Typhoid Mortality and Sewerage. Typhoid fever is the sanitary index of a city. The mortality has everywhere declined with improvements in the sanitary conditions. Mr. J. H. Hill, an engineer, has recently tabulated the statistics of sixty-five cities with reference to the death rate from typhoid fever during the years 1890-94 inclusive, and has grouped them into seven classes. Class I., comprising

thirteen cities which have a death rate from typhoid fever under ten per 100,000 living, contains no American city. On the other hand, in Class VII., which comprises thirteen cities with a death rate from typhoid fever of over 60 per 100,000 inhabitants, all are in this country, except Milan, Cairo and Alexandria. The lesson of several of the European cities is worth reading. For example, the mortality per 100,000 inhabitants in Munich in 1857 was 292, and kept at a high rate until 1865, when there was an improvement in the water supply, with a reduction of almost 50 per cent. in the number of cases of typhoid fever. After the introduction of the new system of drainage, the mortality was still further reduced, and in 1887 it was only 10 per 100,000 inhabitants.-DR. OSLER, in Maryland Med.

Jour.

Foul Air a Predisposing Cause of Typhoid Fever.

Before the discovery of Eberth's bacillus, the opinion was quite generally prevalent that typhoid fever was not only due to the use of bad water or of milk or similar foods contaminated with bad water, but that it was also not infrequently contracted by the inhalation of foul gases, such as sewer-gas, odors from barn-yards, cesspools, etc.; but the discovery of the specific bacillus of typhoid fever led to the general adoption of the idea that the disease owes it origin almost exclusively to the use of contaminated water or milk. More recent studies of the subject, however, have developt facts which afford ample ground for believing that, as at first held, sewer-gas and other forms of bad air are an exceedingly important factor in the production of typhoid fever.

The human body, when in a state of perfect health, is capable of resisting germs of all kinds; even cholera germs, as well as typhoid fever germs, are digested in a perfectly healthy stomach, so that they are incapable of mischief.

But the germicidal power of the gastric juice is only one of the means of resistance to germs which the body possesses. The living cells in the muscles, as well as those in the blood and tissues, are also capable of capturing and destroying germs. The activity of the living cells in destroying germs depends, of course, upon their vital condition. Various causes may produce a lowered state of vitality, and hence a lowered resistance, so that the cells are no longer capable of resisting or destroying the invading microbes. It thus becomes evident that bad air as well as errors in diet-such as overeating, the free use of flesh foods, and the use of tobacco, alcohol and other drugs-may result in so lowering the vital resistance of the body as to prepare the way for the development of any infectious disease to which the system is susceptible.

Some years ago it became the writer's duty, as a member of the State Board of Health of Michigan, to investigate an outbreak of typhoid fever which occurred in a State institution for girls. A large number of cases occurred in a short time, several of which had terminated fatally. A careful examination of the water supply and the milk supply showed no grounds for suspicion. An investigation of the ventilation and sewerage system, however, showed a very unfortunate state of things. The sewers were ventilated thru the rain-water leaders, and these had become chokt up with ice, and, as the result, sewer gas was frequently forced up into the laundry, kitchen and other portions of the house in great quantities, and for a number of weeks the inmates of the institution had lived in an atmosphere more or less redolent with sewage odors. To add to the gravity of the situation, the janitor had undertaken to economize by shutting up the cold-air inlets and admitting the air to the steam coils, supposed to supply warm fresh air to the building, from the basements. But these were almost constantly filled with sewer

gas. The sewers had been infected a few weeks before by a case of typhoid fever received from a distance. Thoro disinfection of the sewers from all fecal discharges and a correction of the system of ventilation quickly terminated the epidemic.

Alessi, an Italian investigator, showed, several years ago, by experiments conducted upon animals in the Hygenic Institute of Rome, that bad air produces a susceptibility to typhoid infection. Rats were placed in a cage with a perforated bottom, and this was placed in communication with an ordinary privy vault. Guinea-pigs and rabbits were placed in cages the cleaning of which was entirely neglected, the fecal matters being allowed to accumulate. After exposure for a time to the influence of foul gases, these animals were inoculated with a pure culture of Eberth's bacillus, with the result that death occurred in from thirteen to thirtysix hours. Injections made into other animals which had been kept under healthy conditions were without effect. Animals were found to differ somewhat in their susceptibility to the influence of foul gases; for example, in the case of rats, the time required was from one to ten weeks; guinea-pigs, one to eight weeks, and rabbits three to eighteen days. It was also found that animals sometimes became habituated to the influence of foul gases, so that the injurious effects seemed to be somewhat mitigated. The fact that human beings may likewise become habituated, to some extent, is shown by the experience of the sewer men of Paris, many of whom practically live in the sewers of that great city, and yet apparently enjoy very good health. The writer has known a number of instances in which persons have suffered from typhoid fever who had apparently been exposed to no other cause of infection than the breathing of impure air.

This is a subject well worthy of consideration, especially during the winter season, when houses are, for the most part, closed and often poorly ventilated.-Modern Medicine.

Dr. Harvey A. White, of Chicago, writes: "Your 'Monthly Talks' are all right. Keep on. I hope the people will get their eyes open some time.'

Dr. Alex. Montague, of Galt, Cal., writes: "I inclose $3 to pay for four years in advance. Your Monthly Talks' are simply admirable. The inevitable reforms now permeating the minds of thinking people can be greatly accelerated by the combined efforts of the doctors, and yours was the happy task of putting the ball in motion among them. Strike straight from the shoulder. Your blows cannot fail to be effective."

Hydrotherapy in Typhoid Fever Fifty Years Ago.

It is very encouraging to note the rapidity with which intelligent physicians are abandoning the use of antipyrin, antifebrin and all other toxic antipyretics, which a few years ago were so generally used in the treatment of typhoid fever, and resorting instead to the use of water, which has been so well shown by Winternitz, Ziemmsen, Brandt, and a host of others, to be capable of producing infinitely better results than can be obtained by any other

means.

As the opinion seems to prevail quite generally that the use of cold water in typhoid fever is a modern procedure, we take the liberty to call attention to the fact that Dr. Scoutetten, professor of surgery in the military college at Strausburg, made very successful use of cold water in typhoid fever as long ago as 1842. Of course, Jackson and Curry had made use of water in various fevers a half century earlier, but their practice, for some reason, did not make a sufficiently profound impression upon the medical profession to lead to its general introduction. Dr. Scoutetten was first sent by the French government to visit the empiric Priessnitz, whose water cure establishment at Graefenberg was then at the zenith of its fame. He returned convinced of the intrinsic value of water as a therapeutic agent. The German government had already recognized its value in granting Priessnitz a diploma allowing him to practice, notwithstanding his lack of a medical education. Thru Scoutetten's recommendation and personal efforts, hydrotherapy soon became quite widely known in France, and several institutions were organized for its employment. He seems to have recognized the fact that typhoid fever was a germ disease, for he refers to it as being "introduced by an internal or external miasmatic cause." He remarks as follows with reference to the application of hydrotherapy in cases of typhoid fever:

"Water administered as a beverage or by enema relieves thirst, promotes secretion, especially of perspiration and urine. It dilutes and washes the blood, and removes from it foreign substances.

"External means-that is to say, moist compresses, sponge baths, the half bath, the wet girdle-absorb heat from the skin and promote perspiration, and by removing heat they relieve the internal inflam

mation. These effects are exactly what one desires to obtain..

"I have observed, as an almost constant result of these means, very great diminution in the abdominal meteorism. I have

many times seen, in cases of typical typhoid fever, complete disappearance of the abdominal distension within twentyfour hours, especially in cases in which patients were able to retain the cold enema. The sordes accumulated about the tongue, lips and teeth disappears with equal promptness.'

It was also noticed that the pulse was diminisht in frequency, and the delirium, when present, was diminisht in violence. Even by these imperfect means of applying water, Scoutetten found that the mortality, which at that time was one-half, was reduced at once to one-third during a very severe epidemic.

Greater experience has taught us how to employ water in a more rational and scientific manner in the treatment of typhoid and other fevers, so that the mortality can at the present time be said to be no more than three per cent. to five per cent. in cases in which the patient can receive proper treatment from the onset of the diseases, certainly a very noticeable contrast with the fifty per cent. mortality which was a not uncommon record fifty years ago.-Modern Medicine.

Sweet Oil Treatment in Typhoid Fever. By Dr. Owen F. Paget (The Lancet, November 27, 1897.) During his residence in Freemantle, Australia, he had attended over a hundred cases of typhoid fever, many under most disadvantageous circumstances, and did not lose a case. Among those patients removed to the hospital and treated in the orthodox way, there was a mortality of twenty per cent. in one year, and eleven per cent. in another. He gave sweet oil in the form of an enema every twelve to twenty-four hours during the first four or five days, about half a pint at a time. After the fifth day the injection was given every two days, or discontinued entirely if the temperature was steadily falling and the patient had a normal movement every day. Sometimes the oil was given by the mouth. In the closing paragraph he said, "Salad oil, one pint by the mouth and a half pint per rectum, has also given the most gratifying results in two cases of typhlitis under my care." [The results here detailed are among the best thus far

recorded in the treatment of this disease. If they are confirmed in the hands of other observers, a great advance will have been made.]-The Post-Graduate.

University of the State of New York-Medical

Examination.

[From the Med. Review of Reviews (rearranged).] QUESTIONS IN OBSTETRICS AND ANSWERS.

1. Give a brief anatomic description of the female internal organs of generation and mention the function of each.

Answer: The uterus lies in the pelvis, an organ about two-and-a-half inches long, one-and-a-half inches wide above and onehalf inch below. The upper rounded fundus and the flattened anterior and posterior surfaces of the upper portion, the body, are covered with peritoneum. The upper part of the lower section, or cervix, is likewise covered, but below it extends down into the vagina. At this free extremity the long narrow cavity of the uterus opens in the os. The other openings into the cavity are those of the Fallopian tubes, one at each angle. From each angle down each side of the uterus the peritoneum is attacht as the lateral ligaments, including cellular tissue, with copious blood vessels and nerves. The body of the uterus is composed of muscular walls and the cavity is lined with its own peculiar mucous membrane.

Between the folds of the broad ligaments at their upper borders lie the Fallopian tubes, passing outward for three or four inches, each from an angle of the uterus. The calibre of each tube gradually increases outward, ending in a somewhat dilated ostium, which is surrounded by free fimbriæ in the abdominal cavity. One fimbria on each tube is attached to the corresponding ovary.

The ovaries lie one on each side of the uterus between the folds of the broad ligaments. Each is about one-and-a-half inches long-ovoid-with surface scarred by the follicles which have or are about to burst.

The ovary furnishes the germ; the Fallopian tube conveys it to the cavity of the uterus, where, if fecundated, the ovum finds lodging place and nutrition for its subsequent development.

2. In what manner is fecundation accomplisht? What changes in the ovum follow fecundation?

Answer: Fecundation is accomplisht by the junction of one spermatozoon from the

semen with the ovum. This junction takes place probably in the Fallopian tube, though it may be in the uterine cavity or beyond the fimbriated extremity of the tube. To meet the ovum the spermatozoa advance by means of their own motive power from the vagina thru the uterus and tube, and one alone probably pierces the vitelline membrane, loses its tail, and is thus called the male pronucleus. This approaches the female pronucleus; these coalesce and form the segmentation nucleus. This divides and each half gathers about it a portion of the rest of the cell, so that two cells are formed. Each of these cells continue the process of segmentation until an immense number of cells are formed, each with its own nucleus. The cells resulting from the larger of those two cells are called epiblastic; those from the smaller are the hypoblastic. From these two layers of cells by a process of folding and unfolding the early embryonic form develops.

3. How is the placenta formed? What is the function of the placenta ?

Answer: The placenta is formed thus: The outer lamina of the amniotic folds is the chorion, surrounding the ovum and covered on its outer surface with villi. The allantois grows from the ventral surface of the embryo, is vascular, and spreads over the whole inner surface of the chorion and into its villi, remaining connected with the embryo by two arteries and one vein.

The ovum, thus surrounded, becomes embedded in the uterine decidua, and opposite the decidua serotina the true chorion, above described, continues to develop its villi, which become closely adherent to the vascular decidual serrations, and so forms the placenta. Thru this organ, by intermembranous interchange the fetus' circulation absorbs all nutrition, including oxygen, from the maternal blood, and likewise throws off its waste materials.

4. What precautions should be taken against infection during labor and in the puerperal state?

Answer: Aseptic cleansing of the arms, hands and nails of the physician, and of the abdomen, thighs and external genitals of the patient. Perfect cleanliness of the bed linen and all cloths, instruments, etc., which may be used during labor. As few vaginal examinations as may be consistent with careful watch of the progress. Intrauterine insertion of hand or instrument only when absolutely necessary. One

cleansing vaginal douch immediately after the end of labor.

During the puerperium-no douches if possible, aseptic cleansing of external genitals with fairly frequent renewal of vulva pads, which must be sterile.

5. What are the indications for the induction of premature labor after the beginning of the eighth month?

Answer: Moderate contraction of pelvis. Diseases which imperil mother's life

g., placenta previa, nephritis and eclampsia, phthisis, heart disease, pernicious anemia, over-distension of abdomen, etc.

In rare cases of habitual death of fetus just before term.

6. State the principal causes of abortion due to general maternal conditions.

Answer: Irritable uterus, chorea, eclampsia, uncontrollable vomiting, hysterical convulsions, abnormality of mother's blood, as in acute infectious disease, anemia, etc.; misplacement of uterus.

7. How may the knee be distinguisht from the elbow when presenting?

Answer: By its larger size, by the patella, by the spine of the tibia.

8. Mention the different varieties of version and state how each is performed?

Answer: Cephalic version, performed either by external method, i.e., both hands manipulating the fetus thru the abdominal walls, or by the combined method, i.e, one hand in the vagina and fingers thru the os manipulating the fetus, while the other hand assists by pressure thru the abdominal wall.

Podalic version, accomplisht by either the combined method, i. e., two fingers thru the os pushing aside the presenting part, catching a foot or knee and pulling it into the vagina, while the other hand, thru the abdomen, assists in the turning; or the internal, where the whole hand is introduced into the uterus, one or both of the lower extremities is seized and brought down.

9. Define and classify placenta previa and state how it should be dealt with.

Answer: The placenta is termed previa when it is implanted in the lower portion of the uterus, (a) previa centralis when completely covering the dilated internal os, (b) partialis when partially extending across the os, and (c) lateralis when extedning just to the margin cf

the os.

The treatment consists in the induction of labor immediately upon diagnosis.

This is usually best performed by the insertion of a tampon into the os uteri, after which dilatation may be advanced by rubber-bags, or, better, podalic version may be performed, and the extraction of the child accomplisht at will. If the placenta is centrally placed, the inserted fingers necessarily detach the placenta until the membranes can be reacht and ruptured. Post-partum hemorrhage is to be prepared for and checkt by the usual methods. 10. What are the causes of albuminuria in pregnancy? What does it indicate and how should it be treated?

Answer: May be due to an actual ne. phritis-pre-existing or newly developtThe more usual cases are caused by a number of causes, including reflex nervous irritability of the kidney, increast intraabdominal pressure, and pressure of uterus upon ureters, increast amount of effete material in mother's blood. It also occurs as complication in any acute infectious disease occurring during pregnancy. It may indicate nothing beyond itself it may indicate nephritis; it may indicate tendency to eclampsia. Treatment the same as in any nephritis case, regulation of life, diet and exercise-plenty of water to drink. Case must be carefully watcht to avoid uremia or eclampsia.

11. State diagnostic symptoms of a dead fetus in utero, and give the management of such a condition.

In

Answer: Fetal heart sounds not heard. No fetal movements on palpation. earlier months cessation of gradual abdominal enlargements, flabbiness of uterus and of breasts; subjective symptoms of languor, bad taste in mouth, and weight in hypogastrium. Acetonuria is said to be always present.

Management consists of induction of labor, if the diagnosis is certain. If thus sure, and the mother's condition, from any existing complication is urgent, the extraction of fetus can be performed by any method most promptly to relieve the mother. If the death is not certain, treatment is simply expectant.

12. Define ectopic pregnancy. What are its symptoms and how does it occur?

Answer: An ectopic pregnancy is the development of an impregnated ovum outside of the uterine cavity.

Symptoms. The ordinary early signs of normal pregnancy. Cramp-like pains of severe character in lower abdomen, discharge from the uterus of decidual membrane and blood, an extra-uterine tumor in

pelvis, sensitive, and in which ballottement may be obtained. Uterus smaller than normal for the given stage of pregnancy. If rupture occurs, sudden severe pain, followed by symptoms of shock and internal hemorrhage. It may occur in one of the three portions of the tubes, in the ovary itself, or in the abdominal cavity, either primarily, or by rupture from original implantation in one of the other sites.

13. Describe the application of the forceps to the fetal head, moveable above the inlet.

Answer: The left blade is inserted first, held in the left hand of the operator perpendicularly to the patient's abdomen: the handle is then lowered, and the blade. guided by the fingers of the right hand in the vagina, is slipt thru the cervix along the side of the head. The right blade is similarly introduced. Special care is necessary in passing the blades thru the cervix. It may not be possible to approximate the handles until after the head is drawn into the pelvic brim. If the abdominal walls are very lax, pressure down on the child may assist in the grasping of the head by the blades of the forceps.

14. In case of an after-coming head, what are the symptoms and the manage

ment?

Answer: The symptoms are simply the physical signs-i. e., the palpation of the head above and of the small parts and breech below-with the corresponding locality of the fetal heart sounds. By vagina the breech can be felt, and one or both feet.

Management consists in allowing the first stage of labor to be as long as possible to affect softening and dilatation, and expedition in the second stage. After the membranes are ruptured, draw down one or both feet, according to their positions; the breech is then easily expelled. After the head is then well down upon the perineum, the child's body is turned up towards the mother's abdomen, and the head is delivered by a process of flexion, the attendant's fingers aiding by traction. in the child's mouth.

15. Mention two distinct methods of dilatation of the cervix uteri in obstetric practice and describe in detail one of the operations.

Answer: The hydrostatic method. The manual method. The former is best accomplisht by Barnes dilators-rubber bags, fiddle-shapt and of graduated sizes, having a rubber tube attacht to smaller end.