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ium meanwhile continuing and the patient ultimately recovering.

While we recognize and appreciate the refrigerant action of the ice bag it may be that in addition it has a mechanical value. Its weight compresses the intestinal canal, and there is a corresponding or proportionate diminution in the lumen of the bleeding vessel. Again, the pressure being in the right iliac region over the ascending colon, the gas accumulating principally in the large intestine is forced towards the anus-an advantage of significance. This is apparently the correct solution of this problem in mechanics, but whether the advantages have any foundation in fact permit of differences in opinion.

Perhaps that which impresses itself deepest on the minds of most men is the danger from heart failure. To successfully cope with this most alarming symptom, assumes an accurate and practical knowledge of the action of the cardiac stimulants together with a recognition of the changes characterizing the pulse in the different stages. We must as well be familiar with the temperament of the individual, as to this factor can often be attributed cardiac variations which seemingly indicate interference. A regular pulse of ninety or below seldom or never requires correction. Often the rate may be as high as 118 or 120, the same being directly due to nervous excitement. Again we may notice a gradual failure of the heart's action which sometimes indicates reinforcement even before the pulse numbers 110. Our guide, aside from acceleration, lies in the tension. The extremes with recovery have been forty-four and one hundred and forty beats per minute, the former not being entirely dependent on the phlegmatic disposition. The arterial tension in conjunction with the rate enables us to approximately determine the volume of the blood and often serves to confirm a conclusion that there is a hæmic diminution. This diminution may be the result of a direct loss by hæmorrhage or it may be due to a greater proportionate destruction of the blood itself. When it follows the former, rectification must be rapid in order to abort the cardinal strain, and ward off the impending collapse. We must have recourse to transfusion or the normal saline infusion. The latter was tried in the second fatal hæmorrhage case, six ounces of the saline solution being subcutaneously injected under each clavicle as a forlorn hope. The patient died before its absorption. The power of nature to recover itself even after a severe loss, synchronous with lowered vitality, is great. The indication for active interference necessarily depends on the extent of the hæmorrhage and on good judgment relative to nature's powers to recuperate.

Stimulants are often given indiscriminately. Heart failure rarely terminates disastrously and fortunately in this series, never, except when secondary in intestinal hæmorrhage. Whiskey, its reputed value to the contrary, is overrated. It is apparently contraindicated in delirium which latter it may produce in health. It accelerates the pulse and acts as an irritant to the stomach. To those habituated it is beneficial, not on account of any intrinsic merits, but rather for the reason that this time is not auspicious to change the very nature of the man. Its best effects are obtained when given in the form of the milk punch, administered to those patients suffering from general weakness arising from imperfect nutrition. It possesses a food value and herein lies its qualifications. Employed purposely to influence the circulation it is useless, as it increases the pulse without accentuating the valvular sounds.

Strychnine also seems to possess a fictitious value as a cardiac stimulant in typhoid fever. It was tried and appeared to be a general stimulant to all muscular tissue without any particular predilection. In doses of one-sixtieth of a grain every three hours no perceptible advantage was gained. Given when the pulse was as high as 110, and then discontinued, the withdrawal seemed absolutely void of change. If given to its full physiological effect the general muscular uneasiness offset its localized cardiac action. It increases diarrhea while constipation was never relieved by it alone. To reiterate without offering statistics, which seldom do more than confuse, it augments peristalsis, but never primarily induces intestinal motion; and its local action whether on the heart or other organs is proportionate to its action as a general muscular tonic.

The drug by far the best was found to be digitalis. The slow pulse never required treatment. The quick weak pulse of 116 to 120 is frequently encountered, and often gives rise to great apprehension. It is just here that digitalis fulfills every requisite. it we have almost absolute control over the rate. The volume of the arterial wave is increased. The heart sounds are accentuated. The endeavor not to exceed the physiological effect is sometimes perplexing. The rule was to keep the pulse approxi

By mately at ninety, as this number was observed to be consistent with safety and regularity. The choice of the preparation may be immaterial, but in this as in other diseases the fluid extract was most frequently coupled with intermittency and irregularity. Ten minims of the tincture every three or four hours was usually prescribed. Sometimes we fail to obtain the physiologic action as soon as expected because we confound one minim and one drop. They are not equal, one minim being equivalent to five drops as formed by the ordinary pipette. Digitalis is contraindicated in cardiac irregularity as it may produce this annoyance and consequently makes the cause difficult of differentiation. The advent of the "digitalis pulse" precludes further continuance. It is in this latter condition that the diffusible stimulants and strychnine are theoretically of service, and have always been used. The belief in their excellency is readily controvertible.

Complications were not numerous. The third and final fatal case was obscure. The patient, a girl of nineteen became delirious on the fourth day of attendance. The temperature was as high as 103.5 degrees; and the pulse was 120 before the administration of digitalis, which was begun on the fourth day and continued until the thirteenth day, there being a gradual diminution in the dose. The case was remarkable for the small amount of water taken. There had been mild diarrhea throughout. On the fifth day the jaws became rigid, the opening between the two rows of teeth not being sufficient to admit of the protrusion of the tongue. Fluids regurgitated through the nose. There was no discernible cervical swelling. It was impossible to inspect the tonsils. This condition existed until the twelfth day when deglutition became apparently normal. Rectal alimentation was used in the meantime. The temperature and pulse dropped gradually to normal on the fourteenth day of attendance, and nineteenth of fever, the pulse being seventy, full and regular at five o'clock in the afternoon. On the fifteenth day of attendance she died at two o'clock in the morning, while sitting upright to drink. Death ocurred in about thirty seconds, patient gasping and panting. There was no phlebitis. The digitalis has been stopped twenty-four hours and but twenty minims of the tincture were given daily on the eleventh and twelfth days. The urine had not been examined, but later I learned that there was no nephritis, the patient having attended at one of the local dispensaries. The

locked jaw, the regurgitation of fluids and the suddenness of dissolution were and are mysterious.

Gonnorrhoea prevailed throughout the course of one case. The young inan had been under treatment previous to the development of the fever when all medication ceased. Whiskey had been proinibited, but on earnest solicitation one-half ounce, night and morning, given in a milk punch, was permitted. The urethral irritation prone to subside, was so aggravated that the stimulant was stopped in two days, but not before the harm had been done. Delirium and excessive diarrhea supervened. The specific discharge continued throughout the fever but luckily there was no eye infection.

A singular record was that of a young man of twenty-two. His was a typical case, the diazo-reaction confirming the diagnosis. On the eighth day subsequent to first call he passed a lumbricoid worm six inches long. The source of the drinking water was a well, unprotected, unsanitary, and undoubtedly polluted. The surroundings were positively anti-hygienic.

Malaria was considered as a possibility in a young woman of twenty. In the second week she was seized with chills of five minutes' duration on two consecutive nights at the same hour. In consultation it was deemed advisable to withhold quinine in anticipation of a recurrence, which however failed to materialize. The coal-tar products as observed by Osler (Studies in Typhoid, P. 448, extracted from Vols. iv and v, Johns Hopkins Hospital Reports) produce chills and make a diagnosis between typhoid and malaria obscure on account of that fact. While it is not agreed that as antipyretics they are dangerous, yet in small amounts, four migraine tablets in twenty-four hours for not more than two days, they were occasionally given for the initial headache and for menstrual colic coming on during the first week. Their effect was never deleterious.

A drug most valuable but seldom employed is opium. With it we can absolutely control diarrhoea. It produces cerebral congestion; and in accompanying delirium the tendency is toward aggravation of this latter. With coexisting hæmorrhage it insures rest, an essential element in the cure of inflammation, and here recognized as the primary cause of the bleeding. Theoretically, an astringent metal, as iron with opium, alternately, meets every indication whether hæmorrhage exists with constipation or diarrhoea. The fæcal retention for forty-eight hours, as dissimilar to the eliminative treatment, is not more harmful than the latter is beneficial. The alkaloid morphine acted best in insomnia accompanied by restlessness.

From this limited experience the conclusion drawn as to the best management of typhoid fever in private practice are as follows:

(1) A room capable of free ventilation. (2) Removal of feather ticks from the bed. (3) Muslin sheets next to the patient. (4) Substitution of cotton for woolen underwear. (5) Coverings on the bed as light as consistent with comfort. (6) As much water as possible internally.

(7) Sponge baths every three hours, the object being to refresh rather than reduce temperature, assuring patient that there is no danger of "taking cold."

(8) Avoidance of ammonia, whiskey and strychnine as routine measures and a proper appreciation of their detrimental properties.

(9) Advantages of digitalis over all other stimulants. (10) The futility and dangerousness of forcing nourishment. (11) Benefits derived from opium and iron in hæmorrhage.

(12) That the beef broths aggravate diarrhoea and favor meteorism.

(13) The value of opium in the form of sun cholera tablets in excessive diarrhea where bismuth, tannigen, etc., fail.

We may add that trained nurses may be a great aid, and they are a veritable blessing in those families minus an adult female. They were invaluable in three cases where want was dominant. Their services were generously given by the Guild for the Care of the Sick Poor. This covered my experience with trained nurses -from necessity rather than choice.

For the ANNALS

By R. H. IRISH, M. D.,

Lansingburgh, N. Y. Though much has been written of late on the therapeutic application of super-heated dry air, the cases reported have been largely drawn from the records of public and private hospitals,

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