for several days was terribly sick, the whole head being swollen to almost twice its size. On the second day after the stinging, during a violent fit of sneezing, a bee was expelled from each nostril, and on the third. day, two bees were vomited from the stomach. A severe iritis, with keratitis was produced by the apis, which gradually subsided with appropriate treatment, leaving, however, an opaque cornea with decided infiltration. This cleared nicely in three months under succus cineraria, a small infiltrated spot being left where the cornea was punctured by the bee sting. The child has recovered perfect health.

* * *

At the same time that the above case was being treated, an old man of eighty-four presented himself stating that he had been stung in the eye by a bee. Again the cornea was punctured and an ulcer had developed. Trichloracetic acid was used immediately to cauterize the ulcer and the usual treatment for ulcer with iritis given. In this case the cineraria was used with good results and now after three months the eye appears perfectly normal and the patient has good vision.

THE BUTLER TYPHOID FEVER EPIDEMIC.

BY GUY C. KELLER, BUTLER, PENNSYLVANIA.

SENIOR MEDICAL STUDENT AT THE UNIVERSITY OF MICHIGAN.

THE typhoid fever patients at Butler, Pennsylvania, already number one-thirteenth of the population of that city, and the best informed authorities think the disease will claim not less than one-tenth of its population before it is checked. Perhaps no greater typhoid fever scourge has appeared in this country since the epidemic of Plymouth, Pennsylvania, in 1885.

Butler is situated thirty miles north of Pittsburg, on a hill in a hollow, so that one going out of the city in almost any direction must go down one hill and up another. It is an old city, in an oil district, and has a population of sixteen thousand, mostly intelligent and independent people who have massed their fortunes from the oil fields. The population has been doubled in the last five years. A large part of this increase consists of foreigners who located here because of the large iron and glass industries. Naturally this gregarious foreign population is massed in the vicinity of the factories under unfavorable hygienic conditions.

The city is beautifully situated, with all modern improvements, and a visitor merely taking a superficial view of the town would pronounce its sanitary condition excellent, but closer observation would reveal many deficiencies of a sanitary nature. Indeed the eight-inch sewer which is located in the main street does not carry all the sewage at some times of the year. However, the sanitary condition of Butler is as good as in many cities of the same size, and the present epidemic cannot be attributed to this cause, but it certainly has spread faster, and is more difficult to control because of the imperfect sanitation.

The milk used by the city, at first thought to be the chief factor in causing the epidemic, after close analysis was found to be pure. A local

creamery supplies four hundred gallons daily, which is pasteurized. This is a well organized plant conducted on modern plans. It has now been conclusively shown that the water-the only source that could cause such a sudden widespread epidemic during this season of the year-is the propagator of the infection. The south side of the city obtains its water from wells and very few cases of typhoid have occurred here.

The city water supply is taken from Conoquenessing Creek, a small stream running through the city. It is collected seven miles above the city, at Boydstown Dam, which has a capacity of 130,000,000 gallons. From this dam it is piped to a pumping station one-half mile above the city. It is then passed through a mechanical sand filter to a reservoir overlooking the city, which has a capacity of two million five hundred thousand gallons. The dam was swept away August 24, by a heavy rainfall. Then the water was piped directly from a dam above the station into the reservoir. This procedure giving inadequate supply, water was taken at times from Thorn's Run Dam, which is a dam in a little branch of Conoquenessing Creek. The water was not filtered for ten days in the latter part of October because of necessary repairs of the filtering plant. This wholesale pollution of the supply caused the overwhelming infection which became manifest during the latter part of October and the first week of November. At this time the water was shown chemically and bacteriologically to contain typhoid bacilli.

The probable contamination has been traced to a visitor suffering from the prodromes of typhoid fever in a family living two hundred feet above Thorn's Run Dam. This lady came to the city during July and one week after her arrival she went to bed and remained there for one month. Three cases of typhoid occurred in this family. The excreta of the family is said to have been thrown down a bank in the vicinity. The heavy rains of October and November would readily wash this excreta into the stream below. It has also been learned that there had been several cases of typhoid fever in a boarding house on the hill above the dam. However the stream may have been polluted originally, the prime factor in the causation of the epidemic is the failure in efficient filtration of the water supply.

The extent of the epidemic seems to be partly dependent upon: (1) The neglect of the citizens to boil all water used after having been warned by the health authorities; (2) The failure to make the conditions known to the public at an earlier date, the existence of the first cases being withheld because of the business interests of the city; (3) The large number of cases of the abortive type in the earlier part of the epidemic.

When the enormity of the epidemic was realized both city and state health officers took most active measures to check it. On November 25 Francis C. Phillips, Bacteriologist of Pittsburg, gave the following analysis of the city water: Total solids, 5: chlorin, 0.3; nitrogen in nitrites, o.o; nitrogen in nitrates, trace; free ammonia, 0.001; albuminoid ammonia, 0.008; oxygen required, 1.15: bacteria per cubic centimeter, 58. No typhoid bacilli were found. Notwithstanding the negative

report of the water analysis the absolute necessity of boiling all water used was made very emphatic by distributing posters, by the press, and by the profession.

In the early part of the epidemic the number of typhoid fever patients was distributed quite evenly over the city, excepting in that section using well water, which has already been specified. After the necessity of thorough disinfection was made known to the public by the profession and health authorities, the number of new cases in the better part of the city began to decrease, but there was no abatement in the district occupied by the foreign element. Consequently restrictive measures were directed toward the suffering among this population. The necessity for a relief association was now apparent and the citizens set about establishing one. This association is well organized with subcommittees in each ward, and has rendered most excellent service. It is estimated that one hundred thousand dollars will be required to do effective work throughout the epidemic, but as contributions are being received from every quarter of the state, funds will probably be ample. More than one hundred nurses are on duty, going from house to house under the direction of this association and altogether there are over two hundred at work in the city. Among these nurses there are some who served throughout the typhoid epidemic at Ithaca last year and Miss. Gleason, who has done active army service in Cuba and the Philippines, is also an attendant. Food, clothing, laundrying, and medicine are being furnished to more than two hundred patients by this committee. Domestic help is most needed at present. Miss Clara L. Barton, leader

of the Red Cross society, is now in the city doing active work.

The advantage of hospital service was soon recognized, and several dwellings and public buildings have been equipped for the care of the sick and are doing excellent work. Among these the City of Brotherly Love Hospital-formerly the Standard Hotel-is worthy of special mention. Doctor Johnson, of the Philadelphia Hospital, was delegated November 28 by Mayor Weaver, of Philadelphia, to investigate the epidemic, and by his recommendation twenty-five graduate nurses and three physicians, under the charge of Doctor Morris S. French, of Jefferson Hospital, were sent to Butler by the city of Philadelphia. He has equipped this hotel with all the necessaries of a hospital. Fifty typhoid fever patients are now getting sponge baths-for this is the hydrotherapy used-and much other service that could not be had by the poorer classes outside of the hospital.

The daily average of new cases of typhoid fever for November was thirty-five, with nineteen deaths during the month. The daily average of new cases for the first ten days of December was fourteen, with nineteen deaths. Doctor Wilbur Butt, State Quarantine Officer at Large, after taking the census of the city December 10, stated that he had reliable information that there had been one thousand two hundred ten cases of typhoid fever since the epidemic began, and thirty-eight deaths. The number of cases reported to January 10 is fourteen hundred

twenty-five, with eighty-eight deaths-a mortality of over six per cent. The mortality of the Plymouth epidemic was ten per cent and of the late Ithaca epidemic six per cent.

The epidemic is being investigated by many excellent men. Among these are Doctor Friedrich, Health Officer of Cleveland; Doctor J. H. McClelland, of the State Homeopathic Board; Doctor Brown, President of Lehigh University, and Doctor Frederick Preiss, a typhoid fever specialist of Buffalo. Doctor Preiss would use the ozone method of purifying the water, that is, the passage of an electric current through it. After extensive investigation he states that water can be made absolutely germ free by this procedure and at less expense than by filtration.

LECTURES.

CLINICAL REMARKS ON SOME SURGICAL CASES.*

BY HENRY O. WALKER, M. D., DETROIT, MICHIGAN.

PROFESSOR OF SURGERY IN THE DETROIT COLLEGE OF MEDICINE.

REPORTED BY E. C. RUMER, M. D.

SENIOR HOUSE PHYSICIAN AND SURGEON AT HARPER HOSPITAL.

RECURRENT APPENDICITIS.

Case I presents the usual characteristic features of a recurrent attack of appendicitis. The patient's history is as follows: W. H., fireman, aged thirty-seven years. Family history good. He had never had any illness until October, 1903, when he was taken with sudden. diffuse abdominal pain, with nausea and vomiting and general tympanitic resonance. As the condition continued the pain was referable to the right iliac region, with evidence of a swelling in this locality. His physician diagnosed an attack of acute appendicitis. This attack prevented him from pursuing his vocation for about two months. In the latter part of January, 1903, he had another attack which lasted about eight weeks. His health was fairly good, except for pain at times in the right iliac fossa, until about ten days previous to December 7, the date on which he entered the hospital, when he was seen by Doctor Knapp, of Johannesburg, Michigan, and found to be suffering from another acute attack of the former complaint. The doctor withdrew all nourishment by mouth, putting him upon an exclusive rectal alimentation, placing ice over the region of the appendix and administering anodynes as indicated for the relief of pain.

As soon, however, as his condition would warrant the doctor brought him to the hospital, where examination confirmed the diagnosis, although the earlier symptoms of the attack had somewhat subsided, yet there still existed a certain degree of tympany and appreciable iliac rigidity, together with a marked uneasiness on pressure. It was also * Delivered at Harper Hospital, Detroit, December 12, 1903.

quite evident that there was a circumscribed tumefaction round about McBurney's point. The temperature at the time was 99° with a puise of 80. The gradual retrogression of symptoms made it evident that an operation would be safer a few days later, and for that reason it was deferred until today. The treatment instituted by Doctor Knapp was continued until yesterday, when a high enema consisting of two drams of oil of turpentine and one ounce of sulphate of magnesia with sufficient warm water added to make a pint was given, causing a free evacuation. As he lies upon the table it will be observed that there is but little tympany, and the tumefaction is more easily discerned than when he was first seen. Undoubtedly this swelling has been present since the attack in January, an exudate walling off an abscess, and the recent attack being simply an exacerbation of the condition. It is a question whether this patient will ever have any better opportunity for operation than now. Experience has taught us many things since the first scientific removal of the appendix was performed. (1) That the death record from appendicitis left to nature-without operation-is about five per cent. (2) That the death record from operations in advanced acute attacks of appendicitis is about twenty per cent. (3) That the death record from operations performed for appendicitis within twentyfour hours of its onset is about one per cent. (4) That the death record from removal of the appendix in the interval or quiescent stage is about one-fifth of one per cent. If what has been stated is true, it follows that ail cases of appendicitis should be operated upon at some time or other. It will be remembered that there are exceptions to all rules, and that it becomes a personal equation with the operator as to whether he shall operate or not. It should be the rule in advanced acute appendicitis to wait and follow the plan adopted by Ochsner of withholding cathartics or food via the mouth and order that feeding be accomplished by the rectum, performing the operation at a later period. Circumscribed abscesses in connection with appendicitis will have to be opened and drained, usually without further distubance of the abscess cavity.

As has been stated, it will be found that when this patient is opened we will encounter a pus cavity. The length of incision will depend upon conditions, and in this case it is made about three inches or a little more as it will be necessary to cofferdam with gauze the swelling so that when the abscess is opened, infection will be precluded. You will notice that it is opened gently and mopped up as it presents. You will notice further that its consistency is thick like batter, showing that it has. existed for a long time. The appendix, fortunately, lies within the abscess cavity, is friable and easily pulled away. No attempt will be made to close the opening into the cecum, which is small, and although there will be a fecal fistula it will soon close. Drainage will be necessary in this case, best applied by means of gauze covered with guttapercha tissue. The incision is approximated with through-andthrough silkworm sutures, leaving an easy space for the exit of the