The water was as cool as consistent with comfort, the object being to refresh the patient rather than to reduce the temperature. Friction with the towel was not so complete or thorough as to remove all dermal moisture. The baths were omitted during menstruation and in winter when the house thermometer registered below 60 degrees F. as it often does among the poor. When omitted altogether, the fever was presumably prolonged. The plunge bath is impracticable in private practice. It was never used and a comparison must obviously be theoretical.

A moist atmosphere conduces to quietude and improvement. During and following rain falls it was observed that the skin felt. moist where it had been dry and hot, the temperature was lowered, the pulse slower and the mind brighter. This same improvement is also believed to have occurred in three cases in which this atmospheric condition was produced artificially by watering the street with a hose. It can only be of service in summer. A natural moisture of the skin is a most welcome sign in every disease in which the sweat is not an immediate precusor of death.

Restriction of diet should be the rule. Milk can be used in every case at some period but exclusiveness should not be attempted. The meat broths are beneficial in constipation, particularly if there be antipathy to milk. In many cases they, especially mutton broth, increase diarrhoea and tympanites. When these latter conditions are in evidence the ingestion of even one pint of milk daily often suffices. Lime water added is valuable. Ice cream, clam and oyster broths, confining entirely to the liquid portion, were always allowed, no perceptible harm following. The food should be taken every two or three hours, the amount being discretionary with the patient. Nourishment seldom needs to be forced. Death is more frequent from overfeeding than from inanition.

The question of the propriety of foods known to be good media for growth in the laboratory is one whose solution depends most on the physician possessing perspicacity. A theory is not a proof. Empirical treatment is the basis on which the demonstration of most theories is founded. One physician prohibits milk, another beef bouillon, arguing that, as bacterial proliferation is favored artificially, the same result must follow in nature's course. Assuming this hypothesis we naturally expect the fever. to become more malignant. Experience clashes with this assump

tion. A fallacy prevails. Either the germs become no more numerous or the assimilation of these nearly perfect foods by enhancing the resistance, the energy, and the vitality of the individual more than neutralizes the disadvantages accruing.

Germane to this theory is the one relating to antiseptics. Bacteriologists affirm that antiseptic solutions applied to the predominantly local seat of a systemic disease, exert no influence on its course or severity. As an instance we take diphtheria; it can be proved on the best authority that sprays and gargles fail to diminish the number of bacteria on the faucial patch. Such claims are illogical rather than paradoxical. The blandest agent

is contaminated by contact with such a surface. In subtraction the remainder never equals the numerator. In typhoid we are dealing with a problem well understood. Bacilli are most numerous in the small intestine. Antiseptics are introduced. The germs are either killed or their growth is retarded. But the duration of the fever is not lessened nor is the mortality lowered. The conclusion is inevitable that the action of the medicine is wholly local; and that many of the bacteria whose habitat is in other organs escape. Assuming that systemic action is attained and the germicidal properties acknowledged the inference is at least plausible that the toxicity of the agent by destroying or lessening vitality more than counterbalances its otherwise favorable effect. This conclusion, theoretical though it be, in conjunction with that formed in so limited an experience has confirmed a belief in the efficacy of expectancy when reason does not decidedly dictate that the benefit to be derived is not greater than the injury or harm to follow.

As the medicinal treatment is symptomatic there must be times when the mildness of the fever impels absolute passiveness. There are no indications and any drug introduced is detrimental. Thirty-seven of my patients, beyond a placebo, received nothing more than an occasional dose of castor oil or calomel. Constipation often proves troublesome, but withal it was a most happy symptom. An initial dose of calomel, three to five grains, was given to most patients. Improvement in temperature and pulse was observed to follow, but it was ephemeral. When not used, nothing noted indicated any omission.

The onset of the fever is generally marked with a subjective history of constipation or diarrhoea. Constipation, while obsti

nate, yet augars favorably. It occurred thirty-two times in this series. Calomel for this continuing condition should be erased from our list of available drugs. Even the order to follow the initial dose with a saline is often disregarded. Salivation is weakening as well as being an annoyance. Thirteen grains administered in divided doses in the course of ten days salivated a girl of fourteen. Ulcers formed on the tongue and gum. This case extended over a period estimated at eighteen days. As observed by Bouchard (Auto-Intoxication in Disease) salivation and ulceration secondary to calomel mean a speedy recovery or an unfavorable termination. This case referred to was mild from the beginning and is not considered as substantiating the theory. Castor oil if compatible is ideal. It acts easily, surely, and with the least disturbance of the systemic equilibrium; untoward complications are not apt to arise. It was used altogether in four cases, in all of which the duration was shortened from one to five days. Unfortunately it is not well borne by the stomach. Its virtues may rest altogether in its action as a lubricant, but it probably possesses primary healing properties. Similarly olive oil should also answer, as its action is mostly mechanical. It was never used however. We reason by analogy that the good results from its use reported some years ago either bore an intimate relationship to a prevaling mild fever; or to its excellency as a mechanical evacuant, which latter opinion is personally favored. Little or no perspicuity is required as to time. of administration. It seems to meet every indication and probably possesses some additional value as a food. Next in order of merit for the relief of retained excrement comes the glycerine suppository. The mode of insertion is simple, and the results are immediate. Impossibility to inflict injury is its chief characteristic. Its efficacy often fails after the subsidence of the fever or during convalescence when the soap and water enema proves reliable. The latter is not entirely free from danger in the absence of a trained nurse, almost an unknown quantity in the beginning of practice. However if the attendant be of average intelligence and the instructions are obeyed there need be no hesitation in giving the order. With a repugnance to castor oil and even aversion on the patient's or nurse's part to rectal interference, salines have the preference. They deplete the blood serum by osmosis, but the depletion is imperceptible when

accuracy in the regulation of the dose is determined. The secondary anæmia is aggravated more by the salts than by castor oil, but gastric compatibility must not be lost sight of. paroxysm of reversed gastro-oesophageal peristalsis is a marked depressant, and gloom rather than cheerfulness pervades the sick room. A great objection to oral medication, as with salines, the "A. S. & B." pills, et cetera, is the griping which entails a consequent loss of rest. Such a patient so treated invariably had a quickened pulse as one result. Our aim should be to preserve the mutual harmony so essential to a successful termination.

Although we most frequently have accompanying constipation during the period of incubation toward the end of the first week of the fever, diarrhoea is usually announced. Heart weakness, delirium and diarrhoea are correlated and were concurrent sixteen times, in all of which water was taken in sufficient quantities. The correction of the diarrhoea does not depend on the number of movements but rather on the constitutional effect produced. As many as twelve evacuations daily may require no more than dietetic treatment. The meat broths increase the intestinal irritation, while milk in small quantities at frequent intervals and never forced, antagonizes this condition. When milk could not be taken, on account of some pecularity or idiosyncrasy, clam and oyster stews were permitted. The former, being particularly serviceable, as well as tasty, was rendered more advantageous by seasoning with pepper. The diarrhoea is believed to have been unwittingly aggravated, fortunately without disaster, in the treatment of the coincident heart weakness. Strychnine was found to have palpably promoted peristalsis when the tendency was toward diarrhoea. This observation was made in eight cases and of course there is no way in which we can positively determine that the intestinal hypersecretion was directly attributable to the agent employed. Used during constipation, one-eighth of a grain per diem, it is without power as a cathartic. It is an adjuvant and perhaps it is well to remember that it only strengthens or increases the intestinal motion when once begun. Delirium in itself is not a dangerous symptom. It seldom develops when great quantities of water are taken. It may be active or of the low muttering variety and lasted a few hours to six weeks. The conclusion was arrived at that scarcity of water in the tissues was the factor controlling its origin and

severity. This conclusion is based on the following observations: first, that its development was generally noted when but little water was taken; second, on taking an amount ordinarily regarded as sufficient its severity varied in proportion to the loss by hydrocatharsis; and third, on the known affinity of alcohol for water, and its power to absorb the latter, thus possibly explaining its origin in health.

Meteorism was troublesome but once, dyspnoea developing. The patient was constipated and changes are believed to have occurred in the milk, which was exposed to the summer heat, and not preserved by ice. Perforation never complicated.

That the tuberculous diathesis predisposes to intestinal hæmorrhage in typhoid fever has seemingly been so in my hospital experience as interne, and also in private practice. This tendency is also believed to exist in allied epistaxis. The worst case of each was decisively inclined by heredity toward consumption. Eight ounces of blood was positively lost in less than two hours, from the nose of a girl of eighteen. The family history absolutely affirmed the inheritance of the diathesis. These exsanguinary complications may have been coincident in this limited series, but they left an impression. The treatment of the intestinal variety is exemplified by the following record: The patient, a frail woman of twenty-eight, passed one quart of clotted blood on the fourteenth day. The temperature never rose higher than 97 degrees F. on this or the succeeding day. There were diarrhoea of mild severity and mild delirium. A hypodermatic injection of morphine, one eighth of a grain, was immediately given; an ice pack placed over the right iliac region; hot water bags to feet; sheets removed and woollen blankets placed next to the skin; the tincture of iron, twenty minims, given every hour for three hours, and then every two hours until the hæmorrhage ceased. On the fifteenth day the patient lost four ounces more. A camphor and opium pill was administered, the iron being continued until the nineteenth day when bismuth subnitrate, twenty grains, was substituted for the iron, to better control the diarrhoea, which was increasing. The bismuth was a failure. On the twentythird day eight ounces of blood passed the anus. The iron was twice rejected by the stomach. Sun cholera chocolate coated tablets were then used with excellent results. The bleeding ceased, the bowels were held in check at will for six weeks, delir