A brief points as to management of cases in which operation is indicated. A. patient cannot be moved to a hospital for operation. If in a private house, this must be done at the bedside. Every ef fort must be made to save time in oper ating. There must be no handling of distended bowel outside the abdomen. Once escaped this cannot usually be re turned without an amount of trauma which is most fatal. inflamed visceral peritoneum splits and peels off with the greatest ease. A short incision of the bowel made under constant irrigation is by far the less of two evils, and may be quickly and safely repaired. An intes tinal leakage has already occurred, so that the additional danger of soiling the peritoneum may be disregarded. The external incision should he located as for appendicitis. The point of departure for search should be the ileo-necal junc tion, as the majority of perforations oc cur in this neighborhood. if possible, the lateral abdominal wall should be made to form one side of the area packed and drained. Infusion of salt solution is useful as it stimulant. It will tide a weak patient over dangerous period: of depression, and probably also assist in the elimination of typhoid products by the kidneys. The external wound should not be Other things being equal, the patient most likely to recover will be the one to whom the least is Even establishing drainage along with a faecal fistula would be far better than pro longed manipulation. which is are to kill. G. Eretv (Phila. Med. Jour., May 31, 1902).
Epistaxis, as a rule, requires no special treatment. The application of ice to the nose or the use of a weak solution of tincture of iron will often be sufficient.
It is occasionally necessary to plug the posterior nares. Styptics, such as gallic acid and tannic acid, are of doubtful value when given internally, and may derange the stomach. The lungs should be frequently examined to ascertain the presence of bronchitis or pneumonia.
Hypostatic congestion may, to some ex tent, be prevented by changing the tion of the patient every few hours. The presence of pneumonia should not deter the physician from pursuing the ordinary course of the treatment of the fever. pectorants containing ammonium chlo ride may be given for the bronchitis. The heart should be frequently ex amined, and, if it is weak, tonics, such as strychnine and caffeine, may be given. The nitrites, especially amyl-nitrite, have been recommended by Wilson. In cases of cardiac weakness care should be taken that the patient does not sit up or make sudden movements in bed.
The retention of urine is a not infre quent complication, and when the tient is very weak the physician should carefully examine the abdomen for dis tended bladder. A soft-rubber catheter should be used, and the greatest care taken by thorough cleanliness to prevent the introduction of germs into the der. Immediately before the use of the
catheter the part should be washed with a bichloride solution, 1 to 2000.
A continuously-high temperature is very injurious to the patient. If cold baths cannot be given, cold sponging, cold compresses, Leiter's coil, or the ice bag may be used.
Antipyretics—such as antipyrine, anti febrin, and guaiacol—are to be con demned. The writer has seen two cases in which very alarming symptoms fol lowed the taking of a 15-grain dose of antifebrin. Both patients had been strong and healthy persons previous to the onset of the fever.
Treatment by Inoculation. — Within the last few years attempts have been made to shorten the course of typhoid by subcutaneous injections of sterilized liquid from the cultures of typhoid ba cilli.
Fraenkel and Manchot ("Amer. Sys tem of Med.," vol. ii, p. 229) used a ster ilized liquid from the culture of typhoid bacilli in bouillon made from the thymus of the calf and heated to GO°. The in jections were made deeply into the mus cles of the buttock. The first injection —0.5 cubic centimetre of the sterilized liquid—was not followed by any reac tion except in children. On the follow ing day a second injection of 1 cubic centimetre was made, which was followed, in the majority of cases, by rise of tem perature and chilly sensations. After six or seven hours the temperature fell and rose again in those cases in which the treatment was discontinued. Fraenkel gave the injection every second day, in creasing the dose by 1 cubic centimetre each time. The temperature showed de cided remissions. The constitutional symptoms were less marked, and com plete absence of fever resulted in the course of a few days. Fifty-seven cases were treated in this way.
Rumpf publishes the results of the treatment of thirty cases with a sterilized culture of the bacillus pyocyancum tained from thymus bouillon. Favorable symptoms followed its use.
Beumer and Peiper employed 1-per cent.-pepton bouillon as a culture-me dium, and destroyed the bacilli by posure to a temperature between 55° and G0° C. for an hour. Longer exposure or a higher temperature decidedly decreased the virulence of the culture. Sheep were inoculated with these cultures at inter vals, the amount injected being gradu ally increased from 1 to 100 cubic metres. The animals were then bled, and the serum treated with 0.5-per-cent.
solution of carbolic acid and preserved in a dark place. The serum was found to possess both immunizing and curative properties. No dangerous effects fol lowed the injection in healthy men, but further experimentation is necessary to establish its immunizing and curative effect on human beings.