the patient in bed from the first and well into convalescence. They will beg to be allowed up, as they cry for food, but be firm on this point. Remember also that every motion means an expenditure of nerve energy, which it is most important to conserve, especially at the height of the fever.

While our efforts are directed to keeping the fever within safe limits, it is also highly desirable to maintain free elimination. Many cases show a tendency to constipation. Insure a daily movement from the bowels by enemata, as the routine; varied by an occasional mercurial purge, if the liver becomes torpid, or a mild hydragogue, or even castor oil. Cascara Sagrada often acts well and is safe. Remember that malaria often complicates typhoid in our district. Treat it, if suspected, with quinine or Warburg's tincture. In fact, it is often well to administer Warburg's tincture, half an ounce every four hours for a day or two during the invasion, both for its tonic effect and as a means of excluding malarial infection, where a blood examination is not possible.

This may conclude the routine regime of an average case of Typhoid Fever.

Possible complications are always to be had in mind. Some will be prevented by strict adherence to principles already stated; some are unavoidable.

The more frequent complications are: Hemorrhage in the second and third and fourth weeks, often preventible by proper care in diet by limiting meteorism, and by absolute rest. If it occurs, lessen the food, maintain perpect quiet, apply cold applications to the abdomen and administer ergot, hypodermically if necessary; or Bismuth and opium, with or without lead acetate. Keep the bowels confined for several days, then open carefully with enemata.

Combat the attendant shock with stimulants, hypodermically, if necessary only; elevate the foot of the bed;

bandage the extremities; hypodermoclysis may save the life.

Perforation, fortunately rather uncommon, is most serious when it does occur. Combat the shock as for hemorrhage. An enema of strong coffee is a powerful stimulant. As a surgical complication, operate as soon as the general condition will permit.

Localized Peritonitis: Opium is necessary to relieve pain, and to lock up the bowel if hemorrhage complicate; otherwise drain away the congestion by salines, e.g., Magnesium sulphate, administered preferably by enemata and high.

Secondary Bronchitis: May or may not call for special treatment.

Less frequent complications are:

Decubiti: Usually preventible, if proper care is given the patient. In asthenic types, bed-sores may occur despite every precaution, because of trophic disturbances. Use hair or rubber rings to relieve and redistribute pressure. If the skin is unbroken, brush with a 4% solution of silver nitrate, harden with alcohol and alum, brandy and castor oil; if broken, treat along surgical lines.

Pneumonia, usually hypostatic, and pleurisy do not prevent the employment of baths for the pyrexia. Stimulating measures, never depressing, are indications; more alcohol, digitalis, unless the temperature is high, but let strychnia be the sheet anchor. Change the patient's position frequently; encourage deep breaths. The Pneumonia jacket and Counter-irritation are well-tried remedies.

Possible Meningitis, parotiditis, otitis media (suspect if leucocytosis is found), nephritis and uremia, phlebitis, sensory hyperesthesia and paraplegia, typhoid spine, abscesses or furunculosis, erysipelas, retention of urine (the bladder should be palpated daily),-any of these may develop, and of course are to be treated along usual

lines. It would prolong my paper beyond limits to more than mention them.

In general, have a typhoid patient wear an abdominal binder or flannel band for months. It lessens the shock of sudden atmospheric changes, supports the weakened abdominal viscera and is appreciably comforting.

Post-typhoid Alopecia may be lessened by the free use of the ice-coil and occasional scalp massage with some stimulating lotion, as e.g., Pinaud's Eau de Quinine Tonic, or a more formal dermatological prescription.

The anti-typhoid serum, as a prophylactic measure, is still in the experimental stage. The tests made, especially among the British soldiers are on the whole discouraging though they warrant further research.

14

THE RELATION OF THE COUNTRY WELL TO

TYPHOID FEVER.

HERBERT E. SMITH, M.D.,

NEW HAVEN.

Typhoid fever is the chief of our so-called filth diseases, and is always of interest to sanitarians as the typhoid death-rate is in general the best index of certain phases of the sanitary conditions of a community. The disease is caused by the well-known bacillus, which enters the body commonly through the mouth in some article of food or drink. Water is the most common means of infection and dissemination, but milk, green vegetables and other articles of food may become infected, and under certain conditions flies and dust may be important media of dissemination. The bacilli leave the body in the feces, the urine, and probably in the saliva. The most important factor in prophylaxis is the proper disposal of these excreta, for it is from these materials that food and drink become infected. The chief subjects of inquiry in a study of the dissemination of typhoid fever are, therefore, the disposal of the house wastes and the source of the water supply. In sparsely settled districts these terms are reduced to the privy, the sink drain and cesspool, and the well. There is surely no need that I should comment on the convenient relation of the house and these important domestic institutions which is so conservative of minutes, and so wasteful of lives. My object is to call attention to the relatively isolated condition of this country domestic system as compared to those existing in areas of crowded population. The evils arising on the farm are largely confined to the resi dents of a particular house and their visitors, and there

is little liability of one system directly contaminating the more or less remote neighbor. Furthermore, comparatively few persons are exposed to a single infected system. As the population becomes concentrated the risk of infection from one system reaching another increases, until under the conditions in some cities large regions may become infected. As cities increase in size and wells are abandoned for a public water supply brought from a distance, the conditions improve and a further improvement follows the introduction of sewers to replace the privy and cesspool. But the population also increases in the region about the city and the sources of water become contaminated with sewage and there then appear the scattered cases of typhoid and the occasional epidemic due to an infected water supply. After this in natural order follow the best conditions attainable in city life when the public water supply is changed to a carefully protected source, or is purified by efficient filtration, and shallow wells are all abandoned and privies are all abolished.

The cities and boroughs of Connecticut may be said to be in the second of these stages; they all have public water supplies, and all the larger ones have systems of sewerage, yet in most places there are still many wells in use, and many privies. Our water supplies are mostly from impounded surface waters not yet subject to gross pollution. None of our cities draws its water from sources comparable in pollution to the large sewage polluted rivers used in some American cities. On the other hand, none of our towns, with the exception of Greenwich, is provided with filter works, and most of our reservoirs are not as carefully protected as they should be. The conditions prevailing in the large towns of our State, therefore, favor a moderate typhoid death-rate, higher than should prevail in the small towns, but not so high as is to be expected in cities without public sani