and perfect aeration of the lungs possible. If you place a feeble catarrhal patient in the open air in a damp and cold climate, you will risk an increase of the catarrh, and this will diminish pulmonary aeration by blocking up the air passages. The modern open-air treatment is only “new” in its manner of carrying out this idea of hyper-aeration of the diseased lungs, and we must be especially careful in applying it to avoid the risk of aggravating catarrhal conditions. This, I think, has now been fully admitted by some of the most strenuous advocates of open-air treatment per se. The recommendation of a long sea voyage as a cure or phthisis doubtless had its origin in the idea of pulmonary hyper-aeration. It was an early form of “open-air”

treatment, but with grave drawbacks anu risks. It may be interesting to mention that between two and three centuries ago Sydenham seems to have had in his mind also this same idea of hyper-aeration of the lungs in the treatment of consumption. Now climatic treatment is essentially open-air treatment; and the appropriate selection of a climate must depend on the suitability of that climate to open-air life in the particular cases we may have to deal with.

"It is difficult to establish any precise and rigid classification of the cases best suited to particular places, because in many cases, with a limited idea of local disease, the patients will do well and obtain arrest of the disease in a variety of places with somewhat different climatic conditions.

Many chronic stationary cases with sair general health travel about to different winter resorts in successive seasons and appear to benefit more or less in all. Another difficulty in drawing reliable conclusions from statistics is the tendency on the part of certain observers to use somewhat vaguely the terms "incipient phthisis” and “pretuberculous phthisis." I find many practitioners are in the habit of using the term "incipient phthisis” in the sense of "suspected phthisis"; in that case it expresses an opinion rather than a fact. If this practice is largely acted upon it must greatly detract from the value of the statistics obtained. It would be better, I venture to suggest, to discard the use of the term "incipient phthisis” and use the more precise term, "early phthisis," instead; and then in the preparation of statistics

should be stated on what observed symptoms and physical signs this diagnosis is founded. The term "pre tuberculous" phthisis is, I think, still more objectionable. In estimating the results of any form of treatment these terms, I would suggest, should not be used. We are, I suppose, all agreed that early cases with a very limited area of local disease, with little or no fever with integrity of the digestive functions, and in young and otherwise healthy adults do well and are frequently cured in a variety of climates provided they live a perfectly hygienic, open-air life. They recover probably more speeaily in altitude climates than elsewhere.

"Advanced Chronic Cases.--The idea that formerly prevailed that a warm, moist and equable climate, was the best for consumptives had a certain foundation in the suitability of such climates to the advanced catarrhal cases. There was little idea of cure associated with these climates, because consumption was then regarded as incurable, but it was thought that they prolonged life, and made toe slow process of dying less pain: ul. The quality of equability in a climate was at one time greatly overrated. Indeed, we nowadays avoid an equable climate when seeking a cure for early cases of pulmonary tuberculosis. We rather seek a climate with a very wide diurnal range of temperature, if it is a dry climate, as the Engadine (Swiss Alps) or Egypt. While diurnal variations of temperature exert a bracing, invigorating tonic effect, especially when they follow certain regularity. What renders our own climate so very trying at times is that, although very variable, the variations of temperature follow no regularity. We get a week or ten days of very cold, dry weather, and then, just as the organism is adapting itself to the dry external cold, it changes, and we get a spell of moist, southwesterly winds, to be followed after a few days by a

return of the severely cold, dry weather, and so on. It is on this account that our climate can never be well suited to the out-of-door treatment of cases of catarrhal phthisis.

“Early and Moderately Advanced Phthisis.—There is no great difficulty then in deciding what to do with cases at the very onset; we must be greatly influenced by questions of age, sez, temperament, occupation, social conditions and constitutional tendency. They will get well in a variet; of places with careful management. Nor is 'there much room for hesitation as to what course is best to follow in decidedly advanced cases. The progressive febrile cases are best in bed with an abundant supply of fresh air. It is the moderately-advanced case that calls for careful discrimination, and is the most difficult to decide about. It is now that the question of constitutional tendency comes into the foreground. Tuberculosis being an infective disease attended with greater or less dissemination of toxic substances throughout the organism, we find, as we do with the attacks of other infective microbes, varying degrees of reaction, of susceptibility, or infectibility, in different types of constitution.

"Cases Unsutiable for Mountain Climates.-It has been thought that the gouts constitution is antagonistic to tuberculous infection. My impression is that the rheumatic constitution is so also, and that the latter is especially prone to develop the slow, fibroid, pleurogenic form of phthisis. Now this form is not, in my opinion, well suited to altitude climates. These cases do best in dry and warm climates, such as the more protected resorts of the *Riviera and the desert climate, as in Upper Egypt or **Biskra. Setting aside this group, the

*Equivalent to the coast climate of Southern California.-Editor.

**Surpassed by Indio and other Southern California deserts.

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