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Typhoid Mortality and Sewerage. Bouchard showed, some years ago, that Typhoid fever is the sanitary index of a persons who suffer from typhoid fever usu. city. The mortality has everywhere de- ally have dilitation of the stomach, and clined with improvements in the sanitary he says, “There is good reason for believe conditions. Mr. J. H. Hill, an engineer, ing that typhoid fever rarely occurs except bas recently tabulated the statistics of in cases in which the activity of the stomsixty-five cities with reference to the death ach has been so far diminished that it is rate from typhoid fever during the years incapable of producing a sufficient amount 1890-94 inclusive, and has grouped them of hydrochloric acid to destroy microbes into seven classes. Class I., comprising which may be received in the food and thirteen cities which have a death rate

drink." from typhoid fever under ten per 100,000

But the germicidal power of the gastric living, contains no American city. On juice is only one of the means of resistthe other hand, in Class VII., which com- ance to germs which the body possesses. prises thirteen cities with a death rate The living cells in the muscles, as well as from typhoid fever of over 60 per 100,000 those in the blood and tissues, are also inhabitants, all are in this country, except capable of capturing and destroying germs. Milan, Cairo and Alexandria. The les. The activity of the living cells in destroyson of several of the European cities is ing germs depends, of course, upon their worth reading. For example, the mor

vital condition. Various causes may protality per 100,000 inhabitants in Munich duce a lowered state of vitality, and hence in 1857 was 292, and kept at a high rate

a lowered resistance, so that the cells are until 1865, when there was an improve

no longer capable of resisting or destroyment in the water supply, with a reduction ing the invading microbes. It thus beof almost 50 per cent. in the number of comes evident that bad air as well as cases of typhoid fever. After the intro- errors in diet-such as overeating, the duction of the new system of drainage, the free use of flesh foods, and the use of tomortality was still further reduced, and bacco, alcohol and other drugs-may in 1887 it was only 10 per 100,000 inhab

result in so lowering the vital resistance itants.—Dr. Osler, in Maryland Med. of the body as to prepare the way for the Jour.

development of any infectious disease to

which the system is susceptible. Foul Air a Predisposing Cause of Typhoid Some years ago it became the writer's Fever.

duty, as a member of the State Board of Before the discovery of Eberth's ba- Health of Michigan, to investigate an cillus, the opinion was quite generally outbreak of typhoid fever which occurred prevalent that typhoid fever was not only in a State institution for girls. A large due to the use of bad water or of milk number of cases occurred in a short time, or similar foods contaminated with bad several of which had terminated fatally. water, but that it was also not infre- A careful examination of the water supquently contracted by the inhalation of ply and the milk supply showed no foul gases, such as sewer-gas, odors from grounds for suspicion. An investigation barn-yards, cesspools, etc.; but the dis- of the ventilation and sewerage system, covery of the specific bacillus of typhoid however, showed a very unfortunate state fever led to the general adoption of the of things. The sewers were ventilated idea that the disease owes it origin almost thru the rain water leaders, and these exclusively to the use of contaminated had become chokt up with ice, and, as water or milk. More recent studies of the result, sewer gas was frequently forced the subject, however, have developt up into the laundry, kitchen and other facts which afford ample ground for be- portions of the house in great quantities, lieving that, as at first held, sewer-gas and for a number of weeks the inmates of and other forms of bad air are an exceed- the institution had lived in an atmosphere ingly important factor in the production more or less redolent with sewage odors. of typhoid fever.

To add to the gravity of the situation, The human body, when in a state of the janitor bad undertaken to economize perfect health, is capable of resisting by shutting up the cold-air inlets and ad. germs of all kinds ; even cholera germs, mitting the air to the steam coils, supas well as typhoid fever germs, are di- posed to supply warm fresh air to the gested in a perfectly healthy stomach, building, from the basements. But these so that they are incapable of mischief. were almost constantly filled with sewer

gas. The sewers had been infected a few Hydrotherapy in Typhoid Fever Fifty weeks before by a case of typhoid fever

Years Ago. received from a distance. Thoro dis- It is very encouraging to note the rapidinfection of the sewers from all fecal dis- ity with which intelligent physicians are charges and a correction of the system of abandoning the use of antipyrin, antifebrin ventilation quickly terminated the epi- and all other toxic antipyretics, which a demic.

few years ago were so generally used in Alessi, an Italian investigator, showed, the treatment of typhoid fever, and reseveral years ago, by experiments con- sorting instead to the use of water, which ducted upon animals in the Hygenic In- has been so well shown by Winternitz, stitute of Rome, that bad air produces a Ziemmsen, Brandt, and a host of others, susceptibility to typhoid infection. Rats to be capable of producing infinitely better were placed in a cage with a perforated results than can be obtained by any other bottom, and this was placed in communi. means. cation with an ordinary privy vault. As the opinion seems to prevail quite Guinea-pigs and rabbits were placed in generally that the use of cold water in cages the cleaning of which was entirely typhoid fever is a modern procedure, we neglected, the fecal matters being allowed take the liberty to call attention to the to accumulate. After exposure for a time fact that Dr. Scoutetten, professor of to the influence of foul gases, these ani. surgery in the military college at Strausmals were inoculated with a pure culture burg, made very successful use of cold of Eberth's bacillus, with the result that water in typhoid fever as long ago as death occurred in from thirteen to thirty- 1842. Of course, Jackson and Curry had six hours. Injections made into other made use of water in various fevers a animals which had been kept under half century earlier, but their practice, for healthy conditions were without effect. some reason, did not make a sufficiently Animals were found to differ somewhat profound impression upon the medical proin their susceptibility to the influence of fession to lead to its general introduction. foul gases; for example, in the case of Dr. Scoutetten was first sent by the French rats, the time required was from one to government to visit the empiric Priessnitz, ten weeks; guinea-pigs, one to eight whose water cure establishment at Graefweeks, and rabbits three to eighteen days. enberg was then at the zenith of its fame. It was also found that animals sometimes He returned convinced of the intrinsic became habituated to the influence of foul value of water as a therapeutic agent. The gases, so that the injurious effects seemed German government had already recog. to be somewhat mitigated. The fact that nized its value in granting Priessnitz a diphuman beings may likewise become habit- loma allowing him to practice, notwithuated, to some extent, is shown by the ex- standing his lack of a medical education. perience of the sewer men of Paris, many Thru Scoutetten's recommendation and of whom practically live in the sewers of personal efforts, hydrotherapy soon bethat great city, and yet apparently enjoy came quite widely known in France, and very good health. The writer has known several institutions were organized for its a number of instances in which persons employment. He seems to have recoghave suffered from typhoid fever who had nized the fact that typhoid fever was a apparently been exposed to no other cause germ disease, for he refers to it as being of infection than the breathing of im- “ introduced by an internal or external

miasmatic cause." He remarks as folThis is a subject well worthy of consid- lows with reference to the application eration, especially during the winter sea- of hydrotherapy in cases of typhoid son, when houses are, for the most part, fever: closed and often poorly ventilated.-Mod- " Water administered as a beverage or ern Medicine.

by enema relieves thirst, promotes secre

tion, especially of perspiration and urine. Dr. Harvey A. White, of Chicago, writes: “Your Monthly It dilutes and washes the blood, and reTalks' are all right. Keep on. I hope the people will get

moves from it foreign substances. Dr. Alex. Montague, of Galt, Cal., writes: "I inclose $3 to External means—that is to say, moist par for four years in advance. Your .Monthly Talks are simply admirable. The inevitable reforms now permeating compresses, sponge baths, the half bath, the minds of thinking people can be greatly accelerated by the combined efforts of the doctors, and yours was the happy

the wet girdle-absorb heat from the skin task of putting the ball in motiou among them. Strike and promote perspiration, and by removstraight from the shoulder. Your blows cannot fail to be

ing heat they relieve the internal inflam

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mation. These effects are exactly what recorded in the treatment of this disease. one desires to obtain. .

If they are confirmed in the hands of "I have observed, as an almost constant other observers, a great advance will have result of these means, very great diminu. been made.]— The Post-Graduate. tion in the abdominal meteorism. I have many times seen, in cases of typical ty: University of the State of New York, Medical phoid fever, complete disappearance of

Examination. the abdominal distension within twenty

[From the Med. Review of Reviews (rearranged.) four hours, especially in cases in which patients were able to retain the cold

QUESTIONS IN OBSTETRICS AND ANSWERS. enema. Tbe sordes accumulated about 1. Give a brief anatomic description of the tongue, lips and teeth disappears with the female internal organs of generation equal promptness."

and mention the function of each. It was also noticed that the pulse was Answer : The uterus lies in the pelvis, an diminisht in frequency, and the delirium, organ about two-and-a-half inches long. when present, was diminisht in violence. one-and-a-half inches wide above and oneEven by these imperfect means of apply- half inch below. The upper rounded funing water, Scoutetten found that the mor- dus and the flattened anterior and posterior tality, which at that time was one-half, surfaces of the upper portion, the body, are was reduced at once to one-third during a covered with peritoneum. The upper part very severe epidemic.

of the lower section, or cerrix, is likewise Greater experience has taught us bow covered, but below it extends down into to employ water in a more rational and the vagina. At this free extremity the scientific manner in the treatment of ty. long narrow cavity of the uterus opens in phoid and other fevers, so that the mor- the 08. The other openings into the cavity tality can at the present time be said to be are those of the Fallopian tubes, one at no more than three per cent. to five per each angle. From each angle down each cent. in cases in which the patient can side of the uterus the peritoneum is atreceive proper treatment from the onset tacht as the lateral ligaments, including of the diseases, certainly a very noticeable cellular tissue, with copious blood vessels contrast with the fifty per cent, mortality and nerves. The body of the uterus is which was a not uncommon record fifty composed of muscular walls and the cavity years ago.- Modern Medicine.

is lined with its own peculiar mucous

membrane. Sweet Oil Treatment in Typhoid fever. Between the folds of the broad ligaments

By Dr. Owen F. Paget (The Lancet, at their upper borders lie the Fallopian November 27, 1897.) During his resi- tubes, passing outward for three or four dence in Freemantle, Australia, he had inches, each from an angle of the uterus. attended over a hundred cases of typhoid The calibre of each tube gradually infever, many under most disadvantageous creases outward, ending in a somewhat circumstances, and did not lose a case. dilated ostium, which is surrounded by Among those patients removed to the hos. free fimbria in the abdominal cavity. One pital and treated in the orthodox way, fimbria on each tube is attached to the there was a mortality of twenty per cent. corresponding ovary. in one year, and eleven per cent. in The ovaries lie one on each side of the another. He gave sweet oil in the form of uterus between the folds of the broad liga

enema every twelve to twenty-four ments. Each is about one-and-a-balf hours during the first four or five days, inches long-ovoid — with surface scarred about half a pint at a time. After the fifth by the follicles which have or are about to day the injection was given every two burst. days, or discontinued entirely if the tem- The ovary furnishes the germ : the Falperature was steadily falling and the lopian tube conveys it to the cavity of the patient had a normal movement every uterus, where, if fecundated, the ovum day. Sometimes the oil was given by the finds lodging place and nutrition for its mouth. In the closing paragraph he said, subsequent development. “Salad oil, one pint by the mouth and a 2. In what manner is fecundation ac. half pint per rectum, has also given the complisht? What changes in the ovum most gratifying results in two cases of follow fecundation ? typhlitis under my care.” [The results Answer: Fecundation is accomplisht by here detailed are among the best thus far the junction of one spermatozoon from the



semen with the ovum. This junction cleansing vaginal douch immediately after takes place probably in the Fallopian tube, the end of labor. though it may be in the uterine cavity or During the puerperium-no douches if beyond the fimbriated extremity of the possible, aseptic cleansing of external gentube. To meet the ovum the spermatozoa itals with fairly frequent renewal of vulva advance by means of their own motive pads, which must be sterile. power from the vagina thru the uterus and 5. What are the indications for the intube, and one alone probably pierces the duction of premature labor after the beginvitelline membrane, loses its tail, and is ning of the eighth month ? thus called the male pronucleus. This Answer : Moderate contraction of pelvis. approaches the female pronucleus; these Diseases which imperil mother's lifecoalesce and form the segmentation nu- 9., placenta previa, nephritis and cleus. This divides and each half gathers eclampsia, phthisis, heart disease, perabout it a portion of the rest of the cell, so nicious anemia, over.distension of abdothat two cells are formed. Each of these men,

etc. cells continue the process of segmentation In rare cases of habitual death of fetus until an immense number of cells are just before term. formed, each with its own nucleus. The 6. State the principal causes of abortion cells resulting from the larger of those two due to general maternal conditions. cells are called epiblastic; those from the Answer: Irritable uterus, chorea, eclampsmaller are the hypoblastic. From these sia, ancontrollable vomiting, hysterical two layers of cells by a process of folding convulsions,

convulsions, abnormality of mother's and unfolding the early embryonic form blood, as in acute infectious disease, develops.

anemia, etc.; misplacement of uterus. 3. How is the placenta formed? What 7. How may the knee be distinguisht is the function of the placenta ?

from the elbow when presenting? Answer: The placenta is formed thus: Answer: By its larger size, by the patella, The outer lamina of the amniotic folds is by the spine of the tibia. the chorion, surrounding the ovum and 8. Mention the different varieties of vercovered on its outer surface with villi. The sion and state how each is performed ? allantois grows from the ventral surface of Answer: Cephalic version, performed the embryo, is vascular, and spreads over either by external method, i.e., both hands the whole inner surface of the chorion and manipulating the fetus thru the abdominto its villi, remaining connected with inal walls, or by the combined method, the embryo by two arteries and one vein. i.e, one hand in the vagina and fingers

The ovum, thus surrounded, becomes thru the os manipulating the fetus, while embedded in the uterine decidua, and the other hand assists by pressure thru opposite the decidua serotina tbe true the abdominal wall. chorion, above described, continues to Podalic version, accomplisht by either develop its villi, which become closely ad- the combined method, i.e., two fingers herent to the vascular decidual serrations, thru the os pushing aside the presenting and so forms the placenta. Thru this part, catching a foot or knee and pulling organ, by intermembranous interchange it into the vagina, while the other hand, the fetus circulation absorbs all nutrition, thru the abdomen, assists in the turning; including oxygen, from the maternal or the internal, where the whole hand is blood, and likewise throws off its waste introduced into the uterus, one or both of materials.

the lower extremities is seized and brought 4. What precautions should be taken down. against infection during labor and in the 9. Define and classify placenta previa puerperal state ?

and state how it should be dealt with. Answer: Aseptic cleansing of the arms, Answer : The placenta is termed previa hands and nails of the physician, and of when it is implanted in the lower portion the abdomen, thighs and external genitals of the uterus, (a) previa centralis when of the patient. Perfect cleanliness of the completely covering the dilated interbed linen and all cloths, instruments, etc., nalos, (b) partialis when partially exwhich may be used during labor. As few tending across the os, and (c) lateralis vaginal examinations as may be consistent when extedning just to the margin of with careful watch of the progress. Intrauterine insertion of hand or instrument The treatment consists in the induc. only when absolutely necessary.

One tion of labor immediately upon diagnosis.

the os.

This is usually best performed by the in- pelvis, sensitive, and in which ballottement sertion of a tampon into the os uteri. after may be obtained. Uterus smaller than which dilatation may be advanced by rub- normal for the given stage of pregnancy. ber-bags, or, better, podalic version may If rupture occurs, sudden severe pain, fol. be performed, and the extraction of the lowed by symptoms of shock and internal child accomplisht at will. If the placenta hemorrhage. It may occur in one of the is centrally placed, the inserted fingers three portions of the tubes, in the ovary necessarily detach the placenta until the itself, or in the abdominal cavity, either membranes can be reacht and ruptured. primarily, or by rupture from original imPost-partum hemorrhage is to be pre- plantation in one of the other sites. pared for and checkt by the usual methods. 13. Describe the application of the for

10. What are the causes of albuminuria ceps to the fetal head, moveable above the in pregnancy? What does it indicate and inlet. how should it be treated?

Answer: The left blade is inserted first, Answer: May be due to an actual ne. held in the left hand of the operator per. phritis--pre-existing or newly developt pendicularly to the patient's abdomen : The more usual cases are caused by a the handle is then lowered, and the blade. number of causes, including reflex nervous guided by the fingers of the right hand in irritability of the kidney, increast intra- the vagina, is slipt thru the cervix along abdominal pressure, and pressure of uterus the side of the head. The right blade is upon ureters, increast amount of effete similarly introduced. Special care is nee. material in mother's blood. It also occurs essary in passing the blades thru the ceras complication in any acute infectious vix. It may not be possible to approxi. disease occurring during pregnancy. It mate the handles until after the head is may indicate nothing beyond itself-it drawn into the pelvic brim. If the abmay indicate nephritis; it may indicate dominal walls are very lax, pressure down tendency to eclampsia. Treatment the on the child may assist in the grasping of same as in any nephritis case, regulation the head by the blades of the forceps. of life, diet and exercise-plenty of water 14. In case of an after.coming head, to drink. Case must be carefully watcht what are the symptoms and the manageto avoid uremia or eclampsia.

ment? 11. State diagnostic symptoms of a dead Answer: The symptoms are simply the fetus in utero, and give the management physical signs-i.e., the palpation of the of such a condition.

head above and of the small parts and Answer : Fetal heart sounds not heard. breech below-with the corresponding loNo fetal movements on palpation. In cality of the fetal heart sounds. By vaearlier months cessation of gradual ab- gina the breech can be felt, and one or dominal enlargements, flabbiness of uterus both feet. and of breasts; subjective symptoms of Management consists in allowing the languor, bad taste in mouth, and weight first stage of labor to be as long as possiin hypogastrium. Acetonuria is said to be ble to affect softening and dilatation, and always present.

expedition in the second stage. After the Management consists of induction of membranes are ruptured, draw down one labor, if the diagnosis is certain. If thus or both feet, according to their positions ; sure, and the mother's condition, from any the breech is then easily expelled. After existing complication is urgent, the ex- the head is then well down upon the peritraction of fetus can be performed by any neum, the child's body is turned up method most promptly to relieve the towards the mother's abdomen, and the mother. If the death is not certain, treat- head is delivered by a process of flexion, ment is simply expectant.

the attendant's fingers aiding by traction 12. Define ectopic pregnancy. What are in the child's mouth. its symptoms and how does it occur?

15. Mention tuo distinct methods of Answer: An ectopic pregnancy is the do- dilatation of the cervix uteri in obstetric velopment of an impregnated ovum out practice and describe in detail one of the side of the uterine cavity.

operations. Symptoms.-The ordinary early signs of Answer: The hydrostatic method. The normal pregnancy. Cramp-like pains of manual method. The former is best acsevere character in lower abdomen, dis- complisht by Barnes dilators-rubber bags, charge from the uterus of decidual mem- fiddle-shapt and of graduated sizes, hav. brane and blood, an extra-uterine tumor in ing a rubber tube attacht to smaller end.

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