of iodine to the dose, usually given in pepermint water. It may be given in a capsule, provided care is taken that food is in the stomach before it is given. The late William Pepper thought Bartholow's treatment a joke, but he advised giving it three times a day only, in which amount its effect certainly would not be appreciable. At the same time, Pepper was himself an enthusiastic advocate of the use of intestinal antiseptics, only be advocated silver nitrate as the great remedy for this purpose. Two things are necessary for the effective administration of these remedies. They must be given in doses sufficiently large and they must be given at short intervals. The interval between doses must not be greater than two hours. I often give them for a limited period every hour.

It must ever be remembered that typhoid fever is not a local disease, but a systemic infection. One often hears the thought expressed or implied that in the treatment of this disease, control of the temperature is the one paramount object to be attained. This is a fundamental and very hurtful error. It is however true that the degree of fever may be accepted as an index in great measure to the severity of existing toxemia, and consequently a guide in treatment. Now, the only rational method of reducing temperature is hydrotherapy since it alone eliminates the fever-exciting toxines. To employ the coal tar products for this purpose is a positive damage since they actually promote retention of the toxines. The full cold bath of Currie and Brand, in the absence of special contra-indications, is the only proper method of application of hydrotherapy. As has been remarked, "Every deviation from the simple principles of this method gives less satisfactory results." In my opinion, no other mode of application of hydrotherepy is in the same class or comparable in its results with the Brand bath. The test in. this comparison is not the simple, mild case, it is the complicated and dangerous case which demands the best we have. I am in hearty accord, for example, with Edwards when he remarks in reference to cold sponging: "It is a refreshing and quieting placebo. The powerful effect of the Brand method in increasing the toxic coefficient of the urine has been amply demonstrated. In other words, toxic bodies which under every other method of treatment, remain in the blood to accomplish their deadly work, are by this means eliminated as rapidly as formed and the patient escapes uninjured. The advantages of the Brand bath are (I) It saves 6 or 8 lives in each 100 cases. (II) Toxemia is so far diminished that delirium, insomnia and other nervous

symptoms do not apepar. The digestive system maintains a comparatively healthy condition and nutrition does not suffer severely. The heart retains its power and the patient does not become extremely prostrated. Bed sores seldom occur. (III) As already stated, activity of the kidneys is greatly stimulated, resulting in enormously increased elimination. (IV) The clinical course is shorter. The patient is only comfortably sick, the traditional typhoid condition is conspicuous by its absence and the duration of convalescence is greatly abbreviated.

Briefly stated, the contraindications to the use of the Brand method are hemorrhage or perforation, pronounced alcoholism, great prostration, extensive arteriosclerosis or cardiac disease and severe phlebitis. I have not time to discuss the objections offered to this treatment. I will simply remark that it is not cruel. People will not oppose it when they are acquainted with the facts in reference to it. It does not increase the danger of complications. Other methods of applying hydro-therepy do not yield as good results. It is available outside of hospitals and homes supplied with a water system. It does involve some labor for the nurse, but that must not be permitted to prohibit its use.

Now, in mild cases that do not come within the scope of the Brand method a daily sponge bath is desirable.

I may mention a few special symptoms that require attention. The initial bronchitis may be benefited by a simple cough mixture or a few doses of codeine. It seldom persists after the first few days. Common sense should dictate the condition in which the bowels are to be maintained. Some have discovered wonderful efficiency in obstinate constipation and others in a persistent diarrhoea and have even in print advocated such ideas. Enemeta are safe in constipation and yet I have seen the most obstinate constipation develop when there was a daily movement produced in this way. This has its danger and should be forestalled by the use of mild cathartics. Diarrhoea depends as a rule upon toxemia or bad digestion. The best treatment is the bath. Also, calomel, two to two and one-half grains in divided doses followed by a mild saline and attention to the diet are indicated. If the condition is not promptly remedied bismuth should be given. The treatment for tympanites is usually the treatment for diarrhoea or more especially care of the diet. For the early headache an ice bag may help. To continue this throughout the disease is a nuisance to the patient and unnecessary. The worst nervous symptoms vanish when

the bath is employed. The presence of delirium is proof of bad treatment. For heart weakness the best drug is strychnine. Alcohol and ligitalis may be used if found efficacious. Also secure rest and nourish the patient.

Most amazing for their contradictions are the countless measures that from time to time have been advocated in the management of typhoid fever. I suppose the end is not yet. The matter of the feeding of these patients has received its full share of discussion and of diversity of opinion. To me it would appear that common sense is applicable here as elsewhere. It can not be doubted that the typhoid patient has need of all the strength he can muster for the fight he has to make. How best to nourish him is another problem that I have not the time to discuss. In a word it would seem that the food ought to be nourishing, digestable and such as will do the least damage in the intestine. To meet these indications I would urge you to stick to the old friend, milk. It may be more or less modified-diluted, peptonized, mixed with some soft thin gruel or given in connection with lime water. Milk is the best article to serve as the basis for feeding. The stools should be carefully inspected to be sure that it is properly digested. The presence of fever, I take it, creates a demand for some additional carbohydrate. Maltine or a similar preparation or one of the gruels already referred to meets this demand. Give the food not oftener than once in two hours. I prefer to give it every three hours with one six hour interval in the night. In my opinion it is simply fool-hardy to give typhoid patients an unrestricted diet. I protest against any approach to such a thing.

I would like to make a few remarks about the care of the convalescent patient, but dare not take the time.

I am perfectly aware that I have given you nothing new in reference to the treatment of typhoid fever. It was in 1787 that James Currie, the friend of Robert Burns and editor of his poems, advocated this treatment. Nathan Hale of Yale supported it strongly. Since 1861 it has been especially associated with the name of Brand who apprehended its value so fully that he expended enormous labor to convince the profession of their duty in reference to it as a means of saving the lives of their patients. I want to tell you, gentlemen that quite too many therapeutists are like certain ancient Athenians who "Spent their time in nothing else but either to tell or to hear some new thing." This remark is not to be construed to mean the least

disparagement of progress in therapeutics. But as we progress let us bring along with us all that has genuine merit of that which is already in our possession. In this society and in others, as well as in my clinical teaching, I have for many years urged the value of the Brand bath in typhoid fever. I was pleased when the chairman offered me this opportunity to again insist upon it. This treatment is right in principle for the reason that it aims at the elimination of the toxines which destroy the patient. That is to say, it strives for the removal of the cause of the trouble. And yet it does not touch the fundamental cause. It comes the nearest to that, that has so far been possible. One step yet remains to be taken, viz: the discovery of a substance which will prevent the very formation of these deadly toxines. When that remedy has been discovered it will supercede the Brand bath as nothing else will. It may be that this long-sought remedy is even now within our grasp. Let us hope that this is true.

To Dujardin-Beaumetz is credited the remark: "The best treatment for typhoid fever is a good physician." The physician must have a comprehensive view of the disease with which he is contending, recognizing that back of everything is that one active agency which is destroying his patient, yet he must not for a moment forget the multiplicity of its manifestations "Eternal vigilence" is his only safety.

Typhoid Fever In Infants.

*By H. M. McCLANAHAN, M. D., Omaha.

Until recent years typhoid fever was not recognized as an entity among infants. In 1892 the late Dr. Christopher read a paper before the American Pediatric Society on typhoid fever in early life. The sentiment among the members was that the disease was extremely rare. Holt in his last edition says that he has seen no case under two years, in eight years service in the New York Infant Asylum where there were 10,000 cases and 700 autopsies. No case was recognized as typhoid fever in New York Foundling Asylum in 25 years. Morse states that until a few years ago, he had seen but two cases in twenty years in the Infant's Hospital in Boston. It should be remembered that these are in well organized hospitals where the milk and water supply are carefully guarded. Largely through the

*Read before the Nebraska State Medical Association. Lincoln May 7-9, 1912.

writings of Griffith of Philadelphia, the sentiment is growing that typhoid does occur at any age, but that most of the cases are in private practice, and during epidemics of typhoid fever. Hence infants do not present a complete immunity to this infection. It is recognized by all writers that the disease is more difficult of diagnosis during infancy, and it is probably sought for. It is the concensus of opinion that typhoid is less severe in children, that there are fewer complications because of normal organs, and that the lesions in the intestinal tract true that many cases go unrecognized because they are not are not as marked as in adults, that is, there is less ulceration. In infants the lesions of typhoid cannot be differeniated from those occurring in other intestinal diseases.

We will consider the subject under the following classifications.

1st-FOETAL TYPHOID.

The expression foetal typhoid means the infection of the foetus in utero, where the mother is suffering from typhoid, and its premature expulsion. Authorities state that 70% of pregnant mothers with typhoid fever go into premature labor. I quote as follows from McCrae in Osler's System: "In a certain number of cases there is intra-uterine infection; the foetus shows a septicaemia without internal lesions. This is not invariable, as there are instances in which the child escaped, as in some of this series in which the Widal reaction was not given by the blood of the foetus and cultures were negative. The conditions which determine the passage of the bacilli from the maternal to the foetal circulation are not positively known, but probably some disease of the placenta is necessary, and hemorrhagic infarcts have been found in several cases. When the foetus becomes infected, death follows in the majority of cases, but this is not invariable. The presence of bacilli must be proved before a diagnosis is made." It is generally understood that this is due to the influence of the toxin upon the foetus, and this is certainly true in many cases, because frequent examinations of the blood of the foetus have been made with negative results. On the other hands, that the bacilli itself may pass from the mother to the foetus is also established. Griffith in 1892 in the American Journal of Medical Sciences reported six cases of foetal typhoid. Other cases have been reported by McCrae, Wilson and Morse.

2nd-CONGENITAL TYPHOID.

By congenital typhoid is meant children born alive and