WORLD readers to know how we treat typhoid fever at this institution, and what results we have. The treatment is more or less conservative, and in ordinary, uncomplicated cases quite uniform. As soon as the diagnosis of typhoid fever is establisht, the patient is put upon typhoid orders, which, excepting some minor deviations, are similar in the different wards and include:

1. Pulse, temperature and respiration taken every four hours.

2. Liquid diet-which means in this instance, almost exclusively milk, 4 to 8 3 every two hours, diluted with lime water when necessary; only where milk disagrees is a variation in diet (beef juice, albumin water, gruels, etc.) allowed. Plenty

of sterilized water to drink.

3. Sponging for temperature at or above 102.5; some of the wards employ sprinkling with cold water; occasionally the cold pack is resorted to; the tub-bath is less convenient to use, requires more assistance and is hence only exceptionally employed.

4. Daily morning sponge bath-irrespective of temperature, the same as all acute patients receive.

5. Mouth wash after each feeding, but particularly thoro cleansing each morning.

6. Colonic flushing with Thiersch's solution every other morning. Outside of this general management the cases are treated symptomatically; patient is enjoined to use the bed-pan while confined to bed; no solid food is allowed until after seven to ten days from date of normal temperature.

The results are excellent, and no improvement could be desired except in the direction of shortening the usual course (duration) of the disease. During my junior medical service (December 1, 1897, to March 1, 1898) between 50 and 60 typhoid fever patients were admitted to the regular service. Of these no deaths occurred, and only one hemorrhage, which also recovered under the ordinary treatment. regarded these results as very remarkable; but they are not constantly so favorable.

I

This fall I noticed a number of deaths from typhoid fever. I believe in intestinal antiseptics. When I entered on service there were five typhoid fever patients in my ward, every one of which had marked tympanites, some also had active delirium. Tupentine, asafetida, ice coil, etc., had to be resorted to. After this every patient was placed on the following prescription, three or four times a day:

This gave most excellent results; some we also placed upon salol, gr. v, every four hours. We had no further trouble with tympanites, delirium, dry, brown tongue and similar grave symptoms.

While these measures are all very important, there is one in particular which is not emphasized and valued enough, and that is systematic, high colonic flushings at regular intervals. By this means we insure regular bowel movements, and in thoroly emptying the colon prevent absorption of toxin, also favorably influence any present inflammation or ulceration of Peyer's patches in the colon. In addition the watching of the bowels is obviated, which is a great relief; no cathartics are needed after the preliminary "purge". To this factor I attribute the absence of intestinal hemorrhage in our ward.

No stimulants were required, except the above prescription is called such.

L. F. SCHMAUSS, M. D. Member of House Staff, Cook County Hospital.

Chicago, Ill.

A Case of Yellow Fever in Ohio. Editor MEDICAL WORLD:-I wish to describe to the readers of THE WORLD, a case of yellow fever that recently came under my observation, that of Miss Blanche Beck, aged twenty-eight, an accomplisht young lady who graduated from Hiram College last spring, and was called to teach in the Southern Christian Institute, at Mt. Beulah, two miles from Edwards, Miss.

She was there one week and taught but three days. Upon advice of Pres. Lehman the teachers were all directed to leave on account of the prevalence of yellow fever. Miss Beck told him she did not care to leave as she was not afraid of the fever. He insisted upon them all leaving, for he said they had a serious time of it in Edwards last winter for some of them were in quarantine nine weeks. So he thought it best for all of them to leave, as they might not be able to get out even if they should want to go at some future time. So the school was closed and the President chartered a car. There were thirteen in the car. They took a train at Smith's Station above Edwards. But at Edwards five persons got on to go North too. One lady came from the sick bed of her brother-inlaw, who died two days later with yellow

fever. The lady herself never got the fever. A. T. Ross, another member of their party, had the fever at Union City, Ind.

Mr. Lehman, President of the Institute, who has been thru several yellow fever epidemics, and who is a close observer, feels quite sure that this lady was the source of infection for both parties. He thinks she carried it in her clothes. Miss Miss Beck was taken sick one week after reaching her home, which is in Paris, five miles from Newton Falls. I saw her in the night on Oct. 12, '98, first, after having a chill (she had but one chill). Her temperature was 102° F. Her pulse did not correspond with her temperature, and was not rapid but extremely weak. Her pulse thruout the disease gave me more uneasiness than any other symptom, for it seemed impossible to arouse the sluggish circulation. Next morning her temperature was 101° F.; in the evening 102° F. On the third day there seemed to be a complete remission in the morning temperature and hardly any rise in the afternoon temperature. She seemed to be more rested and cheerful than she had been at any time previous, but as Wood says, "it was a delusive calm," for next morning temperature went up again.

Wood, Da Costa, Reynold, and other good authorities say that yellow fever is a disease of a single paroxysm which is seldom or never repeated, but further on they say the fever does not distinctly remit until after from thirty-six to forty-eight hours, when a remission occurs. Upon this remission the fate of the patient hangs, and if the fever goes up, as it did in this case, it usually tends to a fatal issue. The highest I found her temperature at any time was 104° F. The day before she died morning and evening temperatures were 96°. One peculiar feature was that when she had the remission she was about as thirsty as ever.

Dr. Palmer, of Warren, was called in October 16, but at that time was not willing to affirm or deny that she had yellow fever. He said she had all the earmarks of yellow fever, the excruciating headache, the ache in the limbs, back and joints, which are the symptoms of yellow fever, but she did not possess that yellowness of skin and inky vomiting which are the sure signs of the fever, and besides that she had been sick nearly a week and the authorities say this should develop in four days at the most. He said, "I am waiting developments."

When Dr. Palmer saw the case she did not possess that yellowness of skin as markt as later on. The yellowness of skin was very slow in coming out. The characteristic vomiting also appeared. Her mind was clear within a few hours of her death. Miss Beck told me (she had a very good idea of yellow fever and her statements were generally found to be correct) that they told her in the South that people of light complexion (she was unusually fair) did not always turn yellow but that some of the cases instead of becoming yellow fairly bleached or blanched out, and that they did not always have the black vomit.

Dr. Wood says that "the black vomit, yellowness of the skin and hemorrhage have been mentioned as attendants upon this last stage, but patients often die without them. The yellowness of the skin to which the disease owes its ordinary name, tho a common, is by no means an invariable symptom."

He also says that "in fatal cases, death takes place most frequently on the fourth, fifth or sixth day, tho sometimes as early as the third, and sometimes as late as the eleventh day." She died on the morning of the tenth day. The suffused redness of the face was present a good deal of the time.

I had to resort to hypodermics to keep her from vomiting, for she was unable to keep anything in her stomach most of the time. Her stomach was very sensitive to the touch. She told me if she only got a small amount up, it relieved her for a short time. At first the vomited material came up by a sort of regurgitation, then she made considerable effort to throw it off; later, she could throw up mouthfuls without any effort on her part.

She voided very little urine, and with considerable pain. She had a pointed tongue with white coating, not heavily coated at any time, with red edges. She complained of a terrible exhalation from her body. She said the people in the South complained of what they called a "terrible odor." I must confess that I never noticed any odor like that before. I cannot describe it. It was a peculiar odor. Her breath was also very offensive.

Bowels were very much constipated, except at the fatal issue, when they run off. She had a rash after she came home. It lasted but a short time. I did not see it. Authorities speak of some of the cases having a rash early in the disease, before the febrile symptoms develop, which is very uncommon in other febrile diseases.

Her eyes were very much suffused, and had yellow conjunctivas from the first.

When Dr. Brobst, secretary of the State board of health, saw the case on October 19, she was yellow as an orange. He was of the opinion it was yellow fever, and reported the same to the board.

Miss Beck told me that they told her in the South that if it rained the three first days after one was taken down, it was almost sure death. It seems that if wet weather sets in after a dry spell, the germs propagate much faster. She said that after death the germs leave the dead body and seek new fields. That in the South they are much more afraid at this time than at any other.

Upon watching the case closely, I am firmly convinced that it was a genuine case of yellow fever. Would like to have the opinion of the readers of THE WORLD, especially those of the South, who have had experiences in yellow fever, and also their opinion whether the contagion can be carried in the clothes in the South. Newton Falls, O.

H. A. FIESTER.

Uses of the Sulfocarbolates. Editor MEDICAL WORLD:-I have been a silent reader of THE WORLD for over a year, and can say it is the best help I have. I began the use of the sulfocarbolates so soon as I began reading THE WORLD. I have treated several cases of typhoid this year, and have never had any trouble with the bowels when I saw the case early.

I also use these salts a great deal in bowel troubles, especially in cholera infantum. I usually combine pepsin, bismuth and zinc sulfocarbolate, and have not lost a case under this treatment. The worst cases usually recover in two or three days. Tidwell, Tex. E. A. HOPKINS.

Malarial or Yellow Fever?

Editor MEDICAL WORLD:-Kindly publish the within letter and answer:

Dear Dr. Dorris:-To-day in a copy of THE WORLD I saw your note anent "Hemorrhagic Malarial Fever". As I do not like to criticise a man publicly, I send you this letter, and you can publish it if you like. In the first place, let me tell you that I have practised since graduation where we have malaria. Our town is high, and not affected much, but the people go so often to the lowlands of Louisiana, just over the Mississippi River, and the people over there come here constantly.

This is the reason I see so much here, besides I practised two seasons in the

swamp.

If you will study the symptoms of yellow fever you will find that you have given a most excellent description of the disease: 1, A fever of one paroxysm; 2, rapid rise of temperature; 3, epigastric tenderness, very pronounced, and nausea early and persistent; 4, supprest or scanty urine, almost always albuminous; 5, tendency to hemorrhage; 6, jaundice.

Now look over your case as you reported it and see how beautifully markt a specimen you had. But you gave him the one treatment which always kills, either in yellow fever or hemorrhagic malaria. Quinin in any and all forms is positively contraindicated. In the latter, jaundice is rare, and fever rarely lasts over a few hours.

Had you given your patient nothing save small doses of calomel to unload the bowels, and enemas of potassium bromid forty to sixty grains six hours apart, strychnin 1-40 grain hypodermically every three or four hours till physiologic effect was seen, and if stomach would bear it, ergot in full doses, otherwise ergotole ten minims three or four hours apart by hypodermic, you might have saved your patient. When the period of colon (fever begins to leave) arrives, put nothing in the stomach at all. So soon as collapse appears imminent, high rectal injections of hot water and whisky should be resorted to.

Now doctor, see if you cannot trace out a source of infection, and did you not have -in the neighborhood-a good many mild cases of fever, one chill, pains in back, calf of leg, headache, etc.? and were not some of your cases jaundiced? Did it not run thru families?

Yellow fever, in your climate, produces a milder form of fever. One case like you described, will be followed by fifty or sixty, so mild that it is hard to recognize it, unless urine is albuminous. Look up this for me please, and remember that the fomites of yellow fever produce the disease. It is very infectious-provided a suitable atmospheric condition prevails but feebly contagious.

Natchez, Miss. J. C. BALLARD, M. D.

Chief Health Officer.

I appreciate Dr. Ballard's criticism and comments very much, but differ with him both in regard to diagnosis and treatment.

I did not make a microscopic examination of the blood for malarial parasite, but was so sure from the history of the case

72-417

but

that I did not deem it necessary. There had been no exposure to yellow fever, no Jepidemic in the country, no other case similar to this one. Patient had had two for three mild attacks previous, from which he had not entirely recovered and which Shad yielded to quinin, but had relapst two or three times. Two others of the family were suffering at the same time with malarial fever, which yielded to quinin. Thus, I think, yellow fever could be excluded.

The treatment advocated I think is very good under some circumstances, but this case I think would have succumbed on the following day under it. I don't think he would have survived another paroxysm, and this I think would have certainly come on had it not been for the quinin. Under the amount of quinin that was used there were symptoms on the following morning of the second paroxysm, slight rise of temperature, chills and rigors. I firmly believe, had it not been for the use 2 of quinin, he would have had the second paroxysm on the following day. This, I think, would have been fatal.

I don't think anything short of thoro cinchonism would have warded off the second paroxysm, and this was what I wisht to accomplish. I think a smaller quantity would have accomplisht this, but I wanted to be on the safe side. I would rather use too much than not enuf. I can't say whether the quinin was contraindicated or not. Any further comments would be appreciated. S. M. DORRIS. Bandana, Ky.

Difficulties of Practice in India. Editor MEDICAL WORLD:-If the circulation of a journal be judged by the number of references and inquiries it evokes, THE WORLD must indeed be very widely read since I have been deluged with letters from various parts of the mighty West where floats the glorious Stars and Stripes and the Union Jack, saying the writers had read my contributions to THE WORLD and asking me to advise whether there is scope for practice in the sunny East. You must kindly permit me reply to them collectively, as I have neither the time nor the 'almighty" to write them individually.

A number of folks jab a two-cent stamp on their letters to India where the postoffice treats them as "bearing letters" for which the unhappy recipient has to pay the equivalent of ten cents. During the

last month I had only 143 such underpaid letters, for which I had to hand over $14.30, and replying to them separately would mean another $7.15 out of pocket.

A hint also to manufacturers who send out drug and instrument literature, mailed as book packets in open letter envelopes. Post your printed matter in newspaper wrappers, or if you will use envelopes paste the flap inside, or during the process of examination the Sea or Bombay post office may accidentally seal down the envelope and treat it as a letter. In this case it is scarce likely you will hit the addressee for an order by making him cuss. Some for having to pay perhaps fifty cents letter postage for printed matter mailable at two cents.

Dr. Robert J. James of Minneapolis. Minn., asks what opening there is for a young doctor in India, and whether it would be feasible to run a hospital out here. The sooner he abandons the hospital idea the better, as while it is not easy to obtain the Government's sanction for such an institution, it is harder still to get the people to desert the state charitable hospitals in favor of one run by private enterprise. Besides he will have to reckon strongly with the Indian medical service. who are dreadfully conservative and do not look kindly on non-official (i. e. independent) medical persons.

Fuss is the religion of India, and the more show and fuss a man can make the surer his chances of success. Scope for

practice there is plenty if a medico can afford to "cut a dash" and live at the rate of about $180 per mensem for nigh a twelvemonth before he secures his first patient from the 270,000 practitioners he will have to compete against. Calcutta alone contains 7,000 doctors to its 6,700,000 inhabitants, or one doctor to every 957 persons, of whom at least 850 are too poor to be able to pay for medical attendance. At least 450 of the Calcutta doctors draw government pensions or salaries which help them under-bid the non-official doctor in the field for private practice.

According to medical ethics a doctor must not advertise himself. The nonofficial who cannot afford to attend a sick call for less than four rupees (i. e. $1.28) has to pay a license of Rs. 50 (i. e. $16.00) and does not advertise himself, while the government assistant surgeon, who pays a license of only four dollars is largely advertised by the State in all the gazettes and daily newspapers, and attends out-door sick

call for sixteen dents stil

cents per head besides re

ceiving his government salary.

A small idea may be formed of the magnitude of the State competition against which we non-officials have to contend when it is known that in a small province like Bengal there are no fewer than 417 government institutions where anyone who wants it can get medical and surgical aid and medicines for NOTHING (i. e. gratuitously).

At home and in Europe, anybody who was professionally competent to so do could medically certify anybody, whether in official employ or not; and so they could in India till 1895, when the Government ruled that none of its employés could file a sick certificate for leave of absence, unless it were signed or countersigned by a presiding surgeon, who was entitled to a fee of Rs. 4 for such signature; but who could refuse such certificate if he did not himself examine the patient requiring such. This examination meant a fee of Rs. 16. Hitherto, patients had as their family physician non-officials, whose annual contract (or fee) included granting medical or death certificates when necessary. Prior to the passing of this rule there were in Calcutta some 14,000 officials who paid their family doctor from Rs. 100 to 200 per annum, and obtained sick-leave about six times yearly. By this new rule this leave would cost them an additional Rs. 120 per annum for doctors' fees; whereas Rs. 150 to 200 per year would secare them the attendance and certificates of the presiding surgeon as family doctor. Consequence, the non-official doctor was given his walking ticket.

All this is bad enough, but we have a still worse evil to face. I do not know who set the lie a going, but in India there is a wide-spread belief that the majority of American doctors who come out here are too stupid to hold their own at home, or have "purchased their diplomas." Dr. 0. G. Place, of the Adventist Mission, and I have talked ourselves hoarse and worn out our pens in contradicting this infamous libel, which it is to the interest of official doctors and their non-official toadies to foster; but while the Medical Association of India will not help us to fight the lie out, the Indian Medical Association has too many subordinate officials on its rolls to carry weight with the lay public or to dare to defend non-British doctors from the vengeance of the Indian Medical Service, who claim the monopoly of the

practice out here and look upon every fresh arrival as a poaching interloper, whom it is their duty to wipe out, unless he can set up in grand enough style to catch the public eye and mind by imposing consulting rooms, flush conveyances, brilliant dinners and soirés, and a mountain of "outside fuss" to coax a mole-hill of private practice.

Sad tale, but true, from vale to highest range,
In Cabul down to southern Cormorin,
In rajah's palace or in peasant's grange,
'Tis love for money kills the love for kin;
Gold glosses all and silver rings the change,
Here lacking "fussy pomp" the doctor dies
While poverty is thought a deadly sin.
A starveling's death, his best endeavors fail
Where riches cover sins and foster lies

'Gainst State who can prevail when ev'ry side Official barriers rise and he must sink

Beneath their weight unless o'er them he ride. With sycophantic arts that daylight shrink,

Or ought to shrink if truth were paramount, In this bright land where justice and redress Are unknown things or rare, and riches count Most powerful, while he whose heart must bless In words at least tho not at heart rich hand That smote him worst since poor men right to live

Hold forfeit here, and may not honor'd stand Where gaining nought their all poor men must give

To push the rich man further up the tree Of wealth, where Nature smiles in ev'ry phase Of life, save man's, whose chiefest aim to see As his bright gold where'er may fall his gaze.

Cruel and disheartening as seems the story I tell, it is unfortunately true, e'en tho I have not painted it in all the horrors it presents to a sensitive mind. ROGER S. CHEW, M. D.

Calcutta, India.

Puerperal Eclampsia. Editor MEDICAL WORLD: Puerperal eclampsia is of grave import since such cases must cause the greatest possible anxiety to the best equipped accoucheur. If, however, he has been so fortunate as to have had the patient under his care and observation for some time in a major portion of the cases avoidance may be had by care in diet. Saline cathartics should be used and the patient should drink freely of water.

Dry cups should be applied to the back, or if there is a full bounding pulse, with turgid face, scanty, smoky urine, the patient complaining of a rush of blood to the head and vertigo, then venesection to the amount of one pint would be proper. Even a greater amount may be taken when the patient is very strong and of a full habit,