cilli may be found in a single c.c. of urine of a typhoid patient. Richardson of Boston, Blumer of Baltimore and Horton Smith of London have also emphasized this fact.

It has been found on investigation by carefully separating the discharges, that in the earlier stages of the disease the stools contain great numbers of bacilli, which decrease as the disease progresses, while the reverse condition maintains with regard to the urine.

When we consider the intestinal canal as the culture tube where the bacilli are grown, to be later taken up and emptied into the circulation to be still later excreted by the kidneys as one of the principal avenues of elimination, the above statement would seem to be substantiated. But in this connection it would be well to state in view of what may be said later on in regard to treatment that the intestinal tract is not always the battle field of the bacillus, but the meninges of the brain the lungs, kidneys, etc., are sometimes the favored point of the attack, and cases where typhoid has caused death and the autopsy has shown no intestinal ulceration, have frequently been recorded.

Prophylaxis by anti-typhoid inoculation has been given a great deal of study by bacteriologists in the past few years and Wright of England has been using an injection of a fourweeks' old culture of virulent typhoid bacilli in one per cent. lysol solution and his reports in the Lancet of January 30, 1900 and February 9, 1901, of experiments by the medical officers of the British army, both in India, and with soldiers inoculated before leaving England for South Africa to take part in the English-Boer War, go to show that the mortality was greatly lowered in case of those inoculated, as compared with those not so treated. While the percentage of cases of typhoid occurring in the uninoculated,

was more than double that occurring among those inoculated, which is very encouraging at least, and we may hope that the day is not far distant when something in this line may be produced that will rank with antitoxin in the prophylaxis, and treatment of diphtheria.

As to the treatment of typhoid, if we but for a moment stop to consider the great difference in degree of severity and extent of infection and general manifestation of the disease, we will readily see how absurd it would be to attempt to lay down any hard and fast rules to be followed or be governed by. I know of no disease that requires a greater amount of tact and skill and I might add, good common sense, than the management of typhoid. There are cases, though rare, with no fever and even a subnormal tempture that show a profound toxemia, manifested by a weakened heart action, great exhaustion and mental disturbance.

How foolish to use the cold bath which has proven itself so valuable in well-selected cases, in a case like this, then again take the other extreme in temperature with a weak and rapid heart, patient tympantic and with distressed breathing, too weak to move or help himself, and plunge him into a cold bath, I feel as Osler says, "When I see poor fellow (who has been dumped like Falstaff, hissing hot into a cold tub) chattering maledictions upon nurses and doctors, I am inclined to resent it, and to pray method for a which may be, while equally lifesaving, to put it mildly, less disagreeable." But are such measures under such circumsances life saving? I question it very much indeed.

To submit such a patient to such a treatment, not only tends to produce shock and heart failure, but congestion of the abdominal viscera and subsequent hemorrhage. Then again do we accomplish any real benefit by tempor

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arily reducing the surface temperature of the body? As it is a fact that the. temperature of the rectum shows very the bath be little decrease, unless greatly prolonged, when the thermomeindicates ter under the tongue marked depression. As the principal benefit gained from the use of the bath is derived from the rubbing and massage, and consequent improvement in the circulation of the skin, improving the tone of the blood vessels themselves and stimulating the emunctories in ridding the system of toxins. the not accomplish Why may we desired end a great deal easier and with more comfort and less danger to the patient, by cold sponging and in extreme high temperature, ice applied to the spine, which not only cools and relieves the tired and aching muscles, and deeper tissues of the posterior portion of the body which naturally suffer from stasis, owing to position, but by cooling the spinal fluid, have a beneficial effect on the brain as well? Statistics are often misleading, while the conceded mortality is about 12 per cent. under all forms of treatment.

Brand has collected 19,017 cases treated by cold baths showing a mortality of 7.8 per cent. Leibermiester records the treatment of 150 cases, 50 by iodine; 50 by calomel; and 50 by general and indefinite treatment, selecting cases admitted to the hospital about the same time, and all of whom were looked upon as grave cases in their early history, all calomel cases recovered, and yet he rejected all cases which did not reach an axillary temperature of 104, or over.

Mason of Boston records five different series of cases, aggregating 242 with a mortality of only two per cent. The treatment consisted of cold sponging, affusions, the use of antipyretic drugs, antiseptics and tonics. That the cold bath

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Personally it is my judgment that the proper course is a happy medium, or combined antiseptic, bath (or probably sponging with liberal rubbing,) and supportive treatment. Though it is admitted that it is impossible to render the intestinal canal aseptic, yet I use calomel to keep the bowels free from retained and putrifying feces, assisted by such remedies as salol, thymil, guicol carbonate, guiaquin (a combination of guiacol and quinine bisulphate,) oil of turpentine or eucalyptus, thymol, and menthol. We can in a great measure inhibit the formation of toxins and gases which by distention of the gut causes tympanites, which not only increases the liability of perforation, but distresses the patient and interferes with the action of the lungs, heart and general circulation. At the same time you lessen the necessity for baths, antipyretic drugs, (which by the way are as a rule bad) by cutting off the supply of fuel, and by these measures lessen the danger of hemorrhage by encouraging the healing of the ulcerated bowel, and also shorten the duration of the disease. And again by keeping the bowels clear of offending material, there is a better condition of the whole digestive tract, which will enable our patient to take and assimilate more nourishment, which is one of the chief factors to be considered.

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Give the patient liberal quantities of boiled or distilled water not only because it is refreshing and grateful to the patient, but it assists in rendering soluble the poisons to be eliminated, and flushes the sewer, so to speak. As be to diet let it of easily-digested liquid food, and that which is digested

in the stomach as nearly as possible so as not to tax the already weakened intestinal digestion, and leave matter to decompose and act as an irritant.

I believe it is a mistake to feed our typhoid patients beef extract and animal broths as we formally did for the reasons above stated. Milk is the ideal food as it contains all the elements necessary to nourish the patient and has the advantage of being always available, readily sterilized, can be combined with farinaceous foods, eggs, aerated waters, or stimulants when required; and this leads me to speak of alcohol which may be given in various forms with advantage in properlyselected cases, the same as you might give strychnia or digitalis, but not as a routine treatment.

One point we must not overlook is the cleansing of the patient's mouth, which is as essential to his comfort and well being as baths and clean linen some mild antiseptic wash such as listerine, or 5 per cent. solution of H.20.2 with a little glycerine added, does very well.

Should the bowels be constipated, and moderate doses of calomel fail to give the desired results, magnesia sulphate may be given, or enemeta of normal salt solution, carefully given through a colon tube.

As to the complications of typhoid fever, it is impossible to take up and discuss them in a paper of this nature, for I have already taken up too much time; suffice it to say of the most important hemorrhage, perforation, bronchitis and hypostatic pneumonia, prevent, if possible by proper management

of the case in its earlier stages. When hemorrhage occurs, use measures according to the severity of the case, sometimes the administration of opium in some form to quiet peristalsis, is all that is required; then again when hemorrhage is severe it is necessary to retain the blood in the extremities as much as possible, by use of elastic bandages to the arms and legs close to the trunk, external application of ice and internal uses of some astringent such as per sulphate iron.

When perforation takes place, there is only one thing to do that offers any hope of relief and that is abdominal section, and suturing the gut, and that must be done promptly.

Bronchitis and pneumonia will rarely occur where the patient is properly watched. the position frequently changed, draughts of air avoided, and the patient properly rubbed, and the chest protected after baths.

When these complications ensue, they should be met with such measure as would ordinarily be called for, and especially, carb. ammonia, infusion digitalis and whisky, with codeine or heroin to control the distressing cough.

In conclusion I might say treat each individual patient according to the exigencies of the case, using such measures as have been outlined, or others that will accomplish the same ends, as in your judgment may give your patient the most comfort during an enforced illness. Help him to withstand the necessary depression that he must undergo, and give him the best chance for ultimate recovery.

"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. To 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 sta

tionary cases with fair 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 it should be stated on what observed symptoms and physical signs this di

agnosis is founded. The term "pretuberculous" 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 speedily 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 the slow process of dying less painful. 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 a 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 pe greatly influenced by questions of age, sex, temperament, occupation, social conditions and constitutional tendency. They will get well in a variety 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 gouty 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.