that we may carry poison and death under our finger nails, in our clothes, on our instruments; and experience has established as an equally undeniable truth that soap and water are effective disinfectants, are good substitutes for corrosive sublimate. Absolute cleanliness is absolute immunity from all extraneous infection. We are staggered by the numerous groups and very learned scientific names into which the great germ family is divided and by which they are designated.

The dead languages are taxed for epithets. Our learned scientific investigators could save themselves very precious time-time which they could devote to the discovery of practical and scientific truths bearing upon disease and wounds and their treatment, and tax less the vocabularies of the old languages, if they would simplify their nomenclature. If they will take four letters, they can spell out, name and explain their germ theory-dirt. Lister's teaching and that of his disciples can be safely left to the high court of scientific inquiry for its condemnation. The spray was a sort of morning befog; it disappeared before the light of a better knowledge.

Many deaths have been due to the washing-out of the peritoneum with carbolized solutions. The same may be said of solutions when applied in general surgery.

As we approach our higher ideals in the surgical treatment of wounds, antisepsis will pass into disuse; it will come to be regarded as the curious superstition of an unenlightened profession; it will be recognized as in very many instances positively injurious. We will not here question its occasional value in obstetrics. But even in obstetrics the mortality in the practice of physicians in rural districts, where there is no resort to antiseptics, is very low. And in this connection we may take the gynecological operations, or those in general surgery, of this same class of physicians, who in emergencies are too distant from the general surgeon or specialist to call in his aid, and have to act without trained nurse or skilled assistants, with every surrounding against them, without any of the appointments, appliances or aids to be found in the general and private hospital; and yet, in the face of all this handicapping, these embarrassments, they meet with repeated brilliant successes. To the extent to which it is possible they make conditions aseptic. The truth is, if you are seeking for some fad, some fallacy, some old or late rot, some new cure, some new surgical machine, a "free silver" mounted, hardwood operating table with an automatic device attached to do the operating while you sit down and rest, smoke, take a little Kentucky bourbon, or something refreshing from a South Carolina dispensary, why, go to some of the loud, noisy, inventive specialists or general surgeons of our medical centers.

I assert without hesitancy, from conviction, that the great broadening of our therapeutical resources and our great advances in both gen eral and special surgery are largely due to our general practitioners. From their ranks came the fathers. They have not indulged in lofty flights, but have stayed down on the ground and followed the plain, simple ways of common sense.

DENVER MEDICAL TIMES.

AN ADDRESS ON TYPHOID FEVER.

By H. A. HARE, M.D.,

Professor of Therapeutics in the Jefferson Medical College,

Philadelphia, Pa.

When I accepted the invitation of your president to address the Northumberland County Medical Society upon the subject of typhoid fever I was well aware that I was about to visit an area in which this malady was so prevalent that each and every one of my hearers would have formed definite ideas as to the plan of treatment which had proved most satisfactory in his hands. I come before you to-day, therefore, not as one who can instruct, but rather as one who thinks that by a comparison of views we may all return home with clear and definite ideas concerning a disease which in its frequency, duration and possibility of a fatal ending stands next to the great “white plague” of the race, tuberculosis.

It is an interesting fact, however, to note that this disease is, like many others of a preventable character, becoming less and less frequent, less severe and consequently less mortal. The statistics of forty or fifty years ago, which show us a mortality of from 20 to 40 per cent., are only to be found in isolated instances to-day, if at all, and occur only when the circumstances are most favorable to severe infection and most unfavorable to the patient. This fact is the more interesting when we recall the fact that greater knowledge of the disease and consequent increase in diagnostic skill causes the report of many cases of enteric fever which in days gone by would have been called continued fever, gastric fever or swamp fever.

To illustrate these facts, we find that the death rate of Vienna decreased from 12.05 per 10,000 to 1.1 after a pure water supply. In Dantzic the mortality has fallen from 10 per 10,000 to 2.4, and finally to 1.5 per 10,000. In Stockholm it has fallen from 5.1 in 1877 to 1.7 in 1887. So, too, in Boston, from 17.4 in 1846-49 to 5.6 in 1870-84.

In Munich it has fallen from 291 per 100,000 inhabitants in 1857 to 3.4 per 100,000 in 1896, and somewhat similar statistics can be produced for Londen and Manchester, for New York and Philadelphia (see Therapeutic Gazette for March, 1898), and this in face of the fact that the population of these places has increased several hundred per cent.

These tables are supported by the statement of Billings that in Norway, from 1888 to 1891, the mortality from typhoid fever was 755 in 7,467 cases, or less than 10 per cent. In the present Maidstone epidemic the death rate in 1885 is only 7.5 per cent., and a similar mortality obtained at Plymouth, Pa. Again, in the Gazette Medicale des Hopitaur of July 10, 1890, we learn that a collective investigation showed that whereas in the period from 1866 to 1881 the mortality from typhoid was 21.5 per cent., from 1882 to 1888 it was 14.1 per cent.; in 1889, 13.5 per cent.

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DENVER MEDICAL TIMES.

It is evident, therefore, that the mortality to-day should be placed at less than 15 per cent. as a fair percentage, the more so as many years ago Murchison placed it at 17.45 among 27,951 cases in England.

In studying the effect of any given plan of treatment, therefore, we may start with a basis of 15 per cent. at the most, as what may be called the normal death rate. As a matter of fact, I believe it to be lower than this, for I have collected from Germany, France, England and America a large number of statistics, which show that in 27,116 cases the mortality is about 10 per cent., if careful nursing and non-meddlesome treatment is used. This greatly lowered death rate indicates a greatly lowered severity in the symptoms of the disease, and, therefore, the malady runs a milder course naturally at this time than formerly. I mention these facts because they must be recognized before we can give credit to any plan of treatment. There are other facts which must also be considered before the advocate of any plan of treatment can assert that his method is the best. In a disease of this character deductions can only be drawn after the accumulation of a large series of cases, not fifty or sixty, but of hundreds of patients. This is shown by Mason's studies in Boston.

During 1890-91 there were treated in the Boston City Hospital 676 cases of typhoid fever, of which seventy-five were fatal, or 10.4 per cent. This includes all cases-mild, moribund, or doubtful-which entered the house. To illustrate how statistics may mislead, Mason records five different series of cases, aggregating 242 cases, with five deaths, or a mortality of about 2 per cent. It is well in this connection for us to remember that a disease that can not be aborted and which runs a definite course till it is completed will do less damage to the patient, if the case is guided through the storm so that his natural processes are not perverted, than if by meddlesome or absolutely harmful treatment his organs, already bearing the burden of disease, are still further strained by the influence of unnecessary drugs and by the necessity of absorbing and eliminating them.

The best treatment for typhoid fever is to let drugs alone so far as possible. Yet it can not be denied that in some instances routine plans of treatment seem capable of causing good results, probably because they keep their users from resorting to individual plans of treatment which are harmful. To express it differently, it is evident that if a given routine is followed which is manifestly not incorrect in its fundamental details, better results will be obtained than if each physician steers his patient on a course of his own choosing, which may not only be useless but actually dangerous.

This is shown by the facts presented by Liebermeister in his wellknown article in Ziemmsen's Cyclopedia, in which he gives carefully prepared tables of 839 cases, of which 377 were treated non-specifically, with a mortality of 18.3 per cent.; 223 treated by full doses of calomel, with a mortality of 11.7 per cent.; and 239 with iodine, with a mortality of 14.6 per cent. If the grave cases are included in his statistics, the mortality of a general plan of treatment was 25.3, those treated with calomel 16.3, and with iodine 17.2 per cent.

Under cool sponging Jaccoud lost out of 655 cases 10.8 per cent. Riess in 900 cases, with the use of tepid baths, had a mortality of 7 to 8 per cent., and under pure expectant treatment, with plenty of water to drink, Debove had a mortality of 9.2 per cent.

Having discussed these facts, let us turn to what is the best plan of treatment. Before doing this, we must, however, determine what may be called the necessary mortality of typhoid fever. That is to say, no plan of treatment can prevent a certain number of deaths from accidents such as perforation and hemorrhage, even if other ill effects are put aside. The death rate from these causes reaches about 7 per cent. The saving of life which we can expect to produce by good treatment is, therefore, that between 7 and about 15 per cent. at the most.

Now in regard to treatment, the medical profession has learned one dominant fact, namely, that while they can modify the severity of typhoid fever by prophylaxis and by proper treatment, they can not abort it or cure it. To express it briefly, the physician must guide his patient through the storm of his infection as a captain guides his ship. He can relieve dangerous symptoms, protect to some extent certain parts from fatal damage, place the whole system of his patient in a state best qualified to resist the disease; he can prolong it by bad treatment, but he can not shorten the storm by any direct means. This fact rests upon two others, namely, that the infectious process runs a given course in each case so far as its length is concerned; and secondly, the physician, unlike the captain of a ship, takes charge of his patient not before the storm, but after it has in gradually increasing intensity been developing in his patient for two weeks before it has manifested itself, and often for as long a period before its character is recognized. The pathological changes have been produced, and even if they do not progress further the process set up must run its course in the case of the intestine, for example, till the glandular changes are completed in ulceration or recovery. Every plan of treatment which has been tried in a sufficiently large number of cases to be studied statistically emphasizes these facts, and is directed to a modification of the symptoms and a protection of the patient against injury and not the true cure in the sense of specific medication.

In Germany some forty years ago typhoid fever patients were treated by catharsis, emesis and venesection. To-day the vast majority are treated by the cold bath, which, whatever objections may be raised to it, at least permits the system to combat disease and eliminate toxins without fighting the treatment in addition. Again, good nursing and the recognition that the conservation of energy is absolutely essential for the saving of life aid non-meddlesome methods.

At present there is another plan of treatment largely employed in the treatment of this disease, namely, that by antiseptics. In my belief, both the bath method and the antiseptic plan are but gropings in the dark, each possessing a glimmer of the light of truth in them which prevents us being lost. It is a safe rule to practice to a middle stand in accepting and carrying out any particularly highly lauded plan of treatment of disease. Particularly should the physician avoid routine plans

of treatment, for as long as human beings differ in their characteristics and micro-organisms differ in their virulence, each and every patient must be treated by himself; or, in other words, the treatment must be varied by the necessities of the individual. For this reason the plunging of every patient in a tub of water at 70 degrees F. because he has typhoid fever is not good therapeutics, and so the use of purgatives or intestinal antiseptics in practically unvarying amounts is unwise. All great underlying principles may be right in theory, but they must be so utilized as to meet the exigencies of life. In other words, the cold bath treatment and the antiseptic treatment do good in principle, but they must be suited to the patient before us.

There is not time in this discourse to show how a large part of the low mortality claimed by the enthusiastic followers of either of these plans is in part due to the careful nursing, feeding and stimulation of their patients. I have recently (Therapeutic Gazette for March 1, 1898) seemed to prove that the bath only decreases the mortality about 3 per cent. in itself. The chief fault with the adherents of both plans is that they are so well satisfied each with his method that they will not use the other, and nothing is more disastrous to patient and to the success of the doctor than the confidence of the latter that the plan he is using is the best to be found. It may be as good as he knows of, but his business is to find a better one always, or at least to seek for it.

In regard to the antiseptic treatment, so called, it has not found general recognition, because the grain of truth that intestinal fermentation and germ development is harmful has been surrounded with such a mass of theory not in accord with facts, and its technique has been so varied and so futile or heroic, that the grain of fact is overwhelmed. Intestinal antisepsis in typhoid fever is a good thing, but it is not the only good thing and often not a necessity. So, too, the bath is not the only thing needed or always a necessity. Beyond the use of antifermentative drugs to combat evidences of intestinal disorder, I confess that I have never resorted to this sole plan of treatment for the reasons given; and so, too, with the cold bath, I have been impressed with the fact that the full cold bath is not for every one. As I have said before, every one does not need croton oil for constipation or twenty drops of digitalis for a failing heart. The skill of the physician consists in knowing not only the general remedy but the dose. It seems to me, therefore, that in the use of antiseptics and purgatives, we should use judgment and not routine, and that the same rule holds true of baths.

It is our duty to understand the great underlying principles of a plan before we try it or modify it. In the case of the bath we find that its antipyretic powers are now recognized as being its least useful characteristics; that the most able hydrotherapeutists not only admit, but assert, that he who expects to throttle the fever by the use of the bath will be mistaken, and that the benefits to be derived lie in the improvement of the circulation, the overcoming of stasis, the production of leucocytosis, the encouragement of oxidation, and the reactive awakening of dormant and intoxicated venous centers. If these are the desiderata, how are they to be attained? Without doubt, in a fairly large